Pulmonary - Critical Care Associates
of East Texas

Jeffrey M. Shea, M.D., F.C.C.P.
                              Catherine M. Martinez, M.D.

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Gastroesophageal Reflux Disease (GERD)

Introduction

Gastroesophageal reflux disease (GERD) is a very common problem. It is the condition where stomach contents regurgitate back up into the esophagus (the tube that transports food from the mouth to the stomach). Normally the partially digested food leaves the stomach and moves down into the small intestine. In patients with GERD, the partially digested food moves from the stomach backward into the esophagus. The acid juices occasionally reach the breathing passages, causing inflammation and damage to the esophagus with symptoms of heart burn, chest pain, and difficulty swallowing as well as to the lung and voice box, causing hoarseness, dental erosion, coughing, asthma, and sometimes pneumonia and scarring in the lungs.

What Factors Contribute to GERD?

Factors contributing to GERD include fatty foods, cigarettes, alcohol, chocolate, and caffeine which can relax the lower esophageal sphincter muscles, increasing reflux. Obesity and pregnancy increase pressures within the abdomen, pushing the stomach contents into the esophagus. Some patients have "lazy stomachs" that empty contents into the intestines very slowly. A stomach full of food and acid is more prone to reflux, especially when the person lies flat.

Symptoms of GERD

Symptoms of gastresophageal reflux include heartburn, regurgitation with a sour taste, chest pain, difficulty swallowing (dysphagia), hoarseness, and dental diseases. Rarely, bleeding from an esophageal ulcer can cause vomiting of blood. GERD is also increasingly recognized as one of the factors aggravating breathing in asthma patients, and as a cause of a chronic cough, even in those who have no other symptoms.

Night time choking or wheezing can result from the stomach contents entering the lungs, a process called aspiration, which in severe cases, can lead to scarring in the lungs. In some patients with asthma, the symptoms of wheezing and shortness of breath are aggravated by reflux. Adequate treatment of reflux in these persons can significantly improve their asthma symptoms.

Complications

Complications occur when GERD is severe or long-standing. Constant irritation of the esophagus by stomach acid can lead to inflammation, ulcers, and bleeding. Anemia or low blood count may develop. Over time, scarring and narrowing of the esophagus can also develop, making it difficult to swallow foods and liquids. This narrowing is called a stricture.

Diagnosing GERD

The diagnosis of GERD is usually suggested by the patient's symptoms. Tests to confirm GERD include:

  • Upper GastroIntestinal study (UGI) is a test wherein the patient drinks barium which can be seen with x-rays. Reflux of barium into the esophagus can suggest the presence of GERD. Changes in the shape of the esophagus can also suggest the presence of inflammation. Overall, this x-ray test has a low sensitivity for detecting GERD, and other tests may be needed.
  • pH probe study is a more specific measure of reflux and is considered the "Gold Standard" for diagnosing GERD. The pH probe is capable of measuring acid. This probe is placed through the mouth into the esophagus. It can measure the frequency, severity, and duration of acid reflux by detecting changes in the acid content of the esophagus.
  • Endoscopy involves inserting a flexible tube through the mouth into the esophagus, allowing direct visualization. Signs of GERD include redness or ulceration of the esophageal lining. Small tissue samples (biopsies) can be obtained during endoscopy to confirm the diagnosis of esophageal inflammation.

Treating GERD

Treatment of GERD involves 1) changes in life style and diet, 2) weight reduction, and 3) medications.

  • Lifestyle and dietary changes : Reflux is more likely to occur when lying flat. Raising the head of the bed prevents stomach fluid from flowing back into the esophagus. Generally, raising the bed six to eight inches is recommended. Books or blocks under the legs of the bed or a wedge under the mattress can be used. Since stomachs full of food and acid are more likely to reflux, avoiding bedtime snacks and eating meals at least three to four hours before lying down can help reduce reflux.

Certain foods can increase reflux by causing relaxation of the lower esophageal sphincter (LES).

    Caffeinated beverages, carbonated drinks, cigarettes, alcohol, fatty foods, spicy foods, mints and

      chocolate can all aggravate LES incompetence and reflux symptoms.

      Obesity promotes reflux because of increased abdominal pressure. The increased abdominal pressure pushes the stomach contents into the esophagus.

Initial treatment consists of lifestyle changes, which often times is all that is needed to treat GERD. Patients with GERD should follow these recommendations:

    • Avoid eating anything within three hours before bedtime.
    • Stop smoking. Nicotine in the blood weakens the LES.
    • Avoid fatty foods, milk, chocolate, spearmint, peppermint, caffeine, citrus fruits and juices, tomato products, pepper seasoning, and alcohol -- especially red wine.
    • Decrease portions of food at mealtime, and avoid tight clothing or bending over after eating.
    • Review all medications with the physician. Certain drugs can weaken the LES, allowing acid irritation of the esophagus.
    • Elevate the head of the bed or mattress 6 to 8 inches. This helps to keep acid in the stomach by gravity when sleeping. Extra pillows by themselves are not very helpful.
    • Lose weight if overweight. This may relieve upward pressure on the stomach and LES.
  • Medications: When lifestyle and dietary changes fail, medications are prescribed. Although antacids are inexpensive and safe, they tend to give only short term relief and rarely control symptoms. Medications commonly used in the treatment of GERD include H2-antagonists, proton pump inhibitors, and prokinetic agents.

      a) H2-antagonists are drugs designed to block the action of histamine on the stomach cells, thus reducing stomach acid output. Cimetidine (TAGAMET), ranitidine (ZANTAC), famotidine (PEPCID), and nizatidine (AXID) are examples of H2-antagonists. These medications are generally effective and well tolerated. Side effects are rare.

      b) Proton pump inhibitors are stronger acid-reducing medications which include omeprazole (PRILOSEC) and lansoprazole (PREVACID)., which work by nearly completely shutting off all acid production by the stomach. These medications have the advantage of requiring only a single pill daily.

      c) Prokinetic medications work by increasing the pressure of the lower esophageal sphincter and promoting emptying of the stomach. Metachlopramide (REGLAN) was the first drug of this class. Side effects of REGLAN include insomnia, jittery nerves, and anxiety. Cisapride (PROPULCID) has recently been removed from the US market due to recent data showing an increased risk of heart rhythm abnormalities.

Summary

GERD is a common problem that requires medical attention when symptoms and tissue damage become troublesome. Treatment is available and, depending on the severity, requires little intervention such as lifestyle modification or medication. Respiratory symptoms of coughing, worsening asthma, or scaring of the lungs from recurrent aspiration can occur.

 
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