Gastroesophageal Reflux Disease: A Guide

What is Gastroesophageal Reflux Disease?

Gastroesophageal reflux disease (GERD) – more commonly known as acid reflux – is the condition where the contents in your stomach backflows up into your oesophagus regularly, causing bothersome symptoms, and can even damage the oesophagus.

When we swallow, food travels down the oesophagus to the stomach through a rhythmic wave of contraction, also known as peristalsis. The lower oesophagus sphincter, a muscular ring which sits at the bottom end of the oesophagus subsequently relaxes, allowing food to pass through. Once the food enters the stomach, the muscle contracts to prevent food and stomach acid from going back up the oesophagus.

However, these sphincter muscles may sometime weaken and allow stomach acid to backflow regularly, irritating your oesophagus lining.

Complications of GERD

Long term acid reflux may result in injury to the oesophagus, also known as oesophagitis. If severe, stricture or narrowing of the oesophagus may occur, which results in difficulty for food to travel down the oesophagus.

In rare instances, patients may even develop a precancerous condition known as Barrett’s oesophagus, which carry a very low risk of progression to oesophageal cancer.

Symptoms of GERD

The common symptoms of GERD are:

• Heartburn
• Regurgitating sour liquid

In some patients, they may have atypical symptoms as a result from GERD, such as:

• Persistent cough
• Throat discomfort
• Difficulty breathing
• Bad breath
• Chest pain

Causes of GERD

Certain conditions increase the risk of GERD. They include:

Being overweight

There is an increased prevalence of GERD among individuals who are overweight or obese. The reason for this is not completely understood but experts think that excess belly fat may be adding pressure to the abdomen, causing fluid to backflow into the oesophagus. Being overweight can also impair your stomach’s ability to empty properly.

Pregnancy

A significant number of pregnant women report having serious heartburn, especially during their second and third trimesters. This may be due to hormonal changes and the growing baby pressing against your stomach.

Certain medical conditions:

• Hiatal hernia

  Where part of your stomach protrudes into your chest through an opening at the diaphragm, which results in reduced pressure of the lower oesophageal sphincter.

• Scleroderma

  An autoimmune disease which results in ineffective peristalsis of the oesophagus, therefore inability of the oesophagus to clear the acid content back flowed from the stomach.

• Gastroparesis

  The inability of the stomach to empty properly.

Certain medications:

• Calcium channel blockers
• Certain asthma medications

Lifestyle choices:

• Smoking
• Supper before sleeping
• Eating too quickly
• Eating food high in fat, chocolate, mint, garlic, onion
• Drinking alcohol or coffee

Diagnosing GERD

Diagnosis of GERD is usually made based on typical symptoms. Your doctor may recommend further tests such as:

Gastroscopy

Gastroscopy is a flexible endoscope which allows your doctor to examine the internal lining of your oesophagus and stomach. This may be necessary to assess the damage caused by acid reflux and to look for any complications such as ulcer, narrowing, or cancerous growth.

24-hour oesophageal pH study

A long, thin, flexible tube fitted with sensors will be inserted through the nose into the oesophagus. Over the course of 24 hours, it will measure any acid reflux event in the lower oesophagus. This allows your doctor to confirm the acid reflux and to correlate with your symptoms.

When should you seek medical care?

Seek immediate medical attention if:

• Your symptoms are bothersome
• You notice any alarming symptoms, such as
  • Loss of appetite
  • Weight loss
  • Difficulty swallowing
  • Pain while swallowing
  • Vomiting, especially with blood in the vomitus
  • Chest pain (this can sometime be a sign of heart attack)

Treating GERD

GERD can be managed successfully for majority of patients via a combination of lifestyle modification and over-the-counter medications. However, if your GERD symptoms don’t improve, your doctor might recommend prescription medications, or in some cases, surgery.

Lifestyle changes to treat GERD

• Avoid heavy meals, especially if they are greasy
• Avoid taking supper within 4 hours from time of sleeping
• Maintain a healthy weight and diet
• Avoid tight-fitting clothing which increases the pressure in the abdomen, thus increasing the chances of reflux

Medications

Over-the-counter medications, such as antacids, work by neutralising the gastric acid.

If your symptoms are persistent, your doctor may prescribe the following medications which work by reducing acid production:

• Histamine receptor antagonists (H2RA) such as famotidine or cimetidine;
• Proton pump inhibitors (PPI) such as omeprazole, esomeprazole, pantoprazole, rabeprazole and dexlansoprazole, or;
• Potassium competitive acid blocker (PCAB) such as vonoprazan

These medications are generally safe, and your doctor will discuss with you in detail should your symptoms warrant the use of medication. Treatments are usually intended to control symptoms using as small a dose of medication as possible, and tailored according to the frequency and severity of symptoms.

Endoscopic procedures and surgery

Various endoscopic and surgical procedures have been invented to treat GERD via artificially increasing the lower oesophageal sphincter pressure. These generally have limited role as majority of patients with GERD can be treated effectively with lifestyle modification and medications. Example of endoscopic therapies include:

TIF (Transoral incisionless fundoplication)

In this procedure, a medical device is inserted through your mouth to create folds at the distal oesophagus. A barrier is thus created between the stomach and the oesophagus, preventing acid reflux.

Stretta procedure

This procedure uses radiofrequency energy which is delivered to the distal oesophagus. The thermal injury reduces tissue compliance and therefore achieves the target effect of reduced relaxation of the lower oesophageal sphincter.

Fundoplication surgery

Fundoplication is a surgical procedure where the upper part of stomach is wrapped and stitched together at the lower oesophagus. This strengthens and increases the pressure at the lower oesophagus sphincter, thereby reducing acid reflux.

Patients with an abnormal pH study and who do not respond to or are intolerant of medical treatment can consider this treatment option. If you suspect that you may be suffering from GERD, consult a gastroenterologist for an evaluation.