What is Reflux?
Symptoms
Diagnosis
Barrett's Esophagus
Esophageal Cancer

When Should I See a Doctor?
Prevention
Treatment
Prognosis
Additional Info

What is Reflux?
Gastroesophageal reflux disease (GERD) is a condition in which the stomach's juices (acid and digestive enzymes) flow backwards, or reflux, into the esophagus (swallowing tube). Because the lining of the esophagus is not equipped to handle these caustic substances, the esophagus becomes inflamed. This produces the sensation we call heartburn as well as other symptoms of esophageal irritation. Over time, untreated GERD may even lead to permanent esophageal damage.

The underlying problem in GERD almost always involves the esophageal sphincter (LES). The LES is a high pressure zone at the lower end of the esophagus near the entrance to the stomach. Under normal circumstances, the LES keeps the stomach's contents from flowing backwards into the esophagus by opening only when you are eating or swallowing. The rest of the time, the LES acts like a protective valve and remains tightly shut.

In patients with GERD, the LES either does not squeeze tightly or opens at the wrong time, allowing digestive juices to reflux into the esophagus and irritate the esophageal lining. Prolonged exposure to acid can cause esophagitis (inflammation of the esophagus), narrowing of the esophagus or an esophageal ulcer. Chronic acid exposure can also lead to Barrett's esophagus, a condition in which the normal lining of the esophagus is replaced by inflamed tissue. Barrett's esophagus is considered a potentially precancerous condition; 2 percent to 5 percent of patients with Barrett's esophagus eventually develop cancer of the esophagus.

About 40% of the US population has heartburn at least once a month. An estimated 17 million Americans (7%) currently suffer from heartburn and other symptoms of GERD every day.

Symptoms
Symptoms of GERD may include:

• Heartburn (the most characteristic symptom), a burning type pain radiating into the chest or throat which may be worse when you eat, bend over or lie down
  
• Regurgitation (backflow of stomach fluids into your mouth) especially when bending over or straining
  
• Belching, especially belching an acidic or sour-tasting fluid
  
• Chest Pain
  
• Chronic sour or bitter taste in the mouth
  
• Difficulty swallowing
  
• Hoarseness, especially in the morning
  
• Sore throat
  
• Coughing
  
• Wheezing
  
• Globus (repeatedly needing to clear your throat)

Diagnosis
GERD is diagnosed mostly by a careful interview of your symptoms. This includes the frequency and characteristics of your symptoms, and what makes your symptoms worse or better.

Because heartburn like pain can also be a symptom of coronary artery disease, your doctor may ask whether you have any cardiac symptoms (shortness of breath, palpitations, dizziness) or do additional testing to help rule out this problem.

Depending on your symptoms, lifestyle changes (see Prevention) and a trial of over-the-counter medications may be recommend prior to beginning any specialized diagnostic testing.

If you have more serious symptoms (such as severe heartburn, difficulty swallowing, painful swallowing, or weight loss) or if your heartburn is not relieved by medications, then further testing is required. The best way to visualize the esophagus is with esophagoscopy, a form of endoscopy (visual inspection with an instrument called an endoscope). Esophagoscopy allows the doctor to inspect the inside of your esophagus and, if necessary, to take a biopsy (a tissue sample for laboratory analysis). During esophagoscopy, your doctor looks for evidence of esophageal inflammation, erosions, ulcers, strictures or the color changes of Barrett's esophagus. To eliminate other possible causes of your symptoms, the scope may be used to visualize the stomach and first part of the small intestines. The following tests may be ordered in addition to esophagoscopy:

• Barium swallow — This is an X-ray test that outlines the esophagus.
  
• Cardiac evaluation — Patients who have chest pain as a GERD symptom may also need an electrocardiogram (called ECG or EKG) and an exercise stress test to rule out heart disease.
  
• Esophageal manometry or motility studies — These studies can measure how tightly the LES shuts, and they can also check for abnormalities in esophageal pressure and movement.
  
• Esophageal pH monitoring — This test uses electrodes to measure the pH (acid level) in the esophagus, usually over a 24-hour period.
• Abdominal ultrasound — Uses sound waves to image the abdominal organs to look for other abnormalities that account for your symptoms including gallbladder problems.
• Gastric emptying study — Used to check the function of the stomach

When Should I See a Doctor?
Without treatment, GERD is typically a long-term problem that relapses and recurs over many years. In fact, studies have shown that the average GERD patient endures symptoms for one to three years before seeing a doctor. This is unfortunate, because medical and surgical treatments are very effective in treating this condition.

