More About GERD
At the bottom of the esophagus is a specialized muscle called the lower esophageal sphincter (LES) that acts as a check valve. During swallowing the LES opens transiently to allow food entry. A normal LES prevents the backwash, or reflux, of caustic acidic stomach contents into the esophagus. That's a good thing, because the esophageal lining is not designed to withstand the irritating effects of digestive fluids.

In some people, the LES fails to function properly and acid material does find its way into the esophagus. If this happens only occasionally, we recognize the symptom as heartburn: a burning sensation, perhaps accompanied by acid belch or a sour taste. Occasional heartburn certainly is not a big deal. But, if it happens weekly or more often, then GERD exists, and that can be much more serious.

Why some people get GERD is not always clear. A hiatal hernia, which is a partial protrusion of the stomach upwards through the diaphragm, can contribute. However, some people with GERD don't have hiatal hernias, and many with hernias don't experience GERD. Being overweight can aggravate GERD by increasing pressure on the stomach. And, certain lifestyle factors like smoking or ingesting chocolate, fatty foods or coffee seem to relax the LES and encourage reflux.

GERD Symptoms and Complications
The basic symptom of GERD is recurrent heartburn. Interestingly, the severity of the heartburn does not correlate well with the extent of reflux. Some people with minor degrees of reflux experience severe symptoms, and vice versa. Besides heartburn, some people may experience cough, choking, sore throat or hoarseness, resulting from the acid material entering the throat. Acid entering the windpipe can lead to breathing problems; in fact, GERD can be a significant contributor to asthma. Severe chest pain mimicking a heart attack can also occur.

Another serious complication is the formation of erosions and bleeding. Scar tissue and strictures in the esophagus, which obstruct swallowing and cause weight loss, can also complicate the picture. Finally, GERD can lead to a serious pre-cancerous tissue change in the lowermost esophagus, called Barrett's esophagus.

What Is Barrett's Esophagus?
The normal lining of the esophagus differs from that of the stomach. At the gastroesophageal junction there is normally a sharp demarcation between the two types of lining tissue. In about one in ten GERD sufferers, however, stomach-type lining cells extend up into the lower esophagus. Over time, these cells can undergo abnormal changes that eventually result in a type of cancer of the esophagus called adenocarcinoma.

Fortunately esophageal adenocarcinoma is still not very common, but the number of sufferers is growing rapidly due to the widespread prevalence of GERD. Between 1970 and 2000, esophageal adenocarcinoma increased sevenfold, and it continues to increase by 10-20% per year.

Diagnosing GERD
For people with heartburn alone without the complicating symptoms mentioned earlier, many physicians make the diagnosis without further testing. Everyone else requires at least an upper endoscopy, in which a lighted tube is passed into the throat and down the esophagus. Endoscopy permits direct viewing of the esophageal lining and the collection of biopsies, which are particularly critical for identifying Barrett's esophagus.

Many GERD sufferers have normal endoscopies. If the diagnosis remains uncertain, the next recommended test is esophageal pH monitoring, in which a sensor is placed in the esophagus that measures the presence of acidity over a period of time.

Treatment Recommendations
Since GERD is a chronic condition, treatment is ongoing. The goals are both to reduce symptoms and prevent serious complications. The first step involves lifestyle changes: avoid large meals; avoid lying down within two to three hours of eating; stop smoking; lose weight; and, skip chocolate, fatty foods, coffee and certain other foods that can relax the LES. Elevating the head of the bed on four to six-inch blocks is also helpful.

The cornerstone of treatment, however, is acid suppression. That's where the little purple pill and its brothers come in. They belong to a class of drugs called proton pump inhibitors, and they work by blocking the "acid pumps" located in millions of specialized stomach cells that secret acid. Older drugs, called Histamine-2 antagonists (Zantac, Pepcid and others) also reduce acid production, but not nearly as well.

For patients who fail therapy with medications and lifestyle modification, anti-reflux surgery is an option. Now usually performed laparoscopically, thus avoiding a large incision, the procedure involves folding a portion of the top of the stomach around the lowermost esophagus to form a valve of sorts.

Finally, there are several emerging treatments for GERD that are performed via an endoscope. They include the injection of polymers or placement of implants to block reflux. In another technique called the Endo-Cinch procedure, pairs of stitches are placed below the LES to form one or more pleats that help block the backflow of acid.

Whatever the treatment chosen, GERD is certainly nothing to ignore. Left unattended, recurrent exposure of the esophagus to stomach acid can lead to severe consequences indeed.

August 2004