Gastroesophageal reflux disease

What is gastroesophageal reflux disease?

Gastroesophageal reflux disease (GERD), also known as chronic acid reflux, is a disorder in which the esophagus, the tube that connects your throat to your stomach, frequently becomes exposed to acid-containing stomach contents. Acid reflux occurs when a valve at the end of your esophagus, known as the lower esophageal sphincter, fails to seal correctly as food enters your stomach. Acid backwash then runs up your esophagus and into your throat and mouth, leaving you with a sour taste.

Nearly everyone experiences acid reflux at some point in their lives. It's completely natural to experience heartburn and acid reflux occasionally. However, if you experience acid reflux or heartburn more than twice per week over a period of several weeks and are constantly taking antacids and heartburn meds yet still experience symptoms, you may have GERD. Your healthcare provider needs to handle your GERD. Not only to get rid of your symptoms, but also because GERD might trigger more severe issues.

Epidemiology of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) symptoms are among the most typical ones seen in general practice. Because many people do not seek medical attention for GERD symptoms, and because many doctors do not specifically inquire about such symptoms while completing the review of systems, reported symptoms undoubtedly understate the true incidence of this disease in the population.

GERD is one of the most widespread gastrointestinal conditions, affecting 20% of adults in western societies. According to a comprehensive review, GERD affects between 18.1% and 27.8% of Americans. However, because more people have access to over-the-counter acid-reducing drugs, the actual prevalence of this illness may be higher.

Men tend to have GERD at a slightly higher rate than women do. According to a significant meta-analysis study, women are slightly more likely than males to experience GERD symptoms (16.7% vs. 15.4%). In contrast to men who are more likely to have erosive esophagitis, women who arrive with GERD symptoms are more likely to have non-erosive reflux disease (NERD). However, compared to women (14%), males (23%) had a higher incidence of Barrett's esophagus than men with long-term GERD symptoms.

What causes gastroesophageal reflux disease (GERD)?

Frequent acid reflux or the reflux of non-acidic stomach material are the two main causes of GERD. The lower esophageal sphincter, a circular band of muscle at the base of your esophagus, relaxes as you swallow, allowing food and drink to pass into your stomach. The sphincter then contracts once more, closing the esophagus. If the sphincter does not close properly or becomes weak, stomach acid may flow back into your esophagus. The lining of your esophagus is constantly being irritated by this acid backwash, which frequently results in inflammation.

Gastroesophageal reflux disease (GERD) has a complicated pathophysiology that encompasses alterations in visceral sensitivity, epithelial resistance, and reflux exposure. The toxic substance known as gastric refluxate damages the esophagus and causes discomfort. The key factor affecting the severity of the condition is esophageal exposure to gastric refluxate. This exposure results from the anti-reflux barrier being compromised and the esophagus's diminished capacity to remove and buffer the refluxate, which causes reflux disease. However, when there is either inadequate epithelial resistance or excessive visceral sensitivity in the context of normal reflux burden, problems and symptoms can also develop. Therefore, changes in the balance of defensive and offensive forces are what cause reflux to develop.

What are the risk factors for GERD?

The following factors increase your risk of developing gastroesophageal reflux disease:

Obesity
Hiatal hernia
Pregnancy
Some connective tissue disorders such as, systemic sclerosis.

There are some habits and medications that can aggravate GERD, these include:

Smoking
Eating large meals
Eating close to bedtime
Eating fatty or fried foods
Drinking coffee
Drinking tea
Alcohol
Use of nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin

What are the symptoms of gastroesophageal reflux disease (GERD)?

Acid reflux is characterized by heartburn. It's a painful burning feeling in the center of your chest produced by stomach acid irritating the lining of your esophagus. This burning can occur at any moment, although it is usually worse after eating. Many people's heartburn increases when they recline or lie in bed, making it difficult to obtain a decent night's sleep. Fortunately, over-the-counter (OTC) heartburn and acid indigestion drugs may typically be used to treat the disease. Your doctor may also offer stronger drugs to help manage your heartburn.

In addition to acid reflux at night, you might also experience:

Regurgitation of food or sour liquids (backwash) in your throat.
Chest or upper abdominal pain.
Difficulty swallowing (dysphagia).
Feeling a lump in your throat.

