By James C. Rosser, Jr., MD, FACS Jay Redan, MD, FACS Robyn Gardner, MHE, PA-C Advanced Laparoscopic Surgeons Florida Hospital Medical Group
Gastroesophageal reflux disease (GERD) is a condition in which the stomach contents (food or liquid) leak backward from the stomach into the esophagus (the tube from the mouth to the stomach). When you eat, food passes from the throat to the stomach through the esophagus or food pipe. Once food is in the stomach, a ring of muscle prevents food from moving backward into the esophagus. These muscle fibers are called the lower esophageal sphincter (LES). If this sphincter muscle doesn’t close well, food, liquid and stomach acid can leak back into the esophagus. This is called reflux or gastroesophageal reflux. This action can irritate the esophagus, causing heartburn, other symptoms and damage that can lead to cancer.
What Are the Symptoms?
There are two groups of symptoms that are produced with reflux. We refer to them as the “Two Faces of Gastroesophageal Reflux Disease.” There is the face that represents the most commonly noted symptoms and a more sinister face that represents what are called the “silent symptoms.” The common symptoms are:
- Burning breast plate (sternal) chest pain; increased by bending or lying down, worse at night, and relieved by antacids
- Food sticking after swallowing behind breast plate
- Acid in back of throat/sour taste upon awakening
- Upper abdominal pain
- Temporary relief obtained with OTC antacids
These are classic symptoms of reflux that many of us will have as part of our lives. When these symptoms are aggressive, there is no doubt that there is a problem. A more concerning presentation are those patients that do not have this symptom pattern. These symptoms are not the ones listed earlier and historically have not been associated with reflux.
Silent reflux is an often overlooked or misdiagnosed scourge that most patients do not know they have. Many physicians are not familiar with their significance and relationship to reflux. Silent reflux symptoms include:
- Postnasal drip
- Persistent cough
- Lump in throat
- Raspy or hoarse voice
- Non-cardiac chest pain
Frequently, the patient will present initially with these symptoms and none of the typical symptoms listed above. Classic reflux is absent in 60% of asthmatics, 43-75% of patients with chronic cough and 54%-94% of patients with ENT complaints such as hoarseness, post-nasal drip and chronic sinusitis. There are direct and indirect reasons for this association. Understandably, if acid refluxes all the way back up into the larynx and bronchus, there is a direct cause and effect that leads to laryngitis, chronic cough, or asthma. However, there is a little known indirect causation that can be explained by the fact that the esophagus and bronchial tree share a common embryologic and neural origin via the vagus nerve. When acid comes into the distal esophagus there is stimulation of the acid-sensitive receptors. This can cause non-cardiac chest pain, cough, or bronchoconstriction and asthma. This is a problem that has a strong footprint. Up to 38% of pulmonary referrals are for patients with a chronic cough of up to 3 weeks duration. Furthermore, there are 15 million people in the US with asthma, and 50-80% may have GERD.
How Common Is It?
It is absolutely shocking how many people this disease affects. Here are some startling facts about the widespread nature of GERD, and we often refer to this segment as “Gosh, I Didn’t Know That.”
- Upwards of 40 % (60-120 million) Americans have heartburn once a month
- 20% (60 million) Americans have heartburn once a week
- 3-7% (9-21 million) Americans have a more serious problem called GERD where they have reflux every day
- 1 in 33 people in the US have GERD
- The incidence is rising
- 22% of the primary care visits in this country involve GERD symptoms, and this is an increase of 46% over the last five years
- One theory is that the increase in obesity has also increased the incidence of GERD
Why Should I Be Concerned?
The uncontrolled bathing of the esophagus (food tube) with acid is not a good thing. The stomach has certain structural features that allow it to be bathed in acid without any damage occurring. However, the esophagus is not designed to tolerate extensive exposure to acid without damage ultimately occurring. The prolonged presence of acid in the esophagus leads to complications that can produce a range of problems from annoyance to death. The following are the complications that can occur with GERD:
- Erosive Esophagitis occurs from irritation and subsequent erosion of the lining of the food tube secondary to acid coming up from the stomach. This leads to heartburn, inflammation and, ultimately, tissue damage.
- Esophageal ulcers and strictures – represents a more aggressive attack on the food tube from acid in the stomach. The inflammation goes deeper, making a crater or multiple craters that make up an ulcer. When the inflammation continues unabated, it tries to heal with scar tissue. When the scar tissue becomes prominent, a stricture (a shrinkage of the opening of the food tube by scar) develops that can cause difficulty swallowing (dysphagia). Now the disease has taken a more serious debilitating profile that can change your life forever. This circumstance should be avoided at all cost.
- Barrett’s esophagus – the bathing of the esophagus (food tube) with acid is something that is absolutely not the natural state of things for the human gastrointestinal system. The body senses this imbalance and tries to adapt and compensate. The cells lining the esophagus have no protection against acid; therefore, over time, the cells begin to change. Slowly, the squamous cells lining the food tube began to take on the characteristics of the stomach cells. The stomach cells have characteristics that protect them from acid damage. Unfortunately, these cells cannot make the change and are in fact abnormal. This is called Barrett’s esophagus. There is no way that a patient can tell when this condition occurs, and years can pass before symptoms from this situation present. The main problem with Barrett’s esophagus is that these abnormal cells can develop cancer if left untreated over many years.
- There are two types of esophageal cancer. Squamous cell carcinoma begins in the tissues that line the esophagus and can occur anywhere in the esophagus. It happens more frequently in the middle to upper part. A second type is adenocarcinoma, and it is more common as a result of Barrett’s esophagus and is found in the lower-third of the esophagus. For both of these two conditions, the take away is do not ignore symptoms and seek proper evaluation early.
GERD and Esophageal Cancer
GERD recognition is more important today than at any other time in history. Esophageal cancer is the fastest growing cancer in the US and often the signs and symptoms are silent or are not taken seriously. Here are some facts about esophageal cancer:
- Has increased by 400% since the 1970s
- Especially in white males
- In 2012,18,000 men and women were diagnosed
- 14,000 men and 4,000 women
- 15,000 died from esophageal cancer in 2012
- 4.5 new cases per 100,000 people
- This is compared to 33,000 deaths from auto accidents in 2010
- Imagine if 60 airplane crashes with an average of 250 passengers being lost on each one occurred in the US each year. This would be the cause for a high level of concern.
What Can I Do?
I know that many of you are scared to death. You probably did not know that “a little heartburn” could possibly threaten your well-being or life. Now that you have become aware, we want to let you know how to proceed to be evaluated and, if necessary, obtain a cure from the disease. The steps to the cure include performing a Heartburn Status Test. If the HST determines that you are at risk, you should proceed to the proper medical professional for a thorough evaluation. From that evaluation you usually proceed with conservative interventions (diet modification, weight loss, stop smoking, etc.), medical management, and, depending upon your response to treatment, more aggressive surgical options may be used. The key point to remember is that once diagnosed, this disease can be treated successfully.
Your first step should be to take the Heartburn Status Test (HST). This is a self-evaluation questionnaire that can help determine if you should seek medical evaluