Gastro Esophageal Reflux Disease

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Almost everyone has experienced heartburn. About 25 million American adults suffer daily from heartburn. It is that burning sensation felt behind the breastbone and sometimes in the neck and throat. Heartburn is caused by stomach acid refluxing or splashing up into the esophagus, the muscular tube that connects the throat to the stomach. Occasional heartburn is nothing to be concerned about; however, anyone who has heartburn on a regular basis should consult a physician. Constant exposure to stomach acid can irritate the lining of the esophagus and cause other medical problems. Serious heartburn is known as gastroesophageal reflux disease or GERD.

What is GERD?

The esophagus carries food and liquid into the stomach. At the lower end of the esophagus where it enters the stomach, there is a strong muscular ring called the lower esophageal sphincter (LES). The LES should remain tightly closed, except to allow food and liquid to pass into the stomach. Reflux occurs when the LES is not working properly. It may relax for periods of time throughout the day and night, or it may be constantly too weak to function effectively. This allows the stomach's acid juices to flow into the esophagus. How severe the disease becomes depends on how weakened the LES is, and the amount and duration of acid refluxed into the esophagus.

It is also common to find a hiatal hernia complicating GERD. With a hiatal hernia, the upper part of the stomach actually pushes up into the chest through a weakness in the diaphragm. The diaphragm is the thin, flat muscle that separates the lungs from the abdomen. When part of the upper stomach is stuck above the diaphragm, stomach acid is retained there for a longer period and is more likely to reflux into the esophagus.

Symptoms and Causes of GERD

Frequent heartburn is the most common symptom. However, patients may also experience some of the following:

* sour or bitter taste
* bitter stomach fluid coming into the mouth, especially during sleep
* hoarseness
* repeatedly feeling a need to clear the throat
* difficulty swallowing food or liquid
* wheezing or coughing at night
* worsening of symptoms after eating, or when bending over or lying down.

Certain diet and lifestyle choices can contribute to the condition. For example, certain foods increase acid production, and fatty foods increase the time food remains in the stomach. Chocolate, peppermint, coffee, alcoholic beverages, and especially nicotine in cigarette smoke weaken or relax the LES. Obesity places added pressure on the upper abdomen, and during pregnancy the LES weakens for unknown reasons.

Complications

Complications occur when GERD is severe or long-standing. Constant irritation of the esophagus by stomach acid can lead to inflammation, ulcers, and bleeding. Anemia or low blood count may develop. Over time, scarring and narrowing of the esophagus can also develop, making it difficult to swallow foods and liquids. This narrowing is called a stricture. Some patients develop a condition called Barrett's esophagus, which is a serious change in the cells lining the esophagus. Barrett's esophagus may be a forerunner of esophageal cancer.

Diagnosis of GERD

The diagnosis can usually be suspected by the physician, simply by taking the medical history. Beyond that, the physician may order an x-ray examination of the esophagus and stomach. For this x-ray, the patient swallows a liquid containing barium. This makes it possible to see the reflux and a hiatal hernia on the x-ray. Endoscopy is the most important test for patients with GERD. It is done with the patient under sedation. The physician examines the lining of the esophagus and stomach with a thin, lighted, flexible tube called an endoscope. This exam is helpful in determining how severe the disease is, how much tissue damage there is, and if there are any complications. Certain conditions, such as narrowing or stricture in the esophagus, can usually be corrected during this procedure. During an endoscopy, the physician can also look for signs of Barrett's esophagus, and perform a biopsy to see if precancerous changes have occurred.

There are other tests that are helpful. A pressure recording of the esophagus is called esophageal manometry. It measures the pressure in the LES and any abnormal muscle contractions in the main part of the esophagus. Finally, a 12 to 24 hour recording of the acidity in the esophagus is often helpful.

What is the treatment?

Treatment is aimed at reducing reflux and damage to the lining of the esophagus. Initial treatment is with lifestyle changes. Patients with GERD should follow these recommendations:

* Avoid eating anything within three hours before bedtime.
* Stop smoking. Nicotine in the blood weakens the LES.
* Avoid fatty foods, milk, chocolate, spearmint, peppermint, caffeine, citrus fruits and juices, tomato products, pepper seasoning, and alcohol -- especially red wine.
* Decrease portions of food at mealtime, and avoid tight clothing or bending over after eating.
* Review all medications with the physician. Certain drugs can weaken the LES, allowing acid irritation of the esophagus.
* Elevate the head of the bed or mattress 6 to 8 inches. This helps to keep acid in the stomach by gravity when sleeping. Extra pillows by themselves are not very helpful.
* Lose weight if overweight. This may relieve upward pressure on the stomach and LES.

Lifestyle changes are often all that is needed to correct mild forms of GERD. When symptoms are bad or GERD is moderate to severe, the physician will prescribe medications. Some that reduce stomach acid include Tagamet, Zantac, Pepcid and Axid. Certain potent newer drugs, such as Prilosec and Prevacid, can almost eliminate stomach acid entirely. These two drugs are most frequently used when GERD is severe. Other medications, such as Reglan (generic: metoclopramide) tighten the LES. These may be especially useful at night when reflux often occurs.

A number of patients with GERD may need surgery to strengthen the LES. This procedure is called fundoplication. Previously, this surgery required a major operation, often through the chest. It is a difficult operation for the patient, with a long recovery. It is now usually done by laparoscopy. This is a new type of minimally invasive surgery, performed with a tiny incision at the naval and a few needle points in the upper abdomen. The patient usually returns home 1-2 days after surgery, with few problems. Surgery, however, should not be considered until all other measures have been tried. Surgery is often seriously considered for an otherwise healthy patient when the disease is severe, or the patient does not want to face the expense or regimen of long-term treatment with medications.

