GERD / Heartburn /Regurgitation/Indigestion

What is GERD?
Gastroesophageal reflux disorder is reflux or regurgitation of acid content or bitter fluid from the stomach to the esophagus. Most common words used for GERD are heartburn, indigestion, acid reflux and acid regurgitation. It can affect individual’s quality of life so do not ignore if you are having this problem.

Symptoms of GERD
GERD presents with acid content or bitter taste in mouth usually after meals, on lying down or with bending, straining or heavy lifting. GERD often accompanied with other symptoms such as;
• Heartburn or burning sensation or heaviness around middle of the chest or upper abdomen
• Nausea
• Vomiting
• Halitosis or bad breath
• Difficulty in swallowing or pain during swallowing.
• Dry, long-lasting cough with sore throat.
• Wearing away of your teeth/erosion of enamel of your teeth.

Causes of GERD
GERD means acid content coming back up to the esophagus or food pipe. Actually when we swallow food it comes from esophagus to stomach. At the lower end of esophagus there is a band of muscles called as lower esophageal sphincter (LES) which plays an important role in preventing acid reflux from the stomach means it acts as a barrier between lower part of esophagus and stomach. When lower esophageal sphincter relaxes it allows food to enter in to the stomach and then it closes to prevent food particles and acidic content to flow back in to the esophagus, but if there is weakness in the muscles of lower esophageal sphincter it may relax at inappropriate time when actually it should not and causing stomach contents to rise up in to the esophagus. Factors like distention of the stomach, delayed emptying of the stomach, large sliding hiatal hernia, or too much acid in the stomach can also make it easier for acid reflux to occur.

Risk factors of GERD
1. Obesity – Increased weight may cause increase pressure on the abdomen and may causes relaxation of LES at inappropriate time.
2. Pregnancy – In pregnancy due to high progesterone level motility of entire gastrointestinal tract decreases and LES relaxation leads to acid regurgitation and heartburn.
3. Smoking – smoking and passive smoking also relaxes LES leads to acid regurgitation.
4. Certain medications- antihistamines, analgesics, antidepressants, Calcium channel blockers used to treat high BP, Asthma medications eg bronchodilators and theophylline, sedatives, antibiotics and estrogen replacements.
5. Sedentary lifestyle – People who work as sitting for long, do not do any physical activity and late night work or not sleeping in the night increases acid content of stomach.
6. Wrong dietary habits – Oily and spicy food, junk food, chocolates, peppermints and alcoholic beverages increases acid content of stomach and weakens LES.
7. Low gap between meal and sleep – Ideal time gap between meal and sleep (going to bed) should be at least 3 hours but reduced time gap or going to bed just after meal decreases digestion process and increases acid content of stomach.
8. Hiatus hernia – Hiatus hernia is a condition in which the opening in your diaphragm lets the upper part of the stomach move up into your chest, which lowers the pressure in the esophageal sphincter.

Even when the LES and the diaphragm are intact and functioning normally, reflux can still occur. The LES may relax after having large meals leading to distension of the upper part of the stomach. When that happens there is not enough pressure at the LES to prevent reflux. In some patients the LES is too weak or cannot mount enough pressure to prevent reflux during periods of increased pressure within the abdomen.

When you need to go to the doctor
If you are having acid reflux or heartburn twice in week for few weeks, accompanied by other symptoms like nausea, vomiting, abdominal pain, bad breath, chronic dry cough, sore throat then you should take an appointment with your doctor.

Diagnosis
1. Signs and symptoms, medical history, medication history, family history, lifestyle and dietary habits, and physical examination are important to diagnose GERD.

If patient has chronic heartburn, symptoms are not improving, trouble in swallowing then doctor can order few of these diagnostic tests and may refer the patient to gastroenterologist.

2. Ambulatory 24 hour acid pH probe test – It is a test to monitor the amount of acid in your esophagus. This is the most accurate procedure to detect acid reflux. A gastroenterologist performs this procedure at a hospital or in outpatient care as a part of an upper GI endoscopy. A thin tube with pH sensor passed through the patient’s nose or mouth in to the esophagus which measures how much and how many times stomach regurgitates acid, other part of tube is connected to the computer which records the pH readings. Monitoring is for 24 hours.

Bravo wireless esophageal pH monitoring – This is also for pH monitoring but in this the doctor temporarily attaches a small capsule to the wall of your esophagus during an upper endoscopy. The capsule measures pH levels in the esophagus and transmits information to a receiver. The receiver is about the size of a pager, which you wear on your belt or waistband. You can follow your usual daily routine during monitoring, which usually lasts 48 hours. The receiver has several buttons on it that you will press to record symptoms of GERD such as heartburn. The nurse will tell you what symptoms to record. You will be asked to maintain a diary to record certain events such as when you start and stop eating and drinking, when you lie down, and when you get back up. Before this procedure your doctor will ask to stop all GERD medications if you are taking any. After about 5 to 7 days capsule will fall off and pass through the stool.

