Gastroesophageal reflux disease (GERD) occurs when there is a backing-up of stomach contents including acid and digestive enzymes into the esophagus and sometimes higher (throat, and airways). It causes symptoms such as heartburn, acid regurgitation, chest pain, hoarseness and cough. It can lead to complications including, ulceration, scarring, or precancerous change in the lining of the esophagus (Barrett’s esophagus) and cancer of the esophagus (adenocarcinoma). Barrett’s esophagus occurs in about ten percent of patients with GERD. Adenocarcinoma of the esophagus occurs in about one percent of patients with Barrett’s esophagus.
GERD tends to occur when there is a failure of the barrier mechanism between the esophagus and the stomach as a result of a malfunction of the muscular sphincter, or flap, at the bottom of the esophagus, failure of the esophagus to promptly clear or neutralize the refluxed noxious material coming up from the stomach, or failure of the normal protective mechanisms built into the esophageal lining. Oftentimes, it is a combination of factors that cause GERD.
A hiatal hernia is commonly found in patients with GERD. It is a protrusion of the upper portion of the stomach through the diaphragm muscle into the chest cavity. This can contribute to disrupting the gastro-esophageal barrier mechanism and when large and fixed can function as a reservoir above the diaphragm from which gastric fluid can more easily travel up into the esophagus then drain downwards.
The amount of acid reflux required to cause symptoms varies from person to person. Esophageal damage is more likely to occur with more frequent or more prolonged acid reflux episodes.
Diagnosis of GERD is usually made based upon the presence of typical symptoms (heartburn, acid regurgitation) and response of symptoms to acid reducing agents. Upper endoscopy or EGD, where a camera is used to look into the esophagus, is another way of evaluating the problem. It allows the detection of ulceration and complications including strictures, Barrett’s esophagus and esophageal cancer. Sometimes, when the symptoms are not typical and the diagnosis is not clear, direct measurement of acid exposure of the esophagus is required.
Mild symptoms are usually treated with lifestyle modifications such as weight loss, smoking cessation, avoiding fatty foods and caffeinated products and avoidance of late meals consumed close to bedtime. Mild cases may be treated with histamine blockers such as Zantac or Pepcid. In more severe cases treatment is with medications called Proton Pump inhibitors (PPIs) such as Prilosec, Protonix, Aciphex, Prevacid, Nexium, Dexilant etc. In most patients symptoms can be controlled with these medications. PPI medications also promote healing of the esophageal lining, and prevent complications. Surgery is rarely needed to treat GERD.
Complications such as scarring and blockage of the esophagus are usually treated with dilation (stretching) of the esophagus. Patients diagnosed with Barrett’s esophagus should be observed with periodic EGD and biopsies of the abnormal lining to look for a change in the cells called dysplasia that puts them on a closer path to becoming cancerous. When dysplasia is found, occmore frequent monitoring or other treatment modalities may be recommended.
Dysphagiaor difficulty swallowing is a symptom that requires evaluation particularly when solid food hangs-up or gets stuck in the throat or behind the breastbone. This usually indicates that there is a blockage in the esophagus, usually by scar tissue and rarely by cancer. Evaluation is best done by an EGD. On occasion a barium swallow (x ray) may be done.