GastroEast Physicians, Louisville, KY

GERD

GERD or Gastroesophageal reflux disease, is a disease in which the lower end of the esophagus, the LES (lower esophageal sphincter), does not hold back food or acid from refluxing up from the stomach into the esophagus. Occasionally this refluxed acid can be tasted in the woman hurting mouth. The reflux can cause heartburn, burning in the throat, chest pain, or nausea as it touches the lining of the esophagus. GERD can cause hoarseness or difficulty swallowing also.

What causes GERD?
Smoking, pregnancy, being obese, alcohol use, spicy foods, fatty foods, peppermint, chocolate and caffeine can all contribute to GERD. Some people can have every one of these risk factors and develop chronic GERD. Others may have none of these and never have GERD. Therefore, other genetic or environmental factors must contribute and these have yet to be elicited.

Who should visit a physician?
When a patient has had heartburn more than 2 or 3 times per week for a period of time (3 months), he or she should see a physician. After the physician does a complete medical history and performs a physical exam, a diagnostic test may be recommended such as an EGD (esophagogastroduodenoscopy). An EGD involves the placing of a long tube with a camera on the end into the esophagus and stomach. This may be done if symptoms are severe or alarm symptoms exist.

Alarm symptoms prompting EGD are as follows:

Age over 50
GERD for 5-7 years
Food sticking in the esophagus while eating
Unexpected weight loss
Low red blood counts or anemia
Blood in stool or black stools
Vomiting

Treatments

Lifestyle modifications
If EGD is not warranted and heartburn or reflux is mild, your physician will recommend lifestyle modifications such as exercise, weight loss, healthy eating, quitting smoking, avoiding alcohol, eating small meals, remaining upright (for 2 hours) after a meal, and raising the head of your bed 10 inches. The bed can be raised by using concrete or wooden blocks.
If lifestyle modifications and/or over the counter antacids (i.e. Tums, Rolaids, Maalox, or Mylanta) do not alleviate the reflux, a medication will be prescribed. Many doctors begin by suggesting H2 blockers such as Zantac, Pepcid, or Tagamet. These now can be purchased over the counter. If a 6-week trial of H2 blockers does not resolve the reflux, a PPI medication may be prescribed. The five PPI medications are as follows: Omeprazole (Prilosec), Rabeprazole (Aciphex), Pantoprazole (Protonix), Lansoprazole (Prevacid), and Esomeprazole (Nexium). Omeprazole or Prilosec OTC is now over the counter.

A 24 or 48 hour pH monitor
If a patient has had an EGD which was non-revealing and PPI therapy does not improve symptoms, the gold standard test to diagnose reflux, the 24 or 48 hour pH monitor, may be used. A tiny acid sensing probe is placed at the bottom of esophagus. This probe will measure the amount of time that acid is washed into the esophagus during a 24- or 48-hour period. This test will also help determine if symptoms such as wheezing, chest pain, or nausea are associated with acid washing up the tube or not. If the symptoms are from acid contact, a double dose of PPI may be used, or a patient may be referred for surgery to wrap the lower end of the esophagus.

A wrap
A wrap, called a fundoplication, may be the last resort for people with documented abnormal acid contact who are refractory to large dose PPI. The cardia or upper area of the stomach is surgically wrapped around the lower end of the esophagus in hopes of preventing reflux. Unfortunately, this procedure is not 100% successful, and some patients may need to go back on PPI therapy after the wrap is performed. Others may have nasty side effects from a wrap such as food getting hung up in the esophagus or difficulty swallowing after the surgical procedure.

New endoscopic therapeutic procedures
Some endoscopic therapeutic procedures are currently being studied for treatment of chronic reflux. These tests are currently being tested in large scale trials in academic medical centers and are not widely available. Patients with chronic; severe GERD who are refractory to large dose PPI treatment should speak with their Gastroenterologists about these new endoscopic procedures. Keep in mind, these new procedures should only be performed at an academic medical center, such as University of Louisville, while the patient is enrolled in a clinical experimental trial.

Consequences of long-term GERD
Patients with long-term GERD should visit a physician because complications such as esophageal ulceration, esophageal bleeding, and in very few cases, esophageal cancer can develop from long term untreated, severe GERD.