Sunday, December 16, 2012

Facts About Acid Reflux and GERD

Gastroesophageal reflux disease (GERD), gastro-oesophageal reflux disease (GORD), gastric reflux disease, or acid reflux disease is the name given to persistent stomach acid (and sometimes also duodenal gastric juice) regurgitation into the esophagus. This regurgitation, or acid reflux, causes damage to the mucosa of the esophagus (the damage being caused by hydrochloric acid from stomach).

Acid reflux is usually caused because the muscular valve between the stomach and the esophagus is not functioning correctly. This valve is known as the lower esophageal sphincter, which holds the top of the stomach closed. When it relaxes abnormally, whether because of a hiatal hernia, or because of reverse peristalsis (when stomach contents are expelled into the esophagus), the man or woman concerned is likely to feel a burning pain which we commonly call heartburn.

Over a period of time, acid reflux can cause changes in the mucosa of the esophagus, causing severe problems including, ultimately, cancer. Another kind of acid reflux i slaryngopharyngeal reflux (LPR) or “extraesophageal reflux disease” (EERD). This tends not produce heartburn.

The most common signs acid reflux or GERD are heartburn, trouble swallowing, nausea, regurgitation and pain on swallowing.

As I mentioned above, damage to the esophagus may occur with persistent GERD, although it’s comparatively uncommon. The symptoms include ulcers around the junction of the stomach and esophagus, persistent narrowing (strictures) of the esophagus, or Barratt’s esophagus. This name refers to changes in the epithelial cells, changes which may be a precursor to esophageal adenocarcinoma.

Obviously since the regurgitation of stomach contents is acidic, in extreme cases it may cause laryngitis, asthma, erosion of dental enamel and a feeling of choking.

Unfortunately GERD occurs in children and adults alike, although it can be very difficult to detect in children as they have difficulty describing what they are feeling. The symptoms are basically the same as in adults, though, with the addition of repeated vomiting, coughing, and even effortless spitting up of clear mucus.

Children and infants with GERD may cry without cessation, alternately refuse food and indicate they want it, and pull off the bottle or breast. No single symptom is indicative of GERD in all children, and diagnosis tends to be made by observation of a combination of behaviors.

Diagnosis of acid reflux or GERD in adults tends to be done by monitoring the pH within the esophagus. This is a useful system in that it not only allows diagnosis of the condition, but it can be used to monitor the effects of treatment. The diagnosis is made by offering short-term treatment with proton pump inhibitors: monitoring the pH during treatment will reveal any fall in acidity which is indicative of a diagnosis of GERD or acid reflux.

Gastroendoscopy is usually recommended when someone does not respond to treatment or has other symptoms including anaemia, blood in the feces or weight loss. To avoid the danger of missing Barratt’s esophagus, it may be recommended that men and women with persistent long-standing problems in this area have a regular endoscopy so as to eliminate the possibility of esophageal adenocarcinoma.

Biopsies can be conducted during an endoscopy and they may reveal many things: the most common being inflammation of a specific type indicative of basal hyperplasia, lymphocytic, neutrophilic or eosinophilic inflammation (due to reflux, Helicobacter gastritis or other problems).  Eosinophilic inflammation is often due to reflux.

Under normal conditions, the angle at which the esophagus and stomach effectively creates a muscular valve which prevents all stomach and duodenal contents from regurgitation into the esophagus. However when somebody develops a hiatal hernia, and/or some other physical conditions, the likelihood of regurgitation is increased when lying down or when lifting heavy weights. These problems can be accentuated by obesity, possibly due to increased abdominal pressure.

Naturally, any syndrome which increases acidity in the stomach can accentuate the possibility of acid regurgitation; scleroderma and systemic sclerosis may both lead to oesophageal malfunctioning, where peristalsis does not necessarily propel food and drink from the esophagus into the stomach correctly. It also been discovered that certain medications tend to interfere with peristalsis and so contribute to GERD, one example being Prednisolone.

As always in medical issues, there are a number of peripheral factors that may or may not be causative factors in acid problems, but seem to have an association with it. These include obstructive sleep apnoea and gallstones.

There are many things you can do to reduce acid reflux and heartburn. These include sleeping on the left side of the body with your head raised, perhaps by as much as 30 degrees, or even sleeping while sitting up. Eating smaller meals, more often, can reduce excess acid in the stomach, and as you may expect, not eating in the period two or three hours before bedtime can reduce symptoms since the acidity of the stomach will be reduced by the time you retire.

Other factors that have been implicated in lessening the impact of GERD on one’s lifestyle include losing weight, avoiding acidic foods and those which are spicy or rich, cutting out acidic things like fruit juice and irritating substances including alcohol, caffeine, onions and so on.

Remedies for GERD really fall into three categories: lifestyle modifications, surgery and medication.

Lifestyle modifications include not drinking alcohol, getting more exercise, reducing weight, and changing your sleeping habits. It’s also important to ensure that you eat the right foods, because this forms the basis of most home remedies for acid reflux.

It’s important to know that many antacids reduce acidity but actually can increase stomach activity, which means you may not get as much benefit from them as you expect. By contrast, giving up smoking definitely increases the ability of the lower esophageal sphincter to hold stomach contents in place, and it’s also been demonstrated, as suggested above, that you sleep on your left side, with the head of the bed raised. This will reduce nighttime reflux.

There are various therapeutic bed pillows or wedges available, which are much cheaper alternatives to bed and mattresses with an elevation feature. You should aim to raise the head of mattress by 6 to 8 inches or more: it has been claimed that the higher the mattress, the greater the success rate. This can often not be done effectively with a spring mattress, so if you’re contemplating this particular lifestyle change it’s worth investing in a foam mattress which can cope with flexing.

Medications are available to treat GERD and acid reflux.

They include proton pump inhibitors (PPIs), the most well-known of which include omeprazole and esomeprazole. These drugs are effective in suppressing acid production; their precursors were hydrogen receptor blockers, such as ranitidine and cimetidine, known as Zantac and Tagamet. These don’t work for everybody, but they are effective for about 50% of men and women. Nonprescription medications include alginic acid, whic is also known as Gaviscon. This coats the lining of the esophagus with protective substance and increases pH, i.e. makes the lining of the esophagus and stomach less acidic.

Sucralfate – also known as carafate - can help to heal and prevent esophageal damage. There are various other medications available including Baclofen, which is a skeletal muscle relaxant that can also prevent the lower esophageal sphincter relaxing too much. 

It’s difficult to clearly answer the question of which treatment for acid reflux is most effective, because many of the studies on medications are sponsored by pharmaceutical companies. In general, however, a graduated approach starting with antacids and ending with the most powerful proton pump inhibitors tends to be successful.

Surgery can also be used in extreme cases. The most common procedure is the Nissen fundoplication. This is a procedure which involves wrapping part of the upper part of the stomach around the esophagus to make a stronger sphincter and repair any hiatal hernia which may be present. This surgical approach may improve quality of life for men and women with gastro-esophageal reflux disease more effectively than medication.

Acid reflux and GERD occurs in between 10 and 20% of the population in the Western world so it’s an important problem. Unfortunately it’s also most common in the age group between 60 and 70, so with men and women living longer, the number of  cases is only going to increase in the future.

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