Hello. I am Dr. Srujan Dasyam, consultant Gastroenterologist, NuLife Gastrocare. Today we will discuss about gastroesophageal reflux disease or GERD. GERD is one of the most common diseases in the field of gastroenterology.
What is GERD?
In GERD, there is exaggerated gastroesophageal reflux. You must understand that the reflux is from the stomach or proximal intestine into the esophagus which is the food pipe or the esophagus. So, whenever there is exaggerated reflux from the stomach or intestine into the esophagus, the symptoms of GERD arises.
What is the Prevalence or How common is the GERD?
GERD is usually more common in western countries but such is not the scenario in the present situation. The reason being there are more number of cases in our Indian subcontinent as well. Because there has been more westernization of the diet and the prevalence of obesity has also increased, that’s why naturally the cases of GERD has also increased. So when it comes to the percentage broadly 50 % of the general public they suffer from symptoms of GERD.
So now we must understand what are the different causes for gastroesophageal reflux disease or GERD. So, GERD is more common in a patient or a person who is overweight that is obesity is one of the most important causes for the gastroesophageal reflux disease. So, in studies, it is proven that the BMI, increase in BMI is directly proportional to the gastroesophageal reflux disease prevalence. So the more is the body weight, the more of the patient suffering from GERD.
In addition to obesity, there are a few conditions or there are few factors which cause more gastroesophageal reflux, which are smoking, abundance in the intake of fried or fatty foods and there are other medicines which also increase the reflux or acid levels and also excess intake of caffeine or coffee, excess usage of peppermint will all these causes more incidence of gastroesophageal reflux.
What are the Symptoms of GERD?
When it comes to symptoms, we must understand what are the symptoms of gastroesophageal reflux disease? Here we can broadly divide it into two types – the normal ones are classic symptoms of GERD and apart from that, there are other symptoms or extraintestinal symptoms which are caused by GERD as well. When it comes to the classic symptoms of GERD, the most common symptom is heartburn, in which the patient typically presents with a few weeks history of heartburn which is like discomfort or burning sensation in the lower chest region.
Sometimes along with the heartburn the person typically gives a history of reflux of this contents or there is a sensation of burning sensation starting from the chest, lower chest which is going up into the throat region. This is called reflux or regurgitation. Apart from this classic symptoms, there are other symptoms in gastroesophageal reflux disease which are commonly, the patient can have more reflux, can also have vomiting sometimes and also there is excessive salivation which can result in sour or salty sensation in the throat or mouth which is called water brash.
Apart from this typical classic symptoms, the gastroesophageal reflux disease also can cause extraintestinal symptoms. By the term extraintestinal it means that the symptoms can present related to the symptoms of systems which are unrelated to the GI tract of which most common one is respiratory symptoms which includes asthma. It is studied that most of the pediatric patients or more common in obese people, asthma is also prevalent in long-term GERD patients. So why does asthma happen in GERD? Whenever there is an acid reflux it trickles into the throat. So the throat is the site where it has both food pipe and behind that food pipe, it also has respiratory system. So whenever the trickling of these acid secretion occur into the throat some of it might trickle into the respiratory tract. So that it causes reflux spasms or narrowing of this tract. That’s why whenever a chronic reflux patient have asthma, it is always recommended to look for GERD also or the presence of GERD is usually excluded by performing an endoscopy.
Apart from this asthma other ENT problems also arise in case of GERD. So what are these ENT problems? It can also cause chronic dry cough or chronic sinusitis can also happen with GERD. And also patients with chronic reflux, they have dental issues as well. It can cause dental erosions due to chronic acid reflux. So now after finishing what is GERD? What are the causes of GERD? And what are the symptoms of GERD? Let us know how to diagnose GERD & how to treat GERD?
How is GERD Diagnosed?
When it comes to diagnosis of GERD usually GERD is a disease which is diagnosed usually based on history but to rule out other associated complications arising from GERD usually a Gastroenterologist tends to perform upper GI endoscopy, in which the Gastroenterologist visualizes the throat or esophagus and also the stomach areas.
In the esophagus usually, when the patient has chronic reflux, the GERD patient has features of oesophagitis which is an inflammation or swelling of the layers of the esophagus or the food pipe in which we can find thickening or ulcerations in the esophagus. So this is called reflux oesophagitis. But not all GERD patients have this reflux oesophagitis.
Sometimes patient can have a normal endoscopy but still patient can also suffer from GERD or patients can present with symptoms of GERD. In such scenarios, the best investigation to rule out the presence of gastroesophageal reflux disease is by performing a 24-hour pH study in which we put a catheter above the GE junction or in the food pipe and we record for a period of 24 hours.
We record the pH in the lumen of the esophagus near the stomach junction. So in which it is exaggerated or the acid exposure in the esophagus is exaggerated. So this test is a gold standard to diagnose gastroesophageal reflux disease. And especially this is more useful when it is performed in a patient with normal endoscopy but still has present symptoms of gastroesophageal reflux disease. So now after endoscopy and performing a 24-hour reflux study once the diagnosis of GERD is established, we must know how to treat GERD.
Treatment for GERD?
We divide GERD treatment into two settings or two scenarios in which first is the medical management of GERD whenever the patient presents to us with symptoms of GERD or chronic reflux disease usually we tend to monitor the weight that is the best advice what a Gastroenterologist can give to the patient.
Life Style Changes
So if a patient is definitely found to be obese or overweight first the patient must focus in addition to the medical management or in addition to taking medicines he must also focus on losing weight because as we discussed earlier weight loss helps in reducing the reflux symptoms. So the patient has to follow a low-fat diet, the patient has to exercise regularly and he must avoid taking high density or high-energy-dense food, fatty food or fried food and also advice has to be given on quitting smoking and also reducing alcohol intake and also avoiding taking excess coffee. The patient can limit to one or two cups of coffee but not more than that in a patient with typical reflux complaints, coffee intake should be limited to one or two cups in a day. In addition to that patient should also be advised not to take excessive chocolate or excessive mint which can also increase the reflux.
Medical Management of GERD
After this general lifestyle modification measures, we usually put the patient on medical management where we give drugs which reduce the acid levels or prevent the reflux. The drugs are of different classes, so usually a patient is given a trial for two to three months and in that period we tend to assess the response. After this if the patient is still symptomatic then we tend to assess for any changes needed in the dosage or if any further assessment is required or not.
Sometimes in a patient with a hiatus hernia, so even though we use long-term medicines the medicines may not show 100 % relief. In such cases whenever a patient has a significant hiatus hernia who is not responding to medicines even after a few months of usage, what we tend to advise is for laparoscopic procedures which is called fundoplication.
Endoscopic management of GERD
Over the period of last decade, there has been extensive research done in the field of gastroenterology in treating GERD endoscopically. So we have good endoscopic techniques available now to treat gastroesophageal reflux disease of which important ones are ARMA which is called Anti-Reflux Mucosal Ablation and GERD-X which is a technique, a novel technique where we use a separate equipment which is passed endoscopically and which is used to plicate or ligate the junction which is usually loose or lax in case of GERD. So here we must understand that with the advent of new technologies in endoscopy in the field of gastroenterology the surgery rates has also been decreased and the recent studies comparing this endoscopy techniques versus laparoscopic techniques have proven to be almost equal when it comes to efficacy wise. So when it comes to endoscopic management in a patient of GERD who is not responding medically we can safely advise endoscopic management which includes ARMA and GERD-X and also only in cases of non-responsive patients with significant hiatus, then we tend to go for laparoscopic management.
Complications of GERD
When it comes to complications of GERD, what are the complication which can arise in a patient with chronic reflux? Of which few important ones includes strictures or peptic stricture formation. Basically what happens is whenever there is an acid reflux when acid tends to trickle up into the esophagus from the stomach the stricture formation can occur because of chronic acid exposure where the esophagus lumen, the esophageal lumen is narrowed thereby patients will have difficulty in swallowing which is called dysphagia. In addition to stricture formation, there can be bleeding from the ulcers which developed because of acid reflux. So in addition to stricture esophagus and bleeding, there is another complication which is called Barrett’s esophagus which is a separate entity by itself which occurs because of chronic reflux. Here Barrett’s esophagus is a condition in the lower esophagus which is a risk factor for future esophagal cancer. So these are the broad complications arising because of chronic reflux disease. Thank you.