If you have nighttime acid reflux, you might also experience:

A persistent cough.
Vocal cord inflammation (laryngitis).
Asthma flare-ups or new ones.

How do doctors diagnose gastroesophageal reflux disease (GERD)?

By asking you about your symptoms and medical background, your doctor can typically determine whether you have typical symptoms of simple acid reflux (not chronic). You can discuss managing your symptoms with your doctor using food and medication. When complications are suspected or to confirm a diagnosis of GERD, your doctor may advise:

Upper endoscopy:

An endoscope (a small, flexible tube with a light and camera inside) is inserted down your throat. Your doctor can view the inside of your stomach and esophagus with the use of the endoscope. When reflux is present, test results might not indicate any issues, but an endoscopy can identify abnormalities like Barrett esophagus or esophagitis by collecting a tissue sample (biopsy). In some cases, if the esophagus is shown to be narrowed, it may be stretched or dilated during this procedure, this is done to help with swallowing difficulties (dysphagia).

Ambulatory acid (pH) probe test:

A monitor is inserted into your esophagus to track when and how long stomach acid regurgitates there. A little computer that you carry around your waist or with a strap over your shoulder links to the monitor. A thin, flexible tube (catheter) inserted through your nose and into your esophagus may serve as the monitor. Alternatively, it could be a clip inserted into your esophagus during an endoscopy. After about two days, the clip dissolves in your stool.

X-ray of the upper digestive system:

In order to show your esophagus and stomach in silhouette, your doctor will need to take X-rays after you consume a chalky liquid that coats and fills the interior lining of your digestive tract. This is especially helpful for those who have difficulty swallowing. Additionally, you could be instructed to take a barium pill in order to diagnose an esophageal narrowing that might impair your ability to swallow.

Esophageal manometry:

This test counts the regular muscular contractions in your esophagus that occur as you swallow. Esophageal manometry also assesses the efficiency and force of the esophageal muscles. People who have problems of swallowing frequently undergo esophageal manometry.

What are the complications of gastroesophageal reflux?

Esophageal complications:

Erosive esophagitis: When there is an excessive amount of acid and pepsin reflux, the surface layers of the esophagus mucosa become necrotic, which leads to erosions and ulcers. Patients with erosive esophagitis may not exhibit any symptoms or they may experience dysphagia, regurgitation, heartburn, and odynophagia.

Eosinophilic Esophagitis: Eosinophilic Esophagitis is an esophageal disease characterized by an increase in the number of cells called eosinophils in the esophageal walls. Eosinophils are cells that are commonly connected with allergy disorders such as asthma (when they are detected in the airway walls). Eosinophilic esophagitis is linked to allergies (including food sensitivities) and GERD.

The most common symptom is swallowing difficulty, with food becoming lodged in the esophagus when swallowing. Corticosteroid slurries, elimination diets, and GERD medicine may be used as treatments.

Barrett's esophagus: Barrett's esophagus is a disorder in which the stratified squamous epithelium that typically lines the distal esophagus is replaced by metaplastic columnar epithelium. Chronic gastroesophageal reflux disease (GERD) results in the development of the metaplastic epithelium, which increases the risk of esophageal cancer. No symptoms are present in the specific intestinal columnar metaplasia typical of Barrett's esophagus. The majority of patients are initially treated for related GERD symptoms such dysphagia, regurgitation, and heartburn. The link between GERD and long-segment hemorrhage, stricture, and ulceration of the esophagus are common complications of Barrett's esophagus.

Esophageal stricture: The recovery from ulcerative esophagitis leads to peptic strictures. During this stage, collagen is deposited and over time, the collagen fibers gradually contract, narrowing the esophageal lumen. These strictures are often small in size and close to the gastroesophageal junction; endoscopy may also show nearby areas of reflux esophagitis; patients may also experience episodic food impaction and solid meal dysphagia. The management of benign esophageal strictures involves dilation combined with acid-suppressive therapy with a proton pump inhibitor to prevent the recurrence of strictures once they have been adequately dilated.

Esophageal cancer: There are two main forms of cancer that start in the esophagus. The lower portion of the esophagus is where adenocarcinoma typically occurs. This kind may result from Barrett's esophagus. Squamous cell carcinoma first appears in the cells of the lining of the esophagus. The upper and middle portions of the esophagus are typically affected by this malignancy.

Extraesophageal complications:

Several extraesophageal problems have been linked to gastric juice regurgitation and/or aspiration. However, it is sometimes overstated how much GERD contributes to the etiology of these illnesses.

Asthma: Asthma sufferers frequently have GERD, which has been suggested as a possible asthma trigger. Between 34 and 89 percent of people with asthma have GERD. GERD may make asthma symptoms worse, and asthma drugs may make GERD worse. However, managing GERD frequently makes asthma symptoms better.

Chronic laryngitis: Patients with laryngitis present with a change in voice quality or hoarseness due to laryngopharyngeal reflux (LPR). Other symptoms associated with LPR include throat clearing, persistent cough, globus sensation (sensation of a lump or foreign body in the throat), laryngospasm, or choking sensation.

Laryngeal and tracheal stenosis: Laryngeal and tracheal stenosis can be caused by LPR. Patients with a central airway blockage may present with subacute or acute symptoms that are not always identifiable. The severity of the luminal blockage, as well as its location and duration of presence, all affect the clinical symptoms. Dyspnea, coughing up blood (hemoptysis), and wheezing are among the symptoms.

What is the management of gastroesophageal reflux disease?

Diet and lifestyle changes:

GERD symptoms can be managed with dietary and lifestyle adjustments. Try the following suggestions:

Avoid eating rapidly and in large amounts.
Refrain from eating just before bed (wait more than two hours before lying down after a meal).
Limit your intake of high-fat, fried, and spicy meals.
Reduce your intake of acidic foods such as citrus (lemon, lime, orange, and grapefruit) and tomatoes.
Do not consume chocolate, garlic, or onions.
Limit alcohol and caffeinated beverage.
Retain a healthy weight for your body.
Reduce or quit smoking.

Fibrous foods: Fibrous meals help reduce acid reflux because they make you feel full, making you less prone to overeat, which can lead to heartburn. So, fill up on fiber-rich meals like these:

Whole grains including brown rice, couscous, and oats.
Root veggies like beets, carrots, and sweet potatoes.
Leafy green veggies including green beans, broccoli.

Alkaline and watery foods: Higher pH meals are alkaline and can help counteract severe stomach acid. Bananas, melons, cauliflower, fennel, and nuts are among the foods that are alkaline. Foods with a high-water content might weaken and dilute gastric acid. These include celery, cucumber, lettuce, watermelon, soups made with broth, and herbal tea.

Milk: Milk is frequently recommended as a remedy for heartburn, but you must remember that there are various types of milk, including whole milk with all of the fat, 2% fat, and skim or nonfat milk. Milk fat might make acid reflux symptoms worse. Nonfat milk, however, can temporarily buffer the stomach lining from the stomach's acidic contents and offer quick relief from heartburn symptoms. The same calming effects of low-fat yoghurt are also present, along with a healthy serving of probiotics (beneficial bacteria that improve digestion).

Ginger: Due to its therapeutic qualities, ginger is one of the greatest foods to help with digestion. Its natural alkalinity and anti-inflammatory properties reduce digestive system inflammation. If you start to have heartburn, try drinking some ginger tea.

Apple cider vinegar: Even though there isn't enough evidence to support it, many individuals believe that consuming apple cider vinegar reduces acid reflux. However, because it contains a potent acid that might irritate the esophagus, you shouldn't ever drink it at full concentration. Instead, mix a little bit with warm water and consume it together with meals.

Lemon juice with water: Lemon juice is typically thought of as being quite acidic, but when combined with warm water and honey, it has an alkalizing effect that balances stomach acid. Additionally, honey contains organic antioxidants that safeguard cells' health.

Medical therapy:

Your doctor might recommend certain drugs if dietary and lifestyle modifications are ineffective. There are two types of reflux medications. One lowers your stomach's acidity, and the other raises the motility (movement) of your upper gastrointestinal system.

Prokinetic agents: Prokinetic agents are medications that increase the smooth muscle action in your digestive tract. These meds don't work as well as other acid-suppressing treatments do. They might be prescribed by your doctor along with an acid-suppressing medication.
Antacids: For sporadic and infrequent symptoms of reflux, over-the-counter antacids are recommended. Antacids may aggravate the condition if used regularly. They leave the stomach rapidly, causing your stomach to produce more acid as a result. Antacids function by neutralizing gastric acid. They contain calcium carbonate and may offer immediate relief. However, antacids alone will not repair an injured esophagus caused by stomach acid. Overuse of some antacids might result in adverse effects such as diarrhea or, in rare cases, renal issues.
Histamine blockers: Histamine 2 (H2) blockers are medications that aid in reducing acid secretion; they don't work as rapidly as antacids, but they last longer and may reduce stomach acid output for up to 12 hours. About 50% of individuals with esophageal erosions respond well to H2 blockers.
Proton pump inhibitors (PPIs): They cure the esophagus by blocking the three primary acid producing routes. They are more effective acid blockers than H-2 blockers and provide injured esophageal tissue time to repair. PPIs are far more effective than H2 blockers at suppressing acid production. PPIs help many patients, including those with significant esophageal injury, recover from erosive esophagitis.

Surgical therapy:

You might be a candidate for surgery if your symptoms did not get better after making adjustments to your lifestyle or taking medications. Some individuals would rather have surgery than take drugs for the rest of their lives. Strengthening the anti-reflux barrier is the aim of surgery for reflux disease.

Fundoplication: To tighten the muscle and prevent reflux, the surgeon wraps the top of your stomach over the lower esophageal sphincter. A minimally invasive (laparoscopic) method is typically used for fundoplication. The upper section of the stomach might be wrapped completely (Nissen fundoplication) or partially. The Toupet fundoplication is the most common partial operation. Your surgeon will recommend the best kind for you.

LINX device: Around the point where the stomach and esophagus converge, a ring of tiny magnetic beads is coiled. While being weak enough to let food flow through, the magnetic attraction between the beads is strong enough to keep the junction closed to refluxing acid. A less invasive surgical procedure can be used to implant the LINX device. Magnetic resonance imaging (MRI) and airport security are unaffected by the magnetic beads.

Transoral incisionless fundoplication (TIF): With this new technique, the lower esophagus is partially wrapped using polypropylene fasteners to tighten the lower esophageal sphincter. There is no surgical incision necessary for TIF because it is done through the mouth using an endoscope. Its benefits include high tolerance and speedy recovery. TIF alone is not a viable choice if you have a significant hiatal hernia. But if TIF is paired with laparoscopic hiatal hernia surgery, it might be feasible.

Conclusion

Gastroesophageal reflux disease, often known as GERD, is a digestive ailment that affects the muscular ring between your esophagus and stomach. The lower esophageal sphincter (LES) is the name given to this ring. You may get heartburn or acid indigestion if you have it. In most cases, food and lifestyle adjustments help alleviate GERD symptoms. However, some people may require medications or surgery.

The most common GERD symptom is heartburn (acid indigestion). It usually feels like a burning chest pain that starts beneath your breastbone and spreads up to your neck and throat. Many people claim to have an acidic or bitter taste in their mouths, as if food is returning. Heartburn symptoms like burning, pressure, or discomfort might linger for up to two hours. It usually becomes worse after eating. Furthermore, laying down or bending over might exacerbate heartburn. Many people feel better if they stand up straight or take an antacid that clears acid from their esophagus.

Sometimes, GERD causes serious complications like esophageal ulcers that can make swallowing difficult, esophageal strictures that narrow the esophagus, and Barrett's esophagus, which is characterized by changes in the cells in the tissue lining your esophagus and is associated with an increased risk of esophageal cancer.

The severity of symptoms, the presence of esophagitis, and the success of initial therapy all play a major role in how gastroesophageal reflux disease (GERD) is managed. Antacids or over-the-counter H2 receptor antagonists should be advised to individuals with mild to moderate symptoms, along with lifestyle changes. In individuals with moderate to severe esophagitis or GERD-related problems, a proton pump inhibitor should be the cornerstone of treatment. Patients with delayed stomach emptying may benefit from combination therapy with a prokinetic drug.