Gastroesophageal Reflux Disease (GERD)

GERD is short for gastroesophageal reflux disease. It is a chronic disease where the contents of the stomach, particularly acid, reflux into the esophagus. The acid, through various mechanisms, irritates and damages the lining of the esophagus. Some degree of reflux is normal. GERD occurs when there are bothersome symptoms because of the reflux of acid. Typical symptoms include burning traveling from the mid-abdomen up the chest. Many patients experience a metallic or bitter taste in the back of their mouth when they wake up. Atypical symptoms include a chronic cough, dental problems, recurrent lung infections, difficulty swallowing, hoarse voice, the feeling of a lump in the throat, and difficulty clearing one's throat.

When left untreated, GERD can lead to potentially serious complications, including:

• Esophagitis (inflammation, irritation or swelling of the esophagus)
• Stricture (narrowing of the esophagus)
• Barrett's Esophagus (Pre-cancerous changes to the esophagus)

Between the esophagus (the food pipe) and the stomach lies a muscle called the lower esophageal sphincter which separates the contents of the stomach from the esophagus. GERD occurs when the sphincter is weak or when there is a structural abnormality such as a hiatal hernia allowing the stomach to slide upward into the chest limiting the ability of the sphincter to minimize reflux. Spicy foods, fatty foods, chocolate, peppermint and garlic can relax the lower esophageal sphincter causing or worsening symptoms. Tobacco and alcohol can also relax the lower esophageal sphincter and cause GERD.

If you have any of the above symptoms that do not improve with over-the-counter antacids or if you are concerned, you should speak to your primary care provider. In cases where symptoms persist despite treatment by your primary care provider or if the diagnosis is unclear, there is further testing that can be done to confirm the diagnosis, look for other causes of your symptoms, or optimize treatment.

Esophagogastroduodenoscopy (EGD). This test uses a flexible tube with a camera and light at the tip to visualize the lining of the esophagus and stomach. This allows for visualization of potential damage from acid and for evaluation of other causes of symptoms

24-Hour pH Impedance Testing. For this test, a very narrow tube is placed through your nose with one end near the bottom of your esophagus to measure acid levels. This remains in for 24 hours and you go home with the probe in your nose. You have a monitor that you press when you are experiencing bothersome symptoms and keep a diary so we can correlate your symptoms with acid exposure. This allows us to measure acid levels in the esophagus and to see if acid is the cause of the symptoms.

Capsule pH Monitoring. This is similar to the 24-hour pH impedance test above except that instead of having a tube in your nose for 24 hours, we place a capsule into the bottom of your esophagus with an EGD. You still have a monitor to press when you have bothersome symptoms and you still keep a diary. The benefit is that you do not have a tube in your nose for 24 hours. The limitation is that this requires an EGD.

Esophageal Manometry. This entails a narrow tube being placed into the end of your esophagus through your nose. It measures movement of the esophagus, the strength of the muscle of the esophagus and the strength of the sphincter. This test is very important in those patients who are being evaluated for surgery.

We recommend dietary and lifestyle modifications in all patients. This means:

• Avoid the foods mentioned above that relax the lower esophageal sphincter as well as carbonated beverages.
• Elevate the head of the bed six to eight inches.
• Avoid food or drink for at least two to three hours before sleeping.
• Avoid tight-fitting clothing.
• Weight loss for patients who are overweight.
• Avoid tobacco use and alcohol.

Over-the-counter antacids such as TUMS may be used on an as needed basis. For more persistent symptoms we generally trial proton-pump inhibitors such as Nexium (esomeprazole), Prilosec (omeprazole), and Protonix (pantoprazole). For patients with persistent symptoms despite maximal medical therapy as well as changes in diet and lifestyle, surgery to correct a hiatal hernia or tighten the area of the lower esophageal sphincter may be an option.