There is a valve between our food pipe (esophagus) and stomach that normally stays closed. When food passes through our food pipe, this valve opens to allow the food to enter the stomach. The function of this valve is to prevent stomach acid and digested food from flowing back into the food pipe.
If this valve becomes loose in a patient, stomach acid and food can move back into the food pipe. This can cause symptoms like a burning sensation in the chest or a sour taste in the mouth, which can affect the patient’s quality of life.
This condition is called Gastroesophageal Reflux Disease (GERD). It means GERD is a disease of the esophagus where the lower esophageal sphincter becomes loose, allowing acid and food to flow back upwards.
Causes of GERD
Let’s now understand the reasons behind GERD. If there is high pressure inside the stomach, the chances of food and acid coming up increase. For example, if a person is obese, the fat in the stomach increases pressure, which pushes the food and acid upwards into the esophagus.
Another condition is pregnancy. During pregnancy, the pressure inside the stomach can also increase, leading to reflux.
Sometimes, patients have a condition called a hiatal hernia. A hiatal hernia means that part of the stomach has moved up into the chest cavity. The stomach is supposed to be in the abdomen, but if some portion of it moves up into the chest cavity, this condition is called a hiatal hernia.
It has been observed that patients with a hiatal hernia are more likely to develop GERD. They may experience a burning sensation in the chest or a sour taste in the mouth.
How Acid damage the food pipe?
Let’s now understand how acid damages our food pipe. Inside the stomach and esophagus, there is an epithelial lining. The lining of the food pipe and the stomach is different. Inside the stomach, the lining is columnar epithelium, which usually resists acid and prevents injury.
The lining of the esophagus is squamous epithelium. When squamous epithelium comes into contact with acid, it can become inflamed. This condition is called esophagitis.
Symptoms of GERD
Heartburn
The main symptom of GERD is heartburn. Heartburn means a burning sensation in the centre of the chest. This often happens after eating spicy food or after lying down post-meal.
Food Regurgitation
Sometimes patients complain of a sour taste in the mouth or throat or feel like food is coming back up. This condition is called food regurgitation.
Sore Throat
If acid reaches the throat, it can cause inflammation, leading to a feeling of pain or something stuck in the throat. Some patients may also experience frequent coughing if acid repeatedly irritates the throat tissues or enters the lungs, causing coughing.
Asthma
Another symptom of GERD is asthma. If a patient has asthma and also has GERD, it can be difficult to control asthma.
Dysphagia
Another symptom of GERD is dysphagia, or difficulty swallowing. If a patient frequently experiences acid reflux, it can cause swelling in the esophagus, weakening its muscles and making it hard for the patient to swallow food.
Hoarseness of voice
There is a voice box in the throat, and if acid affects the voice box, it can cause the voice to become rough or hoarse. This condition is called hoarseness of voice.
Chest pain
Some patients complain of severe chest pain, which can sometimes be confused with a heart attack. In such cases, we conduct heart tests to rule out any serious heart conditions.
Complications of GERD
Esophagitis and Esophageal Ulcers
The first complication of GERD is esophagitis and esophageal ulcers. If acid keeps coming up frequently, it can cause swelling inside the esophagus, leading to ulcers. This condition is called esophagitis and esophageal ulcers. Sometimes, these ulcers can bleed, and the patient might experience blood in the mouth or pass black-colored stools.
Esophageal Stricture
If acid comes up repeatedly, the food pipe may narrow. This condition is called peptic stricture. When a patient eats, the food may not pass easily, making swallowing difficult, a condition known as dysphagia.
Barrett’s Esophagus
Another complication of GERD is Barrett’s esophagus. There are two types of epithelial lining: columnar epithelium and squamous epithelium. The squamous epithelium can be injured due to excess acid, and in some cases, the squamous epithelium in GERD patients changes into columnar epithelium. This condition is called Barrett’s esophagus.
After Barrett’s esophagus develops, reflux symptoms may decrease, but there is a risk of cancer. Although this risk is not very high, theoretically, cancer can develop in Barrett’s esophagus.
Diagnosis of GERD
After assessing the patient’s history and conducting examination, we suspect the diagnosis and start treatment. If a patient has symptoms for a long time and the condition reappears after stopping medication, we conduct further investigations.
The first step in diagnosing GERD is performing an endoscopy. In this procedure, a small tube, called an endoscope, is passed through the food pipe. The endoscope is inserted through the mouth into the esophagus, allowing us to study the stomach and esophagus. Endoscopy is usually painless. Before the procedure, we ask the patient to fast for 8 hours, and an injection is given to make the patient sleep, ensuring there is no discomfort or pain during the procedure.
During the endoscopy, we check for any hiatal hernia or ulcers in the esophagus. If the endoscopy results are normal, we conduct two more tests. The first is esophageal manometry, where a catheter is inserted through the nose into the food pipe to measure the pressure in the esophagus.
24-hour pH Study
Another test for diagnosing GERD is the 24-hour pH study, which is the best test for diagnosing GERD. In this test, a catheter is inserted through the nose into the food pipe. This catheter has pH sensors that detect when stomach acid enters the esophagus, causing a decrease in pH. These sensors confirm acid reflux. The catheter is kept in place for 24 hours while the patient continues their daily activities and diet.
Treatment of GERD
Now, let’s talk about how we treat GERD. The first step in treatment is making lifestyle changes. We advise patients to have smaller, more frequent meals and avoid lying down immediately after eating. There should be at least a 3-4 hour gap between eating and going to bed.
Additionally, we recommend that patients elevate the head of their bed, lifting it by 6-8 inches. This helps reduce the upward movement of acid. We also suggest that patients sleep on their left side, as this can further minimize acid reflux. Tight clothing should be avoided, and dietary changes are necessary. Foods such as spicy food and citrus fruits like oranges and lemons tend to trigger reflux. Chocolate is also a trigger for some patients. These foods should be avoided.
If a patient smokes or drinks, they should quit, as smoking and drinking can worsen GERD.
If symptoms persist despite these changes, we start medications that patients take before meals. Some syrups help create a barrier in the stomach to prevent acid from coming up. These medications effectively control reflux in most cases, but the problem may return when the medication is stopped. In some patients, the burning sensation may be controlled, but food may still come back up. In such cases, an option is to tighten the loose valve or treat the hiatal hernia.
For this, we either suggest endoscopy or surgery to tighten the valve. One surgical procedure is called fundoplication. In this procedure, the upper part of the stomach is wrapped around the food pipe to tighten the valve and prevent acid reflux.
There are also newer endoscopic techniques that can tighten the loose part of the valve. If the hiatal hernia is not very large and the valve is not excessively loose, we can perform this procedure via endoscopy.
Now, let’s understand how we treat the complications of GERD. If a patient has a peptic stricture, we first give medications to heal the ulcers. Once healed, we dilate the stricture using a balloon.
If a patient has Barrett’s esophagus, we screen them for dysplasia and cancer. If cancer or dysplasia is found during endoscopy, we either remove the tissue through endoscopy or, if the lesion is in an advanced stage, we perform surgery on the patient.