Gastroesophageal Reflux Disease [GERD] is a term given to a condition when stomach acids flows upwards or backwards from stomach to esophagus. Normally, lower esophageal sphincter prevents the backward flow. LES most of the time is contracted and relaxes only when you swallow the food. If due to any reason the LES does not remain in the state of contraction the gastric acid flows from stomach to esophagus causing Gastoesophageal Reflux Disease or GERD.
Factors that can result in decreased tone of lower esophageal sphincter thus causing GERD
- Drugs (Anticholinergic drugs, Nitrates, Calcium Channel Blockers)
- Idiopathic (Unknown Cause)
As the tone of lower esophageal sphincter decrease the backward flow of gastric acid from stomach to esophagus results in GERD, especially when a person is lying flat.
SIGNS & SYMPTOMS
Usually, GERD causes dyspepsia or epigastric pain which is most of the time sub-sternal along with following differentiating symptoms:
- Metal like taste in mouth
- Sore throat
Epigastric pain can be due to number of other diseases like gastritis, pancreatitis, ulcer disease etc. The above symptoms along with sub-sternal pain points the cause of discomfort related to Gastroesophageal Reflux disease.
Acid reflux disease is a condition where LES or lower esophageal sphincter is not able to remain in the state of contraction which results in back flow of gastric acids from stomach to esophagus. Diagnosis of acid Reflux Disease [GERD] is mostly clinical. Which means doctor does not have to do any specific test to diagnose GERD. The clinical signs & symptoms of GERD are enough for diagnosing Gastroesophageal Reflux Disease [GERD]. If a person has Epigastric pain which is radiating below the sternum with bad metallic taste in mouth GERD can be suspected and treatment can be started. If clinical diagnosis is made treatment can be started immediately.
Only if the diagnosis of GERD is not clear or the patient’s clinical presentation is equivocal a specific test called as 24-Hour PH monitoring is required. 24 hour PH monitoring is done by placing an electrode few centimeters below gastroesophageal junction (place where gullet and stomach meets). The instrument records the PH and average PH of that area is determined. Endoscopy can be done to see the changes in the lower esophagus, but a normal endoscopic finding does not exclude the presence of Gastroesophageal reflux disease [GERD]
(1) MEDICAL TREATMENT:
Drugs can be used to treat Gastroesophageal Reflux Disease effectively. Three types of drugs can be used
- Proton Pump Inhibitors (PPIs): Example: Omeprazole, Pantoprazole, Rabeprazole. All have equal efficacy. Goal is to keep PH of the stomach acid above 4.0.
- H2 Blockers: These class of drugs are used if the symptoms are mild or moderate and are intermittent.
- Prokinetic Drugs: Drugs like metachlopromide can be used to relieve the symptoms of GERD. Another prokinetic drug “Cisapride” was discontinued from US due to its fatal adverse effect. Cisapride was known to cause Ventricular Arrhythmias.
H2 Blockers and Prokinetic drugs have equal efficacy in treating mild intermittent forms of Gastroesophageal Reflux disease. But these drugs should not be used if symptoms are severe. For severe symptoms of GERD PPIs are the best class of drugs.
(2) SURGICAL TREATMENT
The goal of surgical treatment is to tighten the Lower Esophageal Sphincter (LES) so that stomach acids do not flow back or upwards to esophagus. The indications of surgical treatment for GRED are as follows:
If patient does not respond to medical treatment with Proton Pump Inhibitors
Side Effects of PPIs: diarrhea & headache
Alternative to life long or long term medical treatment with PPIs. Two surgical methods are most commonly used to treat GERD surgically:
Laproscopic Nissen’s Fundoplication
Purse-String Suture in LES to make it tighter.