You should see your doctor immediately if you have any of the following symptoms:

• Heartburn more often than twice a week
  
• Pain or difficulty swallowing
  
• Feeling full after eating only a small amount
  
• Frequent vomiting
  
• Unexplained weight loss
  
• Severe hoarseness or wheezing
• Chest pain
• Blood in your stool or black tarry stools
• Vomiting blood

Prevention
There is much that you can do to prevent the symptoms of GERD. Some simple lifestyle changes include:

• At night, elevate the head of your bed at least six inches. If possible, put wooden blocks under the legs at the head of the bed or use a solid foam wedge under the head portion of the mattress. Simply using extra pillows may not help.
  
• Avoid foods that promote acid reflux, especially coffee, chocolate, fatty foods, spicy foods, carbonated beverages, peppermint, spearmint, citrus fruits, tomatoes, whole milk and onions.
  
• Eat smaller, more frequent meals.
  
• Do not lie down after eating.
  
• Do not eat for three to four hours before going to bed.
  
• Quit smoking, this includes all nicotine containing products.
  
• Avoid drinking alcohol.
  
• Lose weight if you are obese. Obesity can make it harder for the LES to stay closed.
  
• Avoid wearing tight-fitting garments. These increase pressure on the abdomen, opening the LES when it should be shut.

Treatment
For many people, the first step is lifestyle modification as described above. Drug therapy includes over-the-counter antacids and acid-blocking drugs and prescription-strength drugs that target symptoms in different ways. Procedural treatments include endoscopic treatments like the Stretta® procedure, and laparoscopic procedures including the laparoscopic nissen fundoplication.

Over-the-counter antacids — These include Mylanta, Maalox, Tums, Rolaids, Gaviscon and others. The liquid forms of these medications work faster, but the tablets are more convenient. Because the magnesium-containing antacids may cause diarrhea and the aluminum-containing antacids may cause constipation, your doctor may advise you to alternate antacids to avoid these problems. Although these drugs neutralize acid, they do not heal the inflammation of the esophagus. Note: If you are pregnant, always check with your doctor before you take antacids or any other medication.

Over-the-counter H2 blockers — These drugs work by causing the stomach to make less acid, and they are effective in patients with mild to moderate symptoms. They include famotidine (Pepcid-AC), cimetidine (Tagamet HB) and ranitidine (Zantac 75). Because of a phenomenon called "up regulation", after prolonged regular use these drugs often will no longer supress acid adequately.

Prescription medications — Prescription medications include:

• H2 blockers — These are prescribed at higher doses than those available in over-the-counter forms.
  
• Proton pump inhibitors — These drugs selectively block the pump mechanism in the stomach's acid-making cells, shutting off the stomach's acid production. The proton pump inhibitors, including: Omeprazole (Prilosec); Lansoprazole (Prevacid); Rabeprazole (AcipHex); Pantoprazole (Protonix); Esomebrazole (Nexium)
  are very effective medications that can be especially helpful in patients who do not respond to H2 blockers and antacids. These drugs are best taken 30 minutes prior to your first meal of the day.
  
• Prokinetic drugs — These medications may help decrease esophageal reflux, but are not usually used as the sole treatment medication for GERD. They work in a variety of ways. Some prevent reflux by strengthening the muscle tone of the LES, whereas others cause the stomach to empty faster (this narrows the window of time during which reflux can occur). The prokinetic drugs include metoclopramide and bethanechol, and they are commonly used in combination with an H2 blocker or a proton pump inhibitor.
  
• Mucosal protectors — These medications coat, soothe and protect the irritated esophageal lining. They include sucralfate (Carafate).

Procedural treatments
Usually reserved for patients who have frequent symptoms who can not be weaned off medication and for a variety of reasons do not wish to or can not tolerate long term medical therapy. In the majority of patients the procedures are safe, well tolerated, highly effective in relieving symptoms, and have a high degree of patient satisfaction. The two procedures recommended by Dr. Fusco are:
Stretta® procedure: Endoscopic radiofrequency energy delivery to the Lower Esophageal Sphincter
Laparoscopic Nissen Fundoplication

Prognosis
GERD has an excellent prognosis. Eighty to 90 percent of patients improve after treatment with medication. After the Stretta procedure, the majority of patients improve and over 2/3rds require no medications. Laparoscopic Nissen fundoplication even though it is typically used in patients with the most severe cases of reflux, will cure heartburn in over 90% of cases without the need for continued medication.

Additional Info (links)
Society of Laparoendoscopic Surgeons: General info about GERD
Society of American Gastrointestinal Endoscopic Surgeons: General info about GERD
Society of American Gastrointestinal Endoscopic Surgeons: Guidelines for the treatment of GERD
Stretta Procedure: General GERD info along with info about Stretta
News article from Arizona describing the Stretta procedure
Jackson Gastroenterology: Good illustration
GERD diet
American Gastroenterological Association : General info about GERD
GERD information resource center: May be a bit technical for some patients but some nice animations demonstrating GERD
National Digestive Disease Clearinghouse: General info
Heartburn Help Website: Site sponsored by Ethicon

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