The oesophagus is a muscular tube that carries food into the stomach. The secretions of the oesophgus are alkaline and the secretions of the stomach are acidic.
There is a sphincter at the lower end of the oesophagus ( LES) that maintains unidirectional flow of contents from the oesophagus to the stomach and not vice versa. This sphincter is basically a ring of muscles at the lower end of the oesophagus merging with the muscular fibres at the upper end of the stomach. This means that when the LES relaxes (opens), it allows food to flow from oesophagus to stomach, following which it closes. This LES when closed does not allow the return or reflux of food or acid from the stomach to enter into the oesophagus. The LES is not under voluntary control.
Gastroesophageal reflux disease (GERD) is a disease wherein the stomach acid frequently flows back into the oesophagus. This return or reflux of acidic contents into the alkaline environment of the oesophagus tends to irritate the mucosal lining of the oesophagus causing discomfort, the severity of which could vary. This plethora of discomfort is called as GERD.
Symptoms:Heartburn and acid regurgitation are the two most common symptoms of those suffering with GERD. Heartburn is usually after eating, which might be worse at night
Other symptoms include chest pain, nausea, pain while swallowing, sudden excess of saliva, Chronic sore throat, Inflammation of the gums, bad breath, disturbed sleep.
Uncommon symptoms are laryngitis or hoarseness of voice and chronic cough. Many a time people are treated for chronic cough and hoarseness of voice and and not getting any relief with the treatment taken. A simple test like an upper GI endoscopy can diagnose GERD and remedy can be sought.
Worsening of existing asthma: acid reflux can make asthma symptoms worse by irritating the airways and lungs. This, in turn, can lead to progressively more serious asthma.
Risk factors for GERD are:
Gastroesophageal reflux happens when the LES is weak or relaxes when it shouldn’t.
Smoking or passive smoking
Delayed stomach emptying
Ca channel blockers
Factors that can aggravate acid reflux include:
Eating large meals or eating late at night
Fatty or fried foods
Medications, such as aspirin
Most people can manage the discomfort of GERD with lifestyle changes and some medications. When medication and lifestyle changes fail, surgery is the treatment of choice.
GERD affects people of all ages—from infants to older adults to the old.
People with asthma are at higher risk of developing GERD. Asthma flare-ups can cause the lower esophageal sphincter to relax, allowing stomach contents to flow back, or reflux, into the esophagus. Some asthma medications (especially theophylline) may worsen reflux symptoms.
On the other hand, Also, this irritation can trigger allergic reactions and make the airways more sensitive to environmental conditions such as smoke or cold air.
As we have learnt that the acid from the stomach entering the alkaline environment of the oesophagus leads to inflammation in the esophageal mucosa. When this continues for a long time, months or years, the inflammation becomes chronic and can lead to certain complications:
Precancerous changes to the esophagus (Barrett's esophagus). Refluxing acid from the stomach causes metaplastic changes in the oesophageal mucosal cells lining the lower portion of the esophagus, from normal stratified squamous epithelium to simple columnar epithelium. This is a precancerous state and is termed as called Barrets oesophagus.
Step by step changes in the mucosa from normal to Barrets over time due to GERD.
Oesophageal ulcer:This presents as pain while swallowing and at times an esophageal ulcer can bleed.
Narrowing of the esophagus (esophageal stricture). Chronic inflammation scars the mucosa and the muscle layers of the oesophagus leading to the narrowing of he oesophageal lumen. This in turn leads to problems with swallowing.
Diagnosis of GERD:
Endoscopy : The most commonly available, affordable and accessible diagnostic test to diagnose GERD. It has the advantage that it can detect an associated hiatus hernia if present and also biopsy can be taken if there is a suspicion of Barret’s oesophagus.
Endoscopy showing Barret’s oesophagus
PH studies : Ambulatory esophageal pH monitoring is now the gold standard for the diagnosis of gastroesophageal reflux disease
Medical management: This is the first line of treatment in GERD and gives excellent results in most cases of GERD if associated with strict dietary and lifestyle modifications.
Surgical management: This is advocated if a person has no relief at all with medications or if medications need to be continued over years and stoppage of medications causes recurrence of symptoms.
Medications management includes:
Diet and Lifestyle Changes :
Avoid chocolate, peppermint, fatty foods, caffeine, and alcoholic beverages that can relax the LES and thus aggravate GERD symptoms. Avoiding citrus fruits and juices also helps.
Avoid eating full stomach: Splitting the meals into smaller portions, chewing properly and eating slowly helps. This can be compensated if hungry by an additional small meal.
Eat slowly: Take your time at every meal.
Quitting smoking: If one is a smoker, symptoms are reduced to a great extent if one quits smoking as cigarette smoking seems to weaken the LES.
Raising the head end of the bed while sleeping: This is not a treatment method, but help in decreasing the reflux in severe cases until surgical line of treatment is sought for.
Weight reduction: If the person is obese , then substantial amount of weight loss will help reduction in the intra-abdominal pressure and thus decrease the symptoms of GERD along with medication.
Neutralise the acid: Antacids: These tend to give initial relief by neutralizing the acid in the stomach to relieve heartburn, but this is temporary relief .
Reduce acid production: H-2-receptor blockers. These reduce the acid production by blocking the H2 receptors and give longer relief.
Block acid production: Proton pump inhibitors have brought a mega change in the treatment of Gerd as they block the acid production, thus giving time for the healing of the inflamed mucosa in the oesophagus.
Increase gastric emptying: Prokinetics. These drugs enhance gastric emptying and thus do not allow much acid and food to remain in the stomach, thus decreasing the chances of reflux. Associated bloating is also taken care of by these drugs.
Strengthen the lower esophageal sphincter. Baclofen may ease GERD by decreasing the frequency of relaxations of the lower esophageal sphincter.
Surgical management of GERD
Laparoscopic Fundoplication: This is the treatment of choice and can be called the gold standard as it has stood the test of time in giving good results in GERD patients not responding to medical line of treatment. The lower oesophagus is dissected all around. The fundus of the stomach is freed from the omentum (short gastric vessels) and is wrapped around the lower end of the oesophagus in an attempt to mimic the function of the LES. This prevents reflux and symptomatic relief. The wrapping of the fundus around the lower end of the oesophagus could be partial or complete. When the wrap is 180degree, it is called a Dor fundoplication, 270 degree when it is called a Toupet fundoplication and 360 degree when it is called a Nissens Fundoplication. The crura of the diaphragm are approximated, depending on the laxity of the hiatus.
Nissen’s Fundoplication with crural closure:
Bariatric surgery. If Obesity is associated with GERD, then just doing a fundiplication will not work as weight loss is an important part in the management of GERD. In fact doing a gastric bypass surgery alone will serve the purpose in mild cases of GERD without a hiatus hernia. In such cases weight loss surgery i.e the gastric bypass will do a dual job--- weight loss and correction of GERD. No need for a fundoplication.
But, if a moderate or large hiatus hernia is associated with GERD , then along with the gastric bypass hiatal repair is a must.
LINX device. A ring of tiny magnetic beads is wrapped around the junction of the stomach and esophagus. The magnetic attraction between the beads is strong enough to keep the junction closed to refluxing acid, but weak enough to allow food to pass through. The LINX device can be implanted using minimally invasive surgery.
Transoral incisionless fundoplication (TIF). This new procedure involves tightening the lower esophageal sphincter by creating a partial wrap around the lower esophagus using polypropylene fasteners. TIF is performed through the mouth with a device called an endoscope and requires no surgical incision. Its advantages include quick recovery time and high tolerance.
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