GERD - a Systematic Approach

What Is Gastroesophageal Reflux Disease (GERD)?

Gastroesophageal reflux disease is a condition in which our food pipe called the esophagus is exposed to acid produced within the stomach. In normal circumstances, our stomach produces approximately 1 liter of acidic juice, which helps to digest food. In normal healthy individuals, this acid does not come in contact with the esophagus, because of the presence of a competent valve called lower esophageal sphincter. The lower esophageal sphincter is produced by a sling of muscle fibers wrapping the lower part of the esophagus at the junction stomach with the food pipe.

In patients with GERD, this sphincter or in other words this valve becomes loose and patent, allowing acidic juices from stomach to flow in retrograde direction to lower part of the food pipe, resulting in pain, heartburn, sore throat, sore taste of mouth, bad breath, cough, nausea, and vomiting in some patients.

Symptoms of Gastroesophageal Reflux Disease:

A large proportion of patients with GERD present with heartburn, chest pain, and regurgitation of acid into the mouth, altered taste in the mouth in the early morning after one wakes up from sleep, and some other non-specific symptoms such as cough, sore throat, and asthma.

A physician has to have a high level of suspicion to establish a diagnosis of GERD among individuals with chronic symptoms of cough, chest pain, sore throat, and asthma. Initially, this acid reflux could cause simple ulcers, which can respond to acid-suppressant medications, however in the long term, if acidic reflux is not controlled, it could narrow the lumen of the esophagus (peptic strictures) or result in Barrett's esophagus, which is a precancerous condition.

GERD and Barrett's Esophagus:

Barrett's esophagus is a precancerous condition, which means it has the potential to cause cancer in the food pipe. The diagnosis of Barrett's esophagus is established on gastroscopy, and after a close examination of the lower part of Barrett's esophagus. The risk of Barrett's esophagus increases with the number of years the patient had GERD. Patients with GERD for many years are at a higher risk of developing Barrett's esophagus. The lifetime risk of developing Barrett's esophagus among patients with GERD is 1 % to 5 %. And approximately 1 % of all those patients with Barrett's esophagus can develop cancer in the food pipe. It is recommended to have surveillance gastroscopy every 1 to 3 years once the diagnosis of Barrett's esophagus is established.

Diagnosis of GERD:

The confirmation of the presence of gastroesophageal reflux requires typical symptoms and/or evidence of ulcers on endoscopy, and evidence of acidic exposure to the lower part of the food pipe, by using a specialized test called pH impedance testing and/or SmartPill (PillCam).

• Gastroscopy - The investigation of GERD starts with gastroscopy, were an endoscopist or gastroenterologist passes a thin fiber-optic tube having a camera on its one end, from the mouth into the food pipe, stomach, and to the parts of small bowel called the duodenum, while closely observing the lining of your food pipe. In patients with evidence of acid reflux, the lining of the food pipe appears inflamed or red, cracked, ulcerated, or shows spontaneous bleeding or completely normal lining in case patients have clinical improvement by using acid-suppressant medications.

• pH Impedance Test - The other test is a pH impedance testing. In pH impedance testing, a gastroenterologist passes a thin tube made of metallic rings called the probe into the food pipe via the nose and leaves this probe in the lower part of your food pipe for the next 24 hours. The probe measures the acidic reflux from the stomach over a duration of 24 hours. A mean acid exposure of acid to the lower part of the esophagus of more than 4 % in 24 hours suggests the presence of gastroesophageal reflux disease. The pH impedance test frequently accompanies some drawbacks such as inappropriately withdrawal of probe into the more upper part of the esophagus resulting in false-negative test results or pushed more inside the stomach to result in false-positive test results. A clinician should be able to interpret results with caution if certain situations are apparent.

• SmartPill - Nowadays, a SmartPill or PillCam, a capsule-sized instrument swallowed by patients with physician advice, is used. This capsule records serial measurement of pH or acid, and the pressure changes across the food pipe, stomach, and small bowel. The PillCam is easy to operate and does not excessively produce trouble for the patient. It is also important to note that a complete set of investigations is not usually required, especially among patients with typical symptoms and immediate responses to proton pump inhibitors therapy.

Treatment:

After a thorough assessment and evaluation through history, physical examination, and some relevant investigations, patients can be safely started on proton pump inhibitors for a certain duration of time. They can later taper to the minimum dose, which is effective in controlling acid reflux. So, it is always essential to give a trial of proton pump inhibitors to see if it does resolve the patient's symptoms. A close follow-up with a physician is required to evaluate for any improvement after the start of proton pump inhibitors.

In around 30 % of patients, the symptoms of chest pain, heartburn, sore throat, and sore taste of mouth and cough do not improve to a single dose of proton pump inhibitors. Among such patients, a dose-escalation policy is adopted.

Lifestyle Modifications:

1. Reduction of body weight if overweight or obese.
2. Regular exercise (approximately 150 minutes per week).
3. Avoidance of food items that trigger excessive acid production in the stomach, such as spices, carbonated drinks, and deep-fried items.
4. Avoid taking mint, coffee, sweet drinks, or tea after having meals.
5. Give at least 3 to 4 hours in between dinner and bed.

If symptoms are more at night, I suggest using an anti-reflux mattress specially designed for patients with GERD and frequent awakening at night due to acidic taste in mouth or heartburn.

There are certain patients who do not respond even to double doses of proton pump inhibitors therapy, and such individuals have refractory gastroesophageal reflux disease. They require a different approach to diagnosis and management.

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