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Patient Education Topics
What is GERD?
GERD stands for Gastroesophageal Reflux Disease. Gastroesophageal reflux
describes a backflow of acid from the stomach into the swallowing tube
or esophagus. Almost everyone experiences gastroesophageal reflux at some
time and the usual symptom is heartburn, an uncomfortable burning sensation
behind the breastbone, most commonly occuring after a meal. In some individuals
this reflux is frequent or severe enough to cause more significant problems,
that is a disease. Thus gastroesophageal reflux disease is a clinical condition
that occurs when reflux of stomach acid into the esophagus is severe enough
to impact the patient's life and/or damage the esophagus.
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Epidemiology
The disease, also termed "reflux", "reflux esophagitis", and sometimes
unappropriately "hiatus hernia" currently afflicts 7 millon people in the
US, and has no predilection for socioeconomic class or ethnic group. While
individuals of any age may present with the condition, its incidence has
been shown to increase quite dramatically above the age of 40. Greater
than 50% of afflicted individuals are between the ages of 45-64.
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Symptoms
Heartburn (uncomfortable, rising, burning sensation behind the breastbone)
is the most common symptom of GERD. In some patients it may be accompanied
by regurgitation of gastric acid or sour contents into the mouth, difficult
and/or painful swallowing and chest pain. Pulmonary manifestations, such
as asthma, coughing, or intermittent wheezing and vocal cord inflammation
with hoarseness occur in some GERD patients. In addition, acid refluxed
into the throat can cause a sore throat, and if acid reaches the mouth,
it can dissolve tooth enamel.
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Causes
GERD is caused by reflux of stomach acid into the esophagus. In most patients
(>80%), this is due to transient relaxation of the "gate" or sphincter
that keeps the lower end of the esophagus closed (LES - lower esophageal
sphincter) when a person is not swallowing food or liquids. This transient
relaxation happens a few times each day in people without GERD, but at
a much greater frequency in afflicted individuals. The esophagus is not
able to cope with acid as well as the stomach and is easily injured. It's
the acid refluxing into the esophagus that produces the symptoms and potentially
damages its lining.
Dietary and lifestyle choices may also contribute to GERD. Certain foods
and beverages, including chocolate, peppermint, fried or fatty foods, coffee,
or alcoholic beverages may weaken the LES causing reflux and heartburn.
Studies have equally shown that smoking relaxes the LES, causing further
symptomatic exacerbations. A constantly weak, low-pressure LES allos reflux
every time the pressure in the stomach in greater. In conjunction,
if there is delay in emptying of the stomach, the gastric fluid volume
is increased, which makes for a greater amount of fluid available for reflux.
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How is it Diagnosed?
The diagnosis of GERD is made through a multifaceted approach. In part,
the presenting symptoms, as well as similar symptoms in the
past, association with meals and a sensation of fullness, risk factors(which
are mentioned above), and a qualifiable chronicity to the affliction help
in setting the diagnosis.
Laboratory/imaging studies allow the doctor corroborate his primary
diagnosis.
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Endoscopy, is a diagnostic test wherein a tin, flexible tube
is swallowed by the patient to allow the physician to directly inspect
the lining of the espphagus/stomach. This procedure can be used to identify
complication of GERD and to take small samples (biopsies) for further analysis.
GERD patients who have difficult/painful swallowing should be considered
for endoscopy, as should patients who fail to respond to therapy.
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An upper GI series may be performed during the early phase
of testing. This test is a special X-ray that shows the esophagus, stomach
and duodenum (the upper part of the small intestine). It allows to rule
out other diagnoses such as peptic ulcer disease.
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Monitoring of acid levels in the esophagus is also a very
sensitive diagnostic method, and is performed by placing a thin flexible
tube within the esophagus on a constant basis, to measure changes in acid
levels as they relate to activities of daily living.
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The Bernstein test(dripping a mild acid through a tube placed
in the mid-esophagus) is often performed as part of a complete evaluation.
This test attempts to confirm that symptoms result from acid in the esophagus.
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Esophageal manometric studies- pressure measurements of the
esophagus- occasionally help identify critically low pressure in the LES
or abnormalities in esopahgeal muscle contraction.
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Treatment/Lifestyle Modifications
Treatment of GERD aims at decreasing the amount of reflux or reducing the
damage to the lining of the esophagus from refluxed materials.
Avoiding foods and beverages that can weaken the LES is recommended.
These foods, as mentioned above, include chocolate, peppermint, fatty foods,
coffee, and alcoholic beverages. Foods and beverages that can irritate
a damaged esophageal lining, such as citrus fruits and juices, tomato products,
and pepper, should also be avoided.
Decreasing the size of portions at mealtime, eating meals at
least 2-3 hours priors to bedtime, as well as weight loss, in the case
of overweight individuals has been shown to have beneficial effects. Smoking
cessation is important for reduction of symptoms, as is elevation of the
head of the bed to minimize reflux of stomach contents into the esophagus.
Antacids taken regularly can neutralize acid inthe esophagus
and stomach and stop heartburn.
Medications to reduce acid production in the stomach may be prescribed,
and have been shown to have beneficial effects for patients suffering of
chronic reflux.
A small number of people with GERD may need surgery because of
severe reflux and poor response to medical treatment. Fundoplication is
a surgical procedure that increases pressure in the lower esophagus. However,
surgery should not be considered until all other avenues have been tried.
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Side effects of Treatment
Long term use of anatcids can result in diarrhea, altered
calcium metabolism (a change in the way the body breaks down and uses calcium),
and buildup of magnesium in the body, which can be hazardous in patients
with kidney disease. If needed for greater than 3 weeks, a doctor should
be consulted.
Fundoplication surgery may subsequently cause repair-related
dysphagia or difficulties with eructation, but the above may occur in <1%
of the population.
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Complications
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Sometimes GERD may cause further complications.
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Esophagitis may occur secondary to increased acid refluxate in the
esophagus, and may lead to esophageal bleeding or ulcers.
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Equally, a narrowing or stricture of the esophagus may occur from
chronic scarring, which can further lead to the development of a condition
known as Barrett's esophagus.
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Barrett's esophagus is characterized by severe damage/change to
the lining of the esophagus that may be a pecursor to esophageal cancer.
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Where Can I Find Out More?
The following are a few internet sites that may further enhance your knowledge
of the subject at hand.
Bibliography
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Andreoli, T. et al. Cecils Essentials of Medicine, 4th ED. 1997 283-285.
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Dent, J. et al. Mechanisms of lower esophageal sphincter incompetence in
patients with symptomatic gastroesophageal reflux. Gut. 1988 29:1020-1028
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Joelsson, B. et al Heartburn- the acid test. Gut. 19898 30:1523-1525
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Spiro, H. Clinical Gastroenterology, 4th ED New York : McGraw-Hill 1993