Introduction
Gastroesophageal reflux disease (GERD) occurs due to gastric acid refluxing back up the esophagus (food pipe). It is commonly observed in individuals with irregular food habits. It causes acid reflux, which may result in tooth erosion and a burning sensation in the esophageal tract.
What Are the Symptoms?
Heartburn, chest pain, or upper abdomen pain is more pronounced when lying with a full stomach.
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Coughing and choking.
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Hoarseness of voice.
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A shortness of breath or asthma-like symptoms.
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Back pain.
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Persistent vomiting, difficulty and pain during swallowing, weight loss, and dark stools.
What Are the Risk Factors?
Several factors can heighten the risk of gastroesophageal reflux disease (GERD). These include:
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Obesity: Carrying excess weight can increase the likelihood of experiencing GERD.
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Hiatal Hernia: A condition where the top of the stomach protrudes above the diaphragm, which can contribute to GERD.
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Pregnancy: The changes in the body during pregnancy, particularly the pressure on the abdomen, can lead to an increased risk of GERD.
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Connective Tissue Disorders: Conditions like scleroderma, which affect the connective tissues, may contribute to GERD.
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Delayed Stomach Emptying: When the stomach takes longer to empty, acid reflux can increase.
Several factors can exacerbate acid reflux symptoms:
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Smoking: Tobacco smoke can irritate the digestive system and worsen GERD symptoms.
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Large or Late Meals: Eating substantial meals, especially late at night, can trigger or worsen acid reflux.
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Certain Foods (Triggers): Foods high in fat or fried can trigger GERD symptoms.
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Certain Beverages: Alcohol and coffee can potentially relax the lower esophageal sphincter, which may lead to the backward flow of stomach acid into the esophagus.
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Certain Medications: Some medications, such as Aspirin, can contribute to GERD symptoms by irritating the esophagus.
How to Diagnose GERD?
Diagnosing GERD involves a comprehensive physical examination and a discussion of symptoms and medical history. The diagnostic procedure includes:
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Upper Endoscopy: This is a procedure where a flexible tube is inserted through the mouth to check the esophagus, stomach, and the start of the small intestine. It helps diagnose issues like esophagitis, Barrett's esophagus, and esophageal stricture while ruling out other serious conditions that may mimic GERD.
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Reflux Testing: It measures reflux activity over 48 hours. Wireless pH testing involves a small chip in the lower esophagus recording acid levels transmitted to a device worn around the belt. 24-Hour pH Impedance, using a catheter through the nose, monitors pH levels for 24 hours to assess reflux severity.
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Esophageal Manometry: The test evaluates the lower esophageal sphincter's contractions, strength, and relaxation function.
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It helps rule out conditions mimicking GERD and is necessary before anti-reflux surgery.
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Barium Esophagogram: This X-ray study involves swallowing barium to coat the esophagus. It helps detect abnormalities, checks for esophageal narrowing (stricture) and evaluates motor function, though it doesn't directly test for reflux.
What Is the Treatment?
The management of GERD includes a combination of medications as well as diet and lifestyle modifications. It includes:
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Avoid spicy, fatty, fried foods, chocolates, and carbonated drinks.
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Avoid citrus-containing foods like tomatoes, oranges, and fruit juices.
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Eat multiple small portions of food rather than three large meals.
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Limit caffeine intake.
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Have dinner at least two hours before bedtime so the stomach is light before bed.
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Elevate the head end of the bed by placing wooden blocks under the bedpost. Using extra pillows will not provide relief.
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Avoid cigarette smoking and alcohol consumption.
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Maintain a healthy weight. Medications that will help are antacids. They neutralize the stomach acid. H2 blockers block the action of histamine in the stomach cells, and proton pump inhibitors decrease stomach acid production.
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Endoscopic, laparoscopic, or open surgical procedures are indicated for GERD if it does not respond to treatment or in the case of severe erosive esophagitis, Barrett's esophagus, esophageal adenocarcinoma or associated hiatal hernia.
Can GERD Be Cured?
Gastroesophageal reflux disease can be cured. The primary treatment involves medications that reduce stomach acid levels. Additionally, lifestyle changes play a key role in managing the disease. If lifestyle adjustments are insufficient, healthcare professionals may consider surgery a treatment option.
Why Is Endoscopy Needed?
GERD is diagnosed with the patient's symptoms and the positive response to treatment. An endoscopic evaluation is not necessary unless in the following situations:
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Symptoms that are persistent or progressive despite appropriate medical therapy.
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Dysphagia (difficulty in swallowing), odynophagia (pain during swallowing), persistent vomiting.
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Unintentional weight loss.
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The evidence of gastrointestinal bleeding is like black discoloration of stool or hematemesis (vomiting of blood).
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Symptoms of anemia include dizziness, fatigue, palpitations, etc.
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Screening for Barrett’s esophagus in high-risk patients. White men above 50 years of age, a positive family history of Barrett’s esophagus or esophageal adenocarcinoma, prolonged reflux symptoms (persisting for five years or more), persons with a smoking habit, and obesity.
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PH monitoring and manometric studies confirm the diagnosis when an adequate response is not obtained from the treatment.
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Before doing an anti-reflux surgery.
What Are the Complications of GERD?
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Erosive Esophagitis: Inflammation and erosion of the esophageal epithelium due to acid damage. Appropriate management of GERD can prevent the development and progression of erosive esophagitis.
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Esophageal Stricture: Strictures are caused by scar formation during the healing process of erosive esophagitis. Such strictures cause a block in the esophagus, resulting in difficulty swallowing, pain during eating, and persistent vomiting. It is treated with endoscopic dilation of the stricture.
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Barrett's Esophagus: Barrett's esophagus is the change of esophageal epithelium from a stratified squamous type to the columnar epithelium type with epithelial cells. This change in epithelium occurs due to acid damage. When dysplastic or precancerous changes occur in Barrett's esophagus, it acts as a precursor for esophageal cancer (adenocarcinoma). GERD patients with risk factors for Barrett's esophagus will require an endoscopy and biopsy to assess the degree of damage and change in the epithelium and the presence of dysplastic cells, which are precursors for adenocarcinoma. Depending on the endoscopy and biopsy findings, further management is by either serial endoscopic surveillance, endoscopic ablation with laser, radio frequency, or cryotherapy. An endoscopic mucosal resection or surgical resection is done if found to be positive for cancer cells.
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Esophageal Adenocarcinoma - Dysplastic changes occurring in Barrett's esophagus are a precursor for adenocarcinoma development. So, it is essential to appropriately manage GERD, prevent the development of Barrett's esophagus, and carry out an endoscopic evaluation and surveillance in high-risk patients.
Conclusion
GERD is the reflexing back of gastric content, commonly seen in individuals with irregular eating habits. Maintaining a good diet and eating pattern will help manage the condition. Early diagnosis can aid with better treatment. Avoiding certain foods that trigger acid reflux and maintaining a proper schedule to eat on time can help prevent the recurrence of this condition.