Summary

GERD is a common problem that requires medical attention when symptoms and tissue damage become troublesome. Fortunately, there is a great deal that can now be done about GERD. Lifestyle changes can help, and there are many medications and even surgery to treat and correct GERD. Working together with the physician, a good medical program can almost always be developed to successfully treat the patient with GERD.
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Hiatus Hernia

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The hiatus hernia is one of the most misunderstood and maligned conditions in medicine. People blame this hernia for more symptoms than it usually causes. Patients with a hiatus hernia need to understand what it is and what might occur with it. Most importantly, they need to know it is unusual for serious problems to develop from this type of hernia.

Anatomy

The diaphragm is a sheet of muscle that separates the lungs from the abdomen. When a person takes a deep breath, the dome-shaped diaphragm contracts and flattens. In doing this, the diaphragm pulls air into the lungs. The left diaphragm contains a small hole through which passes the tube-shaped esophagus that carries food and liquid to the stomach. Normally this hole, called a hiatus, is small and fits snugly around the esophagus. The J-shaped stomach sits below the diaphragm.

What Causes a Hiatus Hernia?

In some people, the hiatus or hole in the diaphragm weakens and enlarges. It is not known why this occurs. It may be due to heredity, obesity, exercises such as weightlifting, or straining at stool. Whatever the cause, a portion of the stomach herniates, or moves up, into the chest cavity through this enlarged hole. A hiatus hernia is now present. Hiatus hernias are very common, occurring in up to 60 percent of people by age 60.

What Are the Different Types of Hiatus Hernia?

1. Sliding Hiatus Hernia -- In this most common type of hiatus hernia, the herniated portion of the stomach slides back and forth, into and out of the chest. These hernias are normally small and usually cause no problems or even symptoms.
2. Fixed Hiatus Hernia -- In this case, the upper part of the stomach is caught up in the chest. With this hernia, there may be few symptoms, but the potential for problems in the esophagus is increased.
3. Complicated or Serious Hiatus Hernia -- Fortunately, this type of hernia is uncommon. It includes a variety of patterns of herniation of the stomach, including cases in which the entire stomach moves up in the chest. There is a high likelihood that medical problems will occur with this hernia and treatment, frequently involving surgery, will be required. Complicated hernias are uncommon.


Symptoms

In most patients, hiatus hernias cause no symptoms. This is especially true of sliding hernias. When symptoms occur, they usually take the form of heartburn and regurgitation, when stomach acid refluxes back into the esophagus. Some patients with fixed hiatus hernias experience chronic reflux of acid into the esophagus, which may cause injury and bleeding. Anemia, or low red blood cell count, can result. Further, chronic inflammation of the lower esophagus may produce scarring and narrowing in this area. This, in turn, makes swallowing difficult, and food does not pass easily into the stomach.

Does Hiatus Hernia Cause Pain and Indigestion?

It is wrong to always blame a hiatus hernia for pain and indigestion. Hiatus hernias generally do not cause acute pain. This symptom may result from other disorders, such as peptic ulcers or even heart disease. Some patients with coronary heart disease fool themselves into believing their discomfort is due to a hiatus hernia. If upper-abdominal pain or indigestion occurs, people should not mislead themselves into thinking the cause is a hiatus hernia. Instead, the patient should seek medical advice.

Diagnosis

Diagnosis of a hiatus hernia is typically made through an upper GI barium x-ray. A complementary test is gastroscopy, or upper-intestinal endoscopy, in which the physician visually examines the esophagus and stomach using a flexible scope while the patient is lightly sedated.

What Are the Complications?
The complications of hiatus hernia are:

* Chronic heartburn and inflammation of the lower esophagus, called reflux esophagitis
* Anemia due to chronic bleeding from the lower esophagus
* Scarring and narrowing of the lower esophagus causing difficulty in swallowing
* While sleeping, stomach secretions can seep up the esophagus and into the lungs causing chronic cough, wheezing, and even pneumonia

In addition, the complicated hernia can cause serious problems such as difficulty in breathing or severe chest pain, especially in the elderly.

Treatment

Treatment is called for only when the hernia results in symptoms, such as persistent heartburn or difficulty in swallowing. Acid inflammation and ulceration of the lower esophagus also require treatment.

General guidelines for treating heartburn and esophagitis (inflammation of the esophagus) are:

* Avoid (or use only in moderation) foods and substances that increase reflux of acid into the esophagus, such as:
o nicotine (cigarettes)
o caffeine
o chocolate
o fatty foods
o peppermint
o alcohol
o spearmint
* Eat smaller, more frequent meals and do not eat within 2-3 hours of bedtime.
* Avoid bending, stooping, abdominal exercises, tight belts, and girdles all of which increase abdominal pressure and cause reflux.
* If overweight, lose weight. Obesity also increases abdominal pressure.
* Prescription medications. Certain drugs, such as intestinal antispasmodics, calcium channel blockers, and some antidepressants weaken the muscle strength of the lower espohagus.
* Elevate the head of the bed 8 to 10 inches by putting pillows or a wedge under the upper part of the mattress. Gravity then helps keep stomach acid out of the esophagus while sleeping.


Other Treatments

Drugs -- Some medicines effectively reduce the secretion of stomach acid, while others increase the muscle strength of the lower esophagus, thereby reducing acid reflux.

Surgery -- The complicated hiatus hernia occasionally requires surgery on an emergency basis. Surgery is otherwise reserved for those patients with complications that cannot be handled with medications. The mere presence of a hiatus hernia is not a reason for surgery.

Summary

A hiatus hernia is an extremely common condition which usually does not cause symptoms or problems. When symptoms do occur, the physician can frequently treat the problem effectively with a well-planned program. Surgery is infrequently required to treat a hiatus hernia.

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