Gastroesophageal reflux disease (GERD) is the most common gastrointestinal disorder in the United States occurring monthly, weekly and daily in 45%, 25% and 7% of the population, respectively. Gastroesophageal reflux occurs when the contents of the stomach back up into the esophagus and throat. GERD occurs when individuals with reflux (when stomach contents rise up into the esophagus) develop symptoms or injury to the esophagus.
Common symptoms of GERD include heartburn and regurgitation of food into the esophagus and throat. Less common symptoms include upper abdominal pain, chronic cough, hoarseness, chest pain, sensation of a “ball” in the throat, asthma, sore throat, chronic sinus infections, vomiting and difficulty or painful swallowing. Worrisome signs and symptoms include unexplained weight loss, anemia, loss of appetite and bleeding (vomiting blood or tarry stools).
GERD is usually diagnosed based on symptoms and response to treatment. A trial of lifestyle changes and a short course of over-the-counter (OTC) medication is often recommended for individuals with mild symptoms of acid reflux with no evidence of complications. Further testing may be indicated when symptoms fail to improve, if the diagnosis is uncertain or if an individual develops worrisome signs and symptoms.
Endoscopy is commonly used to evaluate patients with GERD symptoms. After sedation is administered, a small flexible tube with a camera known as an endoscope is passed into the mouth, tubular esophagus, stomach and the first part of the small intestine. The image is projected onto a monitor permitting detailed visualization of the gastrointestinal tract’s surface. During the procedure, specimens of the lining of the intestinal tract can be obtained to determine the extent of damage and to establish the diagnosis of certain diseases such as infections or tumors. Specialized instruments passed through the endoscope during the procedure allow diagnostic evaluation and therapeutic intervention. Dedicated endoscopes, such as the endoscopic ultrasound, permit the physician to determine the extent of tumor involvement and, in the case of early detection, perform complete endoscopic removal.
A 48-hour esophageal pH study is the most direct way to confirm the diagnosis of acid reflux. The test involves placement of a small capsule in the esophagus at the time of endoscopy. This capsule contains a pH-sensor which measures esophageal acid exposure during a 48-hour period that can be analyzed to confirm or exclude the diagnosis of acid reflux when the diagnosis of acid reflux is unclear.
Esophageal manometry involves swallowing a small tube that measures esophageal muscle contractions. This procedure can identify abnormal motility patterns of the esophagus and determine if the lower esophageal sphincter, which acts as a barrier to acid reflux, is functioning properly. In a similar manner, esophageal impedance is a procedure that can help determine if non-acid reflux may be responsible for the patient’s symptoms.
Complications of acid reflux include ulcers, strictures, lung disease, throat problems, and the precancerous condition know as Barrett’s esophagus. Barrett’s esophagus is found in 10% of patients with GERD. Periodic endoscopy is performed to monitor patients with Barrett’s esophagus. The most feared complication of GERD is the development of esophageal cancer, often seen in patients with underlying Barrett’s esophagus.
Treatment consists of lifestyle modifications such as weight loss, elevating the head of the bed, cessation of smoking, replacing tight clothing, eliminating foods which induce reflux, and also avoiding large, fatty and late meals. Many patients may require over-the-counter antacids such as Maalox, Mylanta and Tums, while others may obtain relief with drugs which decrease acid production known as histamine-2 receptor antagonists such as ranitidine (Zantac), famotidine (Pepcid), nizatidine (Axid) and cimetidine (Tagamet). The more effective acid decreasing medications know as Proton Pump inhibitors (PPI) include omeprazole (Prilosec, Zegerid), lanzoprazole (Prevacid), rabeprazole (Aciphex), pantaprazole (Protonix), esomeprazole (Nexium) and dexlanzoprazole (Dexilant). Some of the PPI formulations are available over-the-counter and are most effective if taken 30-60 minutes before breakfast.
Surgery is reserved for the rare patient who may not be able to take medications or has developed significant regurgitation despite lifestyle modifications. The most commonly performed procedure is the Nissen fundoplication. Although effective in a select group of patients, this procedure is associated with troublesome and often non-reversible post-operative symptoms such as abdominal bloating and gas, early satiety, diarrhea as well as surgical complications. In some studies, up to 65% of patients continue to require further acid reducing therapy despite successful surgery. Newer endoscopic approaches to the management of GERD are being developed for this group of patients.