Acid reflux disease

ALSO KNOWN AS: Gastroesophageal reflux disease (GERD)

ANATOMY OR SYSTEM AFFECTED: Gastrointestinal system, mouth, stomach, throat

DEFINITION: A chronic digestive disorder in which the lower esophageal sphincter (LES), which keeps digestive juices in the stomach, relaxes and permits gastric acid to rise into the esophagus, causing a burning sensation.

CAUSES: Relaxation of the lower esophageal sphincter, allowing gastric acid into the esophagus; aggravated by some foods, alcohol, some medications, stress, certain positions, late-stage pregnancy

SYMPTOMS: Burning sensation in chest and throat

DURATION: Chronic, with acute episodes

TREATMENTS: Diet and lifestyle changes (smaller meals, avoidance of some foods, etc.), antacids, histamine blockers, acid-pump inhibitors, surgery

Causes and Symptoms

Approximately one-third of Americans experience heartburn at least once a month, and 10 percent experience the sensation daily. Heartburn reportedly affects sufferers during the day and at night, impacting their job performance as well as their sleep. Heartburn is the major symptom of acid reflux disease, also called gastroesophageal reflux disease (GERD). A burning sensation radiating up through the middle of the chest behind the sternum (breastbone) characterizes heartburn, which can be aggravated by a variety of foods; alcohol; emotions such as anger, fear, or stress; and even particular positions such as reclining, lifting, or bending forward. Abdominal exercises, girdles, and tight belts can increase abdominal pressure and trigger reflux. Many women experience heartburn during pregnancy, especially in the later stages. Overweight people and smokers are also commonly affected.

Common foods and beverages implicated in acid reflux disease include coffee, tea, cocoa, cola drinks, mints, chocolate, fried and fatty foods, onions, garlic, citrus fruits, tomato products, and spicy foods. This list is not exhaustive, and certain people may be troubled by substances not included. Medications can exacerbate heartburn and reflux, including, but not limited to, oral contraceptives; aspirin; medications used to treat asthma, rheumatoid arthritis, and osteoporosis; antidepressants; and tranquilizers. Additionally, medical conditions such as asthma, diabetes, peptic ulcers, and some cancers may contribute to acid reflux disease, as can treatments such as chemotherapy or narcotic use for pain management.

The lower esophageal sphincter (LES), which connects the esophagus to the stomach, acts as a barrier to protect the esophagus from the backflow of acid from the stomach. Normally, it works like a dam, opening to allow food to pass into the stomach and closing to prevent food and acid from flowing back into the esophagus. If the sphincter weakens or relaxes, the contents of the stomach flow up into the esophagus. The reason for this occurrence is uncertain, but it is known that sphincter function can be impaired by diet, medications, and nervous system factors. Other factors that can also contribute to acid reflux disease include impaired stomach motility or an inability of the stomach muscles to contract normally, resulting in a delayed emptying of the contents. The acid remains at the top of the stomach near the LES rather than moving downward, creating pressure and reflux. Failure of contractions to clear the acid or a shortage of saliva to neutralize the acid may also contribute to heartburn.

Hiatal hernia, a condition in which a portion of the stomach protrudes into the chest cavity through an opening (hiatus) in the diaphragm (the muscle separating the chest and abdomen), exists to some degree in about 30 percent of Americans. In cases of hiatal hernias so large that they risk strangulation (becoming twisted and cutting off blood supply), complicated by severe GERD or esophagitis, surgery may be performed. Otherwise, medication in the form of a histamine blocker, which suppresses the secretion of stomach acids, is used.

Treatment and Therapy

Medical tests often used to evaluate the presence and severity of acid reflux disease include barium studies and upper endoscopy. Other tests performed less frequently include pH monitoring (to measure reflux over a twenty-four-hour period), the Bernstein test, and esophageal manometry. In the Bernstein test, which is used to evaluate the cause of chest pain after heart problems have been ruled out, saline and diluted hydrochloric acid are infused into the esophagus. If this reproduces the patient’s symptoms, it can be inferred that reflux is the cause. Esophageal manometry measures pressure in the esophagus and LES.

Counseling patients to modify their diet and lifestyle is the basic treatment for reflux symptoms. Generally, patients should eat smaller meals more often and more slowly, avoiding spicy foods and those that increase acid production. They should not have bedtime snacks. Patients should relax both while eating and between meals. They should remain upright after eating and should not bend, strain, or lift for the following three hours. Those who are overweight should lose excess pounds, and patients should not smoke or chew gum. They should exercise on an empty stomach and avoid tight, constricting clothing, which may put pressure on the stomach. Patients with GERD should elevate the head of their beds by placing blocks under the beds’ legs.

Over-the-counter antacids (Tums, Rolaids, and Mylanta, for example) can be effective in reducing or neutralizing acid in mild cases of heartburn. In chronic cases, however, histamine blockers may be prescribed. These medications act directly on the acid-secreting cells in the stomach to stop them from producing hydrochloric acid that can wash into the esophagus. Several of these medications (Tagamet, Zantac, and Pepcid) are available over the counter. Prokinetics or gastrokinetics are a group of medications that increase the speed at which the stomach empties food, acid, and fluids. In severe cases of GERD, they may be used instead of histamine blockers. Another class of medication is the proton-pump inhibitor or acid-pump inhibitor, which suppresses acid secretion in the stomach by inactivating the enzyme responsible for acid release in the stomach. These medications include Prevacid, Aciphex, Protonix, Nexium, and Prilosec (the latter is available over the counter). Additionally, chamomile, ginger, licorice, catnip, papaya, pineapple, marshmallow root, and fennel have all been said to aid in digestion.

Approximately 95 percent of GERD cases are controlled by medication; the remainder require surgery (fundoplication) to tighten the LES. Another technique is radiofrequency ablation, which applies controlled radiofrequency energy to the LES and upper part of the stomach, causing the lining to expand slightly as the valve tightens. The Bard endoscopic suturing system places stitches on either side of the sphincter; as the physician ties the sutures together, the valve tightens.

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