3. Upper GI endoscopy and Biopsy –Procedure performed by surgeon or gastroenterologist in the hospital usually under sedation. Endoscope is a thin flexible tube fitted with camera to see inside the organs. Doctor carefully feeds the endoscope in to the upper gastrointestinal tract (esophagus, stomach and duodenum) to examine and if need to take small sample of tissue (biopsy) for further examination.

4. X-ray images of Upper GI – Upper GI series usually performed by X -ray technician at hospital or outpatient center. Patient is asked to drink barium to coat the inner lining of your upper GI tract. With help of barium (contrast) X-ray doctor can detect hiatal hernia, esophageal stricture, ulcers or any other problem.

5. Esophageal manometry – Esophageal manometry measures muscle contractions in your esophagus. A gastroenterologist may order this procedure if you’re thinking about anti-reflux surgery.

Treatment
Depending upon signs and symptoms doctor may recommend naturotherapy, pharmacotherapy or surgery.

Naturotherapy
1. Lifestyle change – If you have sedentary life style, change it and try to walk every day for 30 min and in the sitting job try to walk after each meal and after every 2 hours for 5-10 min.
2. Dietary habits – Avoid caffeine, avoid spicy, fatty and junk food and alcoholic beverages. Increase intake of fibers, fruits and fresh vegetables. Do not overeat. Healthy breakfast is must to prevent acid reflux.
3. Meal time – You should follow a strict pattern of meal time. Last meal of the day should be at or around 7 pm, so that you can have time gap between meal and sleep at least 3 hours. Do not go on the bed just after a meal.
4. Sleeping habits – Always try to go to bed around 9 pm- 10 pm and minimum 6 hours sleep is very important for healthy life. Sleep on a slight angle. Elevate the head of your bed 6 to 8 inches by safely putting blocks under the bedposts.
5. Quit smoking – smoking increases acid production and quitting smoking will prevent from cancer and many diseases.
6. Stop taking over the counter available analgesics and medicines which can increase acid production.
7. Weight loss- if you are overweight or obese try to loose your weight to prevent obesity related disorders.
8. Aloevera – Aloevera soothes the burn or inflammation, so drinking aloevera juice is beneficial in GERD.
9. Banana and apple are natural antacids.
10. Avoid tight-fitting clothes.
Follow healthy lifestyle and Health tips.

Pharmacotherapy
1. Antacids to relieve heartburn and other mild symptoms. Antacids are available over the counter are Maalox, Mylanta, Gelusil, Gaviscon, Rolaids and Tums, may provide quick relief. But antacids alone will not heal an inflamed esophagus damaged by stomach acid. Overuse of some antacids can cause side effects, such as diarrhea or constipation.
2. H2 blockers decrease acid production. H2 blockers are Ranitidine (Zantac 75), Cimetidine (Tagamat HB), Famotidine (Pepcid AC), Nizatidine (Axid AR).
3. PPIs(Proton pump Inhibitors) limit acid secretion in the stomach and resolution of the symptoms with healing of the esophagus. Over the counter available PPIs are Omeprazole (Prilosec),lansoprazole, pantoprazole(protonix), rabeprazole(Acip Hex), esomeprazole (Nexium)
4. Prokinetics help the emptying of stomach faster. On prescription metoclopramide(reglan), Bethanechol (Urecholine)

Surgery
Though most of the time GERD improved and relieved by medications but if symptoms are not improving with medications and lifestyle change, doctor may advice for surgery.

Fundoplication – For long-term reflux prevention Nissen fundoplication is the most common surgery. Surgeon perform this at the hospital under anesthesia by using laparoscope, which is a thin tube fitted with video camera. Fundoplication is a procedure to tightening the lower esophageal sphincter by wrapping the top of the stomach. Hospital stay usually 2-3 days. Return to normal daily activities in 2 weeks.

Using LINX – Linx is a ring-shaped magnetic titanium based device which is used to wrap around lower esophagus and top of stomach to tighten the lower esophageal sphincter. Because of the strong magnetic attraction between titanium beads in the ring it prevents opening during acid reflux.

Complications Of untreated GERD
Respiratory problems – Because of acid reflux in GERD sometimes during sleep acid can go in to the lungs which cause respiratory problems.
Dry and long-lasting cough or sore throat
Chest congestion or fluid in the lungs (Aspiration Pneumonia)
Hoarseness of voice
Wheezing
Laryngitis
Esophagitis – It is inflammation of esophagus because of destruction of normal esophageal lining by acid. If left untreated chronic esophagitis may be cancerous.
Esophageal stricture- In this esophagus becomes narrow.
Barrett’s esophagus – Untreated GERD may sometimes give rise to a serious condition like barrett’s esophagus which is cancerous.

Key point to remember
Heartburn due to GERD and chest pain due to angina (reduced blood supply to the heart) or heart attacks are similar. GERD related heartburn usually after heavy meal or spicy food and gets worse by bending or lying down. Chest pain or discomfort due to angina usually after exertion or emotional stress and not affected by changing in the positions and gets worse after physical activity and does not go away with rest.If you are not sure visit to the doctor without delay.

Please note: Any medical information published on this website is not intended as a substitute for informed medical advice and you should not take any action before consulting with a health care professional.

Source content – The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), International Foundation for Functional Gastrointestinal Disorders aboutgerd.org

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