GERD (Acid Reflux , Heartburn)

What is GERD or acid reflux?

Gastroesophageal reflux disease, commonly referred to as GERD or acid reflux, is a condition in which the liquid content of the stomach regurgitates (backs up or refluxes) into the esophagus .

The liquid can inflame and damage the lining (esophagitis) although visible signs of inflammation occur in a minority of patients.

The regurgitated liquid usually contains acid and pepsin that are produced by the stomach.

Pepsin is an enzyme that begins the digestion of proteins in the stomach. The refluxed liquid also may contain bile that has backed-up into the stomach from the duodenum. The first part of the small intestine attached to the stomach. Acid is believed to be the most injurious component of the refluxed liquid. Pepsin and bile also may injure the esophagus , but their role in the production of esophageal inflammation and damage is not as the role of acid.

GERD is a chronic condition , once it begins it usually is life long. If there is injury to the lining of the esophagus (esophagitis) , this is also a  chronic condition.

Moreover , after the esophagus has healed with treatment and treatment is stopped , the injury will return in most patients within a few months.

Once treatment of GERD is begun it will need to be continued indefinitely although. However , some patients with intermittent symptoms and no esophagitis can be treated only during symptomatic periods.

In fact, reflux of the stomach's liquid contents into the esophagus occurs in most individuals as in patients with GERD, however the refluxed liquid contains acid more often and the acid remains in the esophagus longer. It has also been found that liquid refluxes to a higher level in the esophagus in patients with GERD than normal individuals.

As is often the case , the body has ways to protect itself from the harmful effects of reflux and acid. 

For example, most reflux occurs during the day when individuals are upright. In the upright position , the refluxed liquid is more likely to flow back down into the stomach due to the effect of gravity.

In addition while individuals are awake they repeatedly swallow , whether or not there is reflux. Each swallow carries any refluxed liquid back in to the stomach. Finally the salivary glands in the mouth produce saliva , which contains bicarbonate. With each swallow , bicarbonate containing saliva travels down the esophagus . 

The bicarbonate neutaralizes the small amount of acid that remains in the esophagus after gravity and swallowing have removed most of the acidic liquid.

At night , during sleep  gravity has no effect , swallowing stops and the secretion of saliva is reduced. Therefore , reflux that occurs at night is more likely to result in acid remaining in the esophagus longer and causing greater damage to the esophagus.

GERD can be serious problem during pregnancy. The elevated hormone levels of pregnancy probably cause reflux by lowering the pressure in the lower esophageal sphincter . At the same time , the growing fetus increases the pressure in the abdomen. Both of these effects would be expected to increase reflux. Also patients with diseases that weaken the esophageal muscles, such as scleroderma or mixed connective tissue diseases are more prone to develop GERD.

What causes GERD(Acid Reflux) ?

The cause of GERD is complex and may involve multiple causes. Moreover , different causes may affect different individuals or even in the same individual at different times.

A small number of patients with GERD produce abnormally large amounts of acid , but this is uncommon and not a contributing factor in the vast majority of patients.

The factors that contribute to GERD are : 

• Lower esophageal  sphincter abnormalities 
• Hiatal hernias
• Abnormal esophageal contractions 
• Slow or prolonged emptying of the stomach

What are the symptoms of uncomplicated GERD? 

The symptoms of uncomplicated GERD are primarily :

• Heartburn (sometimes interpreted as chest pain)
• Regurgitation 
• Nausea

What are the complications of GERD?

• Ulcers
• Strictures
• Barrett's esophagus
• Cough and Asthma
• Inflammation of the throat and larynx
• Inflammation and infection of the lungs
• Fluid in the sinuses and middle ears

How is GERD or Acid reflux diagnosed and evaluated?

There are a variety of procedures , tests, and evaluation of symptoms (e.g. heartburn) to diagnose and evaluate patients with GERD.

• Endoscopy : Upper gastrointestinal endoscopy is a common way of diagnosing GERD.
• Biopsies: They are useful in diagnosing cancers or cause of esophageal inflammation other than acid reflux , particulary infections.
• X-rays : X-ray of the esophagus can also diagnose GERD.
• Examination of the throat and larynx.

GERD(Acid reflux) tests : 

• Esophageal acid testing 
• Esophageal motility testing
• Gastric emptying studies
• Acid perfusion test

How is GERD (Acid reflux) treated : 

One of the simplest treatments for GERD is referred to as life style changes , a combination of several changes in habit, particularly related to eating.

Reflux is worse following meals. This probably is so because the stomach is distended with food at that time and transient relaxations of the lower esophageal sphincter are more frequent. Therefore smaller and earlier evening meals may reduce the amount of reflux for two reasons.

First, the smaller meal result in lesser distension of the stomach . 

 Second, by bedtime , a smaller and earlier meal is more likely to have emptied from the stomach than is a larger one. As a result , reflux is less likely to occur when patients with GERD lie down to sleep.

Ceratin foods are known to reduce the pressure in the lower esophageal sphincter and thereby promote reflux.

These foods should be avoided and include :

• Chocolate
• Peppermint
• Alcohol
• Caffeinated drinks.

Fatty foods (which should be decreased) and smoking (which should be stopped) also reduce the pressure in the sphincter and promote reflux.

In addition , patients with GERD may find that other foods aggravate their symptoms. Examples are spicy or acid-containing foods, like citrus juices , carbonated beverages and tomato juices. 

Theses foods should also be avoided if they provoke symptoms.

One novel approach to the treatment of GERD is chewing gum . Chewing gum stimulates the production of more bicarbonate -containing saliva and increase the rate of swallowing. 

After the saliva is swallowed it neutralizes acid in esophagus.

GERD Medications : 

• Antacids : It neutralize the acid in the stomach so that there is no acid to reflux.
• Histamine Antagonists : They work by blocking the receptor for histamine and thereby preventing histamine from stimulating the acid producing cells.
• Proton pump inhibitors : A PPI blocks the secretion of acid into the stomach by acid secreting cells.
• Pro-motility drugs : It works by stimulating the muscles of the gastrointestinal tract, including the esophagus , stomach , small intestine and colon.
• Foam barriers.