Lower esophagus and gastroesophageal reflux disease
Patients affected with gastroesophageal reflux disease usually present with the symptom of heartburn. It can lead to many complications if it is not treated. It can cause inflammation of the inner lining of esophagus called esophagitis. Over a period of years untreated gastroesophageal reflux disease causes a condition called Barrett’s esophagus. Barrett’s esophagus is a premalignant condition and it leads to esophageal cancer.
What causes gastroesophageal reflux disease?
In gastroesophageal reflux disease the following abnormalities lead to the disease process and various symptoms.
- Increased episodes and duration of transient lower esophageal sphincter relaxations
- Decreased tone of lower esophageal sphincter -This could occur if the lower esophagus is inflamed or if there is hiatal hernia. This leads to reflux when the abdominal pressure increases as in coughing, straining and bending over.
- Defective contractions of the esophagus – If esophagus is not contracting well then whatever is refluxed in to it is not cleared and it stays there and cause symptoms
- Decreased salivation – Saliva neutralizes the acid content that is refluxed from the stomach. If salivation is decreased this neutralization is affected. Cigarette smoking and certain medications are causes of decreased salivation. Cigarette smoking also decreases the lower esophageal sphincter pressure
- Delayed emptying of stomach – Persons affected by diabetes have delayed gastric emptying and this can lead to gastroesophageal reflux disease.
Symptoms of gastroesophageal reflux disease
Heartburn is the classic symptom of gastroesophageal reflux disease. The symptoms of gastroesophageal reflux disease are broadly categorized in to esophageal and extraesophageal symptoms. The following are the various symptoms of gastroesophageal reflux disease.
The presence of heartburn is helpful in establishing the diagnosis of gastroesophageal reflux disease. The affected individuals complain of a burning feeling which rise from the stomach or lower chest and radiate towards the neck, throat and occasionally the back. This symptom usually occurs after food especially after ingesting spicy foods, citrus products, fats, chocolates and alcohol. The initial symptom of heartburn for women frequently occurs during pregnancy. Mild heartburn usually improves with consumption of antacids, baking soda or milk which act to both neutralize acidic reflux and stimulate esophageal contractions which clears the esophagus of any refluxed stomach contents.
Acid regurgitation is the second most common symptom of gastroesophageal reflux disease. Stomach secretion is acidic in nature. This gets refluxed in to esophagus. The effortless regurgitation of acidic fluid especially after meals and worsened by stooping and lying down is highly suggestive of gastroesophageal reflux disease.
Difficulty in swallowing
About 30% of the individuals affected by gastroesophageal reflux disease complain of difficulty in swallowing. This symptom is usually seen in those with longstanding acid reflux disease. The difficulty in swallowing is especially for solid food items. Development of this symptom may indicate the following:
- Narrowing of the lumen of the esophagus
- Defective contraction and forward propulsion of food by esophagus
- Formation of a ring like structure called Schatzki’s ring
- Very rarely development of esophageal cancer
Gastroesophageal reflux disease can cause inflammation of the inner lining of esophagus. This is called esophagitis. Individuals with esophagitis complain of pain while swallowing.
Water brash is the sudden appearance of slightly sour or salty fluid in the mouth. In contrast to regurgitation, water brash is not bitter. This is due to increased production of saliva. This is a protective mechanism and the increased salivary juice helps to neutralize the refluxed acidic content.
Other symptoms include burping, hiccups, nausea and vomiting. Burping is usually seen along with acid regurgitation.
The heart and the esophagus have common nerve supply. So the pain originating from the esophagus may mimic cardiac chest pain. It frequently worsens after food and during emotional stress. It awakens the person from sleep. The pain may last for minutes to hours. It resolves spontaneously and after taking antacids.
About 40-80% of individuals affected by asthma suffer from gastroesophageal reflux disease. Other respiratory symptoms associated with gastroesophageal reflux disease are-
- Aspiration pneumonia – due to aspiration of the stomach contents in to the lungs
- Interstitial pulmonary fibrosis – Due to inflammation, the lung tissue gets scarred.
- Chronic bronchitis – Due to inflammation of the lining of the respiratory tract
Ear, nose and throat symptoms
Due to severe reflux and injury of the vocal cords, hoarseness of voice occurs. Sensation of stickiness in the throat which is called globus sensation is sometimes complained by the affected individuals. Chronic cough is reported by 20% of the individuals affected by gastroesophageal reflux disease. Recurrent sore throat, clearing of throat and dental erosions are some of the other commonly reported symptoms.
How to diagnose gastroesophageal reflux disease?
- Heartburn is a classic symptom of gastrointestinal reflux disease and it is highly specific for diagnosing it.
- Proton pump inhibitors which suppress acid production are used in the treatment of gastroesophageal reflux disease. If intake of proton pump inhibitors for 2 weeks results in relief of symptoms then it indicates the symptoms are due to gastroesophageal reflux disease
- 24 hours pH monitoring test – This is the gold standard in the diagnosis of gastroesophageal reflux disease. A pH probe is introduced in to the lower part of esophagus and the pH is recorded. Various parameters with respect to pH less than 4 are calculated for diagnosing acid reflux.
- Endoscopy – Upper gastrointestinal endoscopy is done for evaluation of complications of acid reflux like esophagitis, stricture, Barrett’s esophagus and esophageal cancer.
Complications of acid reflux disease
- Esophagitis – The lower end of the esophagus gets inflamed. This causes pain during swallowing
- Peptic stricture – Over a period of time the inflamed esophagus gets scarred and the lumen becomes narrowed (peptic stricture). This causes difficulty is swallowing
- Barrett’s esophagus – The reflux of stomach contents over a period of many years change the nature of the lining cells. The cells get converted in to cells resembling that in the intestine. This condition is premalignant and can lead to cancer.
- Esophageal cancer – This is a very rare and late complication of gastroesophageal reflux disease. Barrett’s esophagus leads to esophageal cancer. This causes difficulty in swallowing which worsens progressively over a short period or time.
Treatment of gastroesophageal reflux disease
Treatment of gastroesophageal reflux disease is broadly categorized in to lifestyle modifications, medical therapy, surgical therapy and endoscopic therapy.
The implementation of lifestyle and behavioral measures in the treatment of gastroesophageal reflux disease has been a popular notion in the treatment of this disease. These include:
- Head elevation while sleeping
- Small frequent meals
- Going to bed 2- 3 hours after food
- Avoiding bed time snacks
- Avoiding smoking and alcohol
- Avoiding tight fitting clothes
- Avoiding cola, citrus drinks, carbonated drinks, tea, coffee, spicy food
- Weight reduction
The following groups of medications are used in the treatment of gastroesophageal reflux disease.
- Proton pump inhibitors – Omeprazole, Lansoprazole, Rabeprazole, Pantoprazole and Esomeprazole
- H2 receptor antagonists – Cimetidine, Ranitidine, Famotidine and Nizatidine
- Prokinetics – Bethnechol, Metaclopromide, Cisapride, Tegaserod, Domperidone and Erythromycin
Antireflux surgery reduces acid reflux by increasing the lower esophageal sphincter pressure and decreasing the episodes of transient lower esophageal sphincter relaxation episodes. The steps include-
- Reduction of hiatal hernia which is a risk factor for acid reflux
- Strenthening of the lower esophageal sphincter. This is done by Nissen fundoplication surgery which can be done laparoscopically.
Endoscopic therapy is not popular among the various treatment options. Many are still under trial. The various options are-
- Radiofrequency application
- Endoscopic sewing technique
- Endoscopic injection technique