Reviewed by DR. D. DATTA.
Ex. Emergency Medical Officer.
Gastroesophageal reflux disease is a common condition that may affect 20% of the population. It may occur in any age group, but incidence increases with age.
In gastroesophageal reflux disease stomach acid and other contents repeatedly come back into the esophagus from the stomach. As a result, the inner lining of the esophagus becomes irritated.
(Esophagus is a tube through which food or liquid goes to the stomach from the mouth).
Symptoms of gastroesophageal reflux disease
1 Frequent regurgitation of food or liquid in the esophagus that may cause a burning sensation (heartburn) in the middle of the chest behind the sternum, usually after taking a meal.
2 Frequent regurgitation of stomach content into the mouth.
3 Pain in the epigastric (abdomen below sternum) region.
4 Feeling of food stuck in the throat.
5 Dysphagia (difficult in swallowing)
6 Hoarseness of voice.
7 Bad breaths
8 Nighttime refluxes may cause coughing
Causes of acid reflux-
Lower esophageal sphincter (LES) is a muscular valve at the junction of esophagus and stomach. This valve opens temporarily when food or liquid enters the stomach from the esophagus and closes tightly after food enters the stomach. When due to some reason this valve cannot close properly, there is backflow of the stomach content into the esophagus.
Risk factors of gastroesophageal reflux disease
1 Obesity
2 Hiatus hernia- In this condition the upper part of the stomach bulges into the chest through a small opening in the diaphragm (a muscle that separates the chest from the abdomen).
3 Pregnancy
4 Delayed stomach emptying
5 Some connective tissue disorders such as scleroderma, rheumatoid arthritis.
6 Smoking (active or passive)
7 Eating late at night.
8 Eating large meal.
9 Alcohol and coffee
10 Some medicines such as aspirin, medicines to reduce blood pressure, pain killers.
11 Spicy fatty or fried foods.
Complications of gastroesophageal reflux disease
1 Gastric acid and content causes irritation of the esophagus that may lead to esophagitis (inflammation of the esophagus), ulcer in esophagus, bleeding from the esophagus. These may cause dysphagia (difficulty in swallowing).
2 Esophageal stricture – acid reflux from the stomach causes scarring of esophageal tissue and narrowing of esophageal lumen leading to dysphagia.
3 Barrett’s esophagus – it is a precancerous condition. Acid of the stomach causes changes of mucosa (inner lining) of the esophagus.
4 Chance of esophageal cancer increases.
5 Aspiration pneumonia- when gastric contents enter the lungs during regurgitation.
6 Chance of asthma is more in patients with gastroesophageal reflux disease.
[Read more about Barrett’s esophagus].
Diagnosis of gastroesophageal reflux disease
Doctor takes history of symptoms from the patient.
Physical examinations done to see any sign of gastroesophageal reflux disease.
Some investigations are done to confirm the diagnosis and also to see if there are any complications of gastroesophageal reflux disease.
1 Upper gastrointestinal endoscopy- A flexible tube mounted with light and camera (endoscope) can be passed through the mouth to visualize the esophagus and the stomach. It can assess the integrity of the lower esophageal sphincter, esophageal inflammation(esophagitis), ulcer and stricture of the esophagus, tissue samples for biopsy can also be taken if Barrett’s esophagus or any cancerous lesion is suspected.
2 24-hour pH test- a thin tube with a sensor is passed through the patient’s nose into distal esophagus. The sensor is connected with a small computer that the patient wears around the waist or by a strap around the neck. The sensor can detect acid reflux and computer record reflux of acid in the esophagus from the stomach. This test is performed for 24 hours, and the patient can do his normal activities during this time.
3 Barium swallow x ray- Barium solution is swallowed, several x-rays are taken after drinking barium solution. The solution coats the inner lining of the esophagus. It can diagnose whether the esophagus is dilated or not and whether the food or liquid is passing through the esophagus in time or accumulates in the esophagus. It can also detect any filling defect in the esophagus, narrowing the lumen of the esophagus.
4 Esophageal manometry- Here a catheter is inserted through the nose. It measures the force of esophageal muscle contraction, pressure of LES, how LES relaxes and opens during swallowing. It can detect any motility disorder of the esophagus such as achalasia cardia that may cause symptoms of gastroesophageal reflux disease.
[Read more about achalasia cardia].
Treatment of gastroesophageal reflux disease
1 Lifestyle changes for gastroesophageal reflux disease-
Avoid becoming overweight.
Take small, frequent meals.
Foods that cause more acid secretion or increased reflux of acid secretion such as citrus fruits, alcohol, caffeine, ketchup should be avoided.
Avoid spicy, fried and fatty foods.
Eat a meal at least 3 hours before lying down at night.
Maintain upright position for 45 minutes after taking food.
Stop smoking.
Raise the head end of the bed or raise the upper portion of the body while sleeping with a wedge pillow.
Avoid tight clothes that squeeze your belly.
2 Medications of gastroesophageal reflux disease-
Antacids- antacids give quick relief by neutralizing stomach acids.
H2 blockers such as ranitidine, famotidine- These drugs can decrease gastric acid production for a few hours.
Proton pump inhibitors such as omeprazole, rabeprazole- These are stronger acid blockers, they also help to heal damaged esophagus.
Prokinetic drugs such as domperidone, metoclopramide – these drugs cause early stomach emptying. Prevent abdominal bloating and gastroesophageal reflux disease.
3 Surgery for gastroesophageal reflux disease –
If lifestyle changes and medications fail to control or patients cannot tolerate medicines, then surgery is recommended.
Fundoplication- Fundoplication is the most common surgical procedure done to prevent acid reflux from the stomach to the esophagus in gastroesophageal reflux disease. In this procedure the upper portion of the stomach(fundus) is wrapped around the lower portion of the esophagus and sewed in place. As a result, the strength of lower esophageal sphincter increases and reflux of stomach content back into the esophagus is prevented. A hiatus hernia if present may also be repaired at the same time.
[Read more about Fundoplication].
Transoral incisionless Fundoplication (TIF)-This is a newer form of surgery. With the help of an endoscope the stomach is wrapped around the lower esophageal sphincter.
LINX device- It is a minimally invasive surgery. A ring with small magnets implanted at the junction between the stomach and esophagus. This ring allows food to enter the stomach but is strong enough to close the junction after food enters the stomach and prevent acid reflux.
Stretta procedure- this is an endoscopic procedure. LES is reshaped with the help of low radio frequency energy delivered by electrodes placed at LES.
Weight loss surgery- if obesity is the cause of gastroesophageal reflux disease.
