Heartburn/GERD
Heartburn or gastroesophageal reflux (GERD) is typically caused when the acidic contents of the stomach reflux into the esophagus. Heartburn most commonly is described as a burning sensation located in the upper abdomen and behind the sternum which may radiate up the esophagus to the mouth. When stomach contents reflux up the esophagus, patients may experience difficulty swallowing (dysphagia), pain with swallowing (odynophagia), chest pain, chronic cough, hoarseness, increased salivation (water brash) or a perception of a lump in the throat (globus). In some instances heartburn may manifest as recurrent sinusitis, asthma, pneumonia or even worsening dental disease. In many cases, heartburn is precipitated by large meals, alcohol, peppermint, tobacco, caffeine and fatty foods (fried or greasy). The diagnosis of acid reflux is typically made based on classic symptoms and a response to therapy. In most cases, reflux will be controlled by the use of acid blocking medications. It is always important to rule out other conditions that may cause symptoms similar to heartburn. In particular, if you experience chest pain you should be evaluated to rule out significant heart disease. Your Borland-Groover Clinic provider may recommend further evaluation if the diagnosis is not clear or if you have concerning symptoms.
The evaluation may include:
Upper endoscopy in which a small flexible endoscope with a camera at the tip is passed down your esophagus, stomach and small intestine. You will be given medications throughout the procedure to assure you are comfortable. If there appears to be any abnormalities on the exam a biopsy of the tissue may be obtained.
Acid measurement may be obtained if there remains doubt about the diagnosis. This can be done by inserting a small flexible catheter through the nose and into the esophagus where it will remain in place for a 24 hr period. At the Borland-Groover clinic we also offer 48 hour pH monitoring with the Bravo capsule. This Bravo capsule is about the size of a Motrin tablet and is placed in the esophagus during your upper endoscopy. It will transmit acid information to a recorder you wear over a two day period.
Esophageal manometry is a method to determine if the muscle contractions in the esophagus are coordinated and functioning properly. It also is able to measure the length and pressure within the lower esophageal sphincter
Complications of heartburn/gastroesophageal reflux may include strictures or areas of narrowing in the esophagus. This can occur when there is prolonged inflammation within the esophagus and may cause difficulty in swallowing particularly solids. Ulcers (breaks extending through the normal esophageal mucosa) may occur. In some, the normal squamous cells of the esophagus are replaced by cells often found in the stomach known as intestinal cells. This condition is called “Barretts” esophagus and is associated with a 40x increase in the risk of developing adenocarcinoma of the esophagus. It is important to note that only a small portion of patients with heartburn will develop barretts esophagus and an even smaller proportion will go on to develop esophageal adenocarcinoma.
Acid suppressing medications include antacids, histamine blockers and for more severe symptoms the proton pump inhibitors. Lifestyle makes a difference. Weight loss reduces the amount of acid reflux and has multiple other health benefits. Smoking reduces the amount of saliva in the mouth and throat. This saliva is important in neutralizing the acid in the esophagus. It is also wise to avoid meals late in the day or large meals.
Finally, surgery is an option for those who fail acid suppression therapy or have contraindications to acid suppressing therapy. The most commonly performed antireflux surgery is known as a “nissen fundoplication” where the upper part of the stomach is wrapped around the esophagus. As with any procedure there is a risk for complications and many patients will have difficulty belching, difficulty swallowing and may have diarrhea. Unfortunately a large percentage of patients will eventually need to have acid suppressing medications restarted in the years after the surgery.
For additional information please visit:
http://www.nlm.nih.gov/medlineplus/gerd.html
http://digestive.niddk.nih.gov/ddiseases/pubs/gerd/
References
1. Kaltenbach, T, Crockett, S, Gerson, LB. Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach. Arch Intern Med 2006; 166:965.
2. Hirano, I, Richter, JE. ACG practice guidelines: esophageal reflux testing. Am J Gastroenterol 2007; 102:668.
3. DeVault, KR, Castell, DO. Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. Am J Gastroenterol 2005; 100:190.
4. Fass, R, Sontag, SJ, Traxler, B, Sostek, M. Treatment of patients with persistent heartburn symptoms: a double-blind, randomized trial. Clin Gastroenterol Hepatol 2006; 4:50.
5. Salminen, PT, Hiekkanen, HI, Rantala, AP, Ovaska, JT. Comparison of long-term outcome of laparoscopic and conventional nissen fundoplication: a prospective randomized study with an 11-year follow-up. Ann Surg 2007; 246:201.