Popularly known as heartburn, the Greek word pyrosis is the burning sensation in the pit of the stomach behind the breast bone, which some people experience with or without ingestion of spicy foods or alcoholic beverages, especially when they are lying flat in bed.
This symptom may be due to GER or the actual GERD. GER, or gastro-esophageal reflux, as the words suggest, is a situation where the normal acids and enzymes in the stomach flows back up into the esophagus (food pipe), which, under normal condition, should never happen.
GERD is the acronym for Gastro-Esophageal Reflux Disease. An anatomical lower esophageal sphincter (a valve) is present at the end of the esophagus (swallowing tube), which prevents the normal hydrochloric acid and other digestive juices produced in the stomach from refluxing (backing up) into the esophagus. While the stomach can tolerate this acid, the esophagus lining is very sensitive and gets easily "burned" by these acid and juices. In some people, this sphincter tone loosens up and becomes incompetent, allowing upward flow of these "chemicals" into the esophagus. When GE Reflux happens more than twice a week, it means the person already has GERD. This condition is also seen among infants and children.
WHAT CAUSES GERD?
Nobody knows. The etiology has not been determined. Hiatal Hernia may be a factor. The diaphragm is a tent-like muscular dome that divides the chest from the abdomen into two separate compartments. At the center of the dome is an opening (hiatus) that allows the esophagus in the chest to go through to connect to the stomach, which is in the abdomen under the diaphragm. When the hiatus becomes abnormally large, part of the stomach in the abdominal cavity goes up to the chest cavity (termed hiatial hernia), and this renders the esophageal sphincter incompetent, allowing reflux.
Other factors that aggravate GERD are smoking, ingestion of alcoholic beverage, citrus fruits, chocolate, coffee, fatty and fried foods, garlic, onion, spicy foods, mint flavoring, tomato-based foods like pizza, chili and spaghetti. Pregnancy and overweight are also contributing factors.
SYMPTOMS OF GERD
Common symptoms and signs are burning sensation in the pit of the stomach under the breast tip, sore throat, frequent burping with acidic (sour or bitter) aftertaste, persistent hiccups, stomach discomfort/fullness, nausea, or even vomiting. Chronic cases may even have upper GI bleeding (black tarry stools) and anemia. Majority of cases are among children under age 12 with GERD, and in some adults too, GERD may be present without any of those symptoms above, and instead, may only have dry cough, difficulty swallowing, or symptoms of asthma. Prompt consultation with your physician is prudent when any of these signs or symptoms appear.
In general, infants with GER appear healthy and happy, although they may spit up or vomit often. They usually outgrow their GE Reflux by their first birthday. If not, the condition may be GERD. Usual symptoms among infants are irritability and/or arching of the back (during or immediately after feeding), refusal to feed, which could lead to loss of weight and poor growth, frequent regurgitation, coughing, upper respiratory infection, laryngitis, wheezing, asthma or pneumonia. Some of these symptoms are also see among children with GERD. Urgent medical care is mandatory among these infants and children.
WHY IS ACID REFLUX BAD?
The stomach mucosa (lining) which normally produces the digestive acid can tolerate this acid well, but not the esophagus. Constant reflux of stomach acid into the esophagus, if allowed to continue untreated, can cause frequent burning chest or stomach pain, chronic cough, bad breath, and esophageal stricture (scarring and narrowing), making the food pipe too narrow for food to pass through. In some cases, the chronic esophagitis can even cause ulcers and bleeding. Some patients develop Barrett's metaplasia, where the cells in the inner lining of the esophagus take on abnormal shape and color, and, over time, this becomes cancer.
The recommended management includes: quitting cigarettes and avoiding alcoholic beverages, avoiding spicy foods and those items listed above, eating small meals, waiting for about three hours after eating before lying down, wearing loose-fitting clothes for sleeping, raising the head of the bed about eight inches (with blocks under the bed posts, adding pillows may not work as they move out of place), and religiously taking the medications prescribed by the physician.
The various medications for GERD are grouped into Antacids (Maalox, Mylanta, Rolaids, Tums, Alka-2 etc) neutralizing acids, foaming agents (Gaviscon), coating the stomach for protection, H2 Blockers (Tagamet, Pepcid AC, Axid AR, Zantac 75) blocks acid production, proton pump inhibitors (Protonix, Prilosec, Prevacid, Aciphex, Nexium), more effective than H2 blockers, and Prokinetics (Recholine, Reglan), which helps strengthen the sphincter, improves muscle action in the GI tract and makes the stomach empty faster. Some of them are more effective when used in combination.
THE NEED FOR SURGERY
When lifestyle changes and drugs do not work, surgery may be considered, either to treat a bleeding ulcer, esophageal stricture, or hiatal hernia. For this type of hernia, Nissen Fundoplication is the commonly performed operation. The upper part of the stomach is wrapped around lower end of the esophagus, thus strengthening the sphincter, making it competent, and preventing reflux. The Nissen could also be done thru laparoscopy. Lap Gastric Banding (LAGB), using adjustable band inserted thru laparoscopy for sliding hiatal hernia, has been found to be effective in helping in the management of GERD.
How successful is the surgery for GERD? Quite successful. Ten-year follow-up studies, some even longer, show that up to 90 percent of the patients are rendered asymptomatic (symptom-free), doing well, provided the changes in lifestyle recommended above are strictly followed, including daily physical exercises.
The US-FDA approved Enteryx "implant" for GERD patients who wish to avoid surgery, has been recalled and no longer used due to reported injuries and deaths in some patients from the polymer/solvent injection, which was supposed to reinforce and help the competency of the esophageal sphincter.*