Heartburn / Gastroesophageal Reflux Disease (GERD)

The Gastroesophageal Reflux Disease (GERD) is caused by the gastric acid reflux present in the esophagus (which represents the tube that connects the neck and the stomach). GERD usually occurs when the lower esophageal sphincter relaxes at an inappropriate moment (in a normal situation, the esophageal sphincter would remain closed and would relax only when swallowing occurs) and remains relaxed for a long period of time. In a regular situation, the esophageal sphincter would open for no more than a few seconds during the process of swallowing. After these seconds, the esophageal sphincter should close.

 

The Difference Between Heartburn and GERD

While GERD is an actual disease, heartburn can occur from time to time after certain types of meals, intense physical exercise or an abusive consumption of meat, lipids, sugar etc. The symptoms of the two affections are similar and the term heartburn is often used to describe GERD. The main difference between heartburn and GERD would be the duration and the recurrence of the symptoms. Heartburn is considered by specialists a symptom of the Gastroesophageal Reflux Disease, but not in all the present cases. Heartburn can disappear in a few days without special treatment, while GERD can’t.

In addition, heartburn is often mistaken for a heart attack. There is a lot of confusion between the two affections simply because they cover an imprecise location and the description of the symptoms is highly similar. Yet, there are certain factors that do make a difference between them. Heart attacks are often presenting the following symptoms, besides encountering heartburn:

  • Pain in the chest area
  • Dizziness
  • Chest pressure which is rapidly getting worse
  • Inflammation in the shoulder area, neck area, jaw area or arms
  • Sweating and blurred vision
  • Breathing difficulties

 

Heartburn / GERD Overview & Facts

The pathophysiological mechanism of GERD should be explained in order to understand how this disease acts upon the human body. GERD that reached a certain level of severity can cause irritation, inflammation or even erosions in the esophageal mucosa. These types of manifestations combined are called esophagitis. Esophagitis can also be caused by other factors such as candida, herpes or the cytomegalovirus. Toxic substances or foreign bodies which are swallowed can cause irritation or burn the esophagus. Alcohol and smoking can do the same for a person who has a weakened immune system. Esophagitis can lead to esophageal strictures, hemorrhages, ulcers or chronic scars – all affecting one’s ability to swallow.

When GERD with no signs of esophagitis, the disease can be considered a non-erosive reflux disease. Yet, when severe symptoms are encountered (including heartburn), GERD is definitely present.

Approximately 85% of pregnant women suffer from gastroesophageal reflux. The reason why pregnant women face symptoms of GERD is that the hormones present during pregnancy cause the intestinal transit to slow down. The esophageal muscles which are responsible for properly transiting the food into the esophagus can also suffer from a certain slowed-down activity. In addition, because the uterus grows in size and pushes against the stomach, it can force gastric acid into the esophagus thus causing GERD symptoms.

Most people will encounter GERD at least once in a lifetime. Depending on the severity of the symptoms the patient experiences, the treatment can be diverse. Long-term treatment, for people who encounter the symptoms of GERD often, can last all of the patient’s life for proper results. In some cases, GERD can be recurrent, even though treatment was followed. In the same situation, when patients do not follow a certain treatment scheme and they are simply changing specific lifetime habits or prescription-free drugs, GERD can require treatment to avoid recurrence.

For people who suffer from GERD until a point where is no longer bearable, surgery can be an option. Yet, the complications and side effects of this surgery make it one of the less selected treatment methods. Fundoplication can be successful in 60% of the cases and it removes the symptoms of GERD along with esophagitis completely. Fundoplication is not a stable procedure and it can have serious consequences if not properly handled. Fundoplication can be realized using only an endoscopic surgery which involves the introduction of a thin tube called laparoscope inside the abdominal cavity through a very small incision. This instrument allows the doctor to properly visualize the intraabdominal organs without being invasive. Other surgical instruments can be inserted into the abdominal cavity through different small incisions.

 

Symptoms of GERD

The main symptoms of GERD include:

  • An intense, persistent sensation of heartburn (an unpleasant sensation in the chest area, associated with back pain) – it occurs after eating a large meal, after lying down in bed or bending forward. Antacid or acid-blocking medication can reduce heartburn. It usually occurs 2 hours after the patient ate. In severe cases of Gastroesophageal Reflux Disease, heartburn can last for a long time, even once treatment was administered.
  • Sensing a sour/bitter taste inside the mouth – the reflux of acidic stomach contents can reach the esophagus and thus cause a sour/bitter taste, which is often accompanied by heartburn.
  • Excessive salivation – acid reflux produces excessive salivation that is visibly deranging to the patient.

When the aforementioned symptoms occur at a greater frequency (more than twice a week), they can be a sign of suffering from GERD. Many patients usually describe the burning or chest pain sensation or the sour/bitter taste one without suffering from GERD. Retrosternal burns are not necessarily present. A person can be suspected of GERD if other symptoms are present: retrosternal pain, dysphagia, sore throat, morning nausea, dry cough, bad breath etc.

The complications of the Gastroesophageal Reflux Disease include:

  • Difficulty in swallowing (in advanced cases of GERD)
  • Acute retrosternal pain (can also be encountered as intense chest discomfort and heartburn). People often confuse this symptom with having a heart attack
  • Nausea – often encountered in the morning
  • Certain affections of the nose, ears or throat (neck injuries, throat discomfort, hoarseness)
  • Lung/breathing disorders including coughing, wheezing, pneumonia, bronchiectasis, chronic asthma. GERD can worsen the symptoms of asthma.

Children suffering from GERD can encounter a development delay and respiratory problems. Peptic ulcer or esophageal infections can also be present along with GERD.

 

Diagnosing Heartburn / GERD

Diagnosing Gastroesophageal Reflux Disease doesn’t require multiple investigations in certain cases. People with usual, mild symptoms can diagnose GERD rapidly by seeing a doctor. A history of repeating symptoms such as burning, or chest pain sensation can raise suspicion and require further investigations. In the case of patients repeating episodes of heartburn, the doctor can prescribe medication which is commonly used for Gastroesophageal Reflux Disease without side effects. If when following this treatment scheme the patient won’t be facing any kind of improvements, the doctor can finally diagnose whether GERD is present or not. An investigation which is called digestive endoscopy will be made by a gastroenterologist and will allow the specialist to visualize the esophagus, stomach and the first part of the duodenum with the help of a thin, flexible instrument with an end-view camera attached to it.

Endoscopy is recommended for patients who:

  • Encountered the symptoms of Gastroesophageal Reflux Disease for a longer period of time than usual cases
  • Observed that the symptoms of Gastroesophageal Reflux Disease didn’t improve after treatment
  • After stopping taking the treatment scheme, the symptoms reappeared
  • Encountered weight loss, vomiting or swallowing issues

Endoscopy helps with:

  • Evaluating the inflammation level of the esophagus and other complications caused by Gastroesophageal Reflux Disease including bleeding or strictures of the esophagus
  • Excluding the case of Barrett’s esophagus

Barrett’s esophagus is a condition where the normal squamous epithelium found in the esophagus area, once exposed to gastro-duodenal reflux (acid and biliopancreatic), is replaced with a metaplastic columnar epithelium consisting of caliciform cells. This condition represents a stage of Gastroesophageal Reflux Disease, which was first described by Norman Barrett in 1950.

At first, Barrett’s esophagus was considered a congenital esophagus, but researchers showed that the congenital primary Barrett esophagus is rarely encountered, its origin being usually of secondary causes. Barrett’s esophagus is encountered due to the direct action of gastroesophageal reflux by substitution of the squamous epithelium as a repair response to the fast-epithelial regeneration of colic epithelial ulcerations. It occurs in approximately 10-12% of patients with chronic Gastroesophageal Reflux Disease, and the more aggressive the Gastroesophageal Reflux Disease, the higher the Barrett esophagus incidence.

The Barrett esophagus invariably affects the distal portion of the esophagus (at the gastroesophageal junction) and extends proximally a few centimeters to the surroundings. At this level, biopsies will be taken into account to confirm the endoscopic diagnosis. There can be identified three different types of columnar epithelium:

If endoscopy is not helping with diagnosing GERD, further investigations are required, even when the symptoms are present. Among these, one can use:

  • Manometry – causes esophageal muscular contractions and assesses the closure of the inferior esophageal sphincter responsible for GERD symptoms apparition. This procedure is indicated before the cases of GERD that require surgery.
  • Monitoring the Ph – which tracks the acid reflux in the esophagus and how much time does it last

Using radiological procedures is not efficient in diagnosing GERD. However, there are certain conditions that can cause similar symptoms, yet totally different consequences. Hiatal hernia or esophageal strictures require other kinds of tests, including radiographs.

 

Heartburn / GERD Treatment

Initial treatment

When encountering symptoms of GERD, the first step towards feeling better would be certain lifestyle changes and H2 blockers administrations (antacids). Patients with severe manifestations of GERD require the administration of stronger medication along with lifestyle modifications in order to achieve therapeutic success. Initial therapeutic methods include:

  • Administering different treatment schemes until the optimal method is found
  • The frequency and dose of medication can be increased gradually until the symptoms reduce
  • Severe symptoms of GERD require lifetime treatment
  • Avoiding fatty foods, chocolate, caffeine, alcohol, smoking etc.

Maintenance treatment

When the aforementioned methods are working for a patient it is advised no to interrupt the treatment scheme for a while. Constantly checking up with a doctor and maintaining a lifestyle which is not worsening the symptoms of GERD is recommended. Approaching the optimal therapy type is based on what was the causing factor of the disease, on how severe the symptoms are and on the overall physical condition of the patient. Effectiveness, safety and costs are the three factors that need to be balanced when choosing a treatment scheme. A yearly visit at the gastroenterologist is necessary.

Emergency treatment

When the symptoms get worse and complications appear, it is advisable to administer higher doses of medications or set up an appointment with a doctor to make sure the diet, lifestyle and treatment scheme are effective enough., In case of severe complications, an abdominal ultrasound investigation is recommended.

At home treatment

Lifestyle changes and prescription-free medication can be useful in treating mild symptoms of GERD (like heartburn):

  • No smoking – nicotine produces a relaxation of the esophageal sphincter which allows gastric acids to reach the esophagus and produce the unpleasant sensation of burning or retrosternal pain
  • A balanced diet – coffee and alcohol should be completely removed from a patient’s lifestyle in order to avoid encountering GERD symptoms
  • Losing weight – for overweight people, it is necessary to lose weight because otherwise there will be a permanent pressure exerted on the stomach and this will increase the risk of heartburn

The following drugs are used for reducing GERD symptoms:

– antacids that neutralize gastric acid and reduce heartburn

– reducers of gastric acid like nizatidine, famotidine, cimetidine, ranitidine, reduce the amount of acid in the stomach.

– proton pump inhibitors such as esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole (prescription drugs)

– prokinetic agents like metoclopramide are associated with side effects. Prokinetic agents are sometimes administered in combination with antacids, but their use is limited by certain side effects that may be severe in some cases.

 

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