Most people experience occasional heartburn, which is usually due to gastroesophageal reflux. For most people, the episodes are brief and infrequent and respond well to over-the-counter medications and lifestyle changes.
However, up to 10 percent of patients may have the more severe form, called gastroesophageal reflux disease (GERD), in which acid splashes back into the esophagus and may take a while to be cleared. Episodes of acid splash-back may be so numerous that the esophageal lining breaks down, which is called erosive esophagitis. Patients with erosive esophagitis often require long-term therapy and may have frequent, reoccurring symptoms. Fortunately, most patients with acid reflux have non-erosive GERD.
Typical reflux symptoms include heartburn, indigestion, burping, chest pain and occasionally, nausea. According to Rosaline Barron, M.D., Gastroenterologist at Mount Auburn Hospital in Cambridge, a teaching hospital of Harvard Medical School, people reflux because they are built to reflux.
“Our chests have negative pressure to suck air into the lungs when the diaphragm goes down to breathe,” she says. “That raises the intrabdominal pressure, so there is always a gradient favoring acid reflux into the chest. This is even further exaggerated if we eat a big meal, which raises our intrabdominal pressure further.”
Many GERD patients are born with a loose fitting diaphragm, called a hiatal hernia, which is when the upper stomach slides into the chest during breathing, taking acid with it. Normally, the diaphragm is snug and pinches the esophagus with each breath to prevent reflux. Other causes of excessive reflux are a lazy stomach (gastroparesis), a low pressure, relaxing lower esophageal sphincter, and delayed clearance of splashed-back acid out of the esophagus.
Lifestyle changes are the main focus of therapy for most patients with reflux, even if they ultimately need prescription or proton pump inhibitor (PPI) therapy. Triggers of reflux include excess weight, fatty foods, coffee, chocolate, mint, spicy foods, alcohol and smoking. Even tight clothing can aggravate reflux. GERD patients should aim to eat smaller meals more frequently, and not eat late at night. Also, it is helpful to avoid bending over from the waist and some patients may benefit by adding a wedge to their bed to keep their head elevated at night.
Complications can occur in patients with long-term GERD. An example of this is esophageal stricture, which is when food cannot pass into the stomach, and usually requires a gastroenterologist to remove the stuck bolus of food in the emergency room. Difficulty swallowing is always a very significant symptom that should be reported to one’s doctor. The esophagus may need to be stretched with a balloon, but difficulty swallowing can also be a warning sign of esophageal cancer. Other complications can include upper gastrointestinal bleeding and chest pain.
Another complication of GERD is Barrett’s esophagus, in which the lining of the esophagus changes, so it becomes more like intestinal lining with mucus-secreting cells.
“While the mucus in the short helps protect from acid injury, these cells are unstable and have a risk of turning into cancer,” says Dr. Barron. “The risk is less than five percent lifelong, but because of this known risk, which actually represents one of the most rapidly rising tumors in the country, periodic endoscopic surveillance for cancer is advised. Newer endoscopic therapies are being investigated that may play a role in the future management of patients with Barrett’s.”
Many different GERD treatments are available and range from over the counter (OTC) antacids to H2RA’s such as Pepcid or Zantac. “OTC medications work quickly but their benefit is short lasting,” says Dr. Barron. H2RAs may not be adequate to heal erosive esophagus, the more serious form of GERD. According to Dr. Barron, those patients often require PPI therapy, which can suppress 90 percent of acid, particularly if it is used twice a day. All PPI drugs are similar in strength and efficacy (Prilosec, Protonix, Nexium, Prevacid, Zegerid, Aciphex and generic omeprazole).
A patient with reflux should consult a gastroenterologist if symptoms occur three or more times per week, or are present for many years, even if they are mild. In addition, anyone with trouble swallowing and people with a family history of esophageal problems should see a gastroenterologist. Endoscopy is often performed, during which a small flashlight is passed down the mouth to examine and take biopsies from the esophagus.
There are many new therapies for reflux and Barrett’s. For patients who do not respond well to standard PPI therapy, laparoscopic and endoscopic surgical repairs are available locally with good results. Further esophageal testing includes 24-hour pH testing and esophageal motility studies.
“At Mount Auburn Hospital, we are here to be of service to patients and answer questions,” says Dr. Barron. “We can guide patients through appropriate work-ups and therapy.”
For a free Mount Auburn Hospital physician directory, please call us at 617-499-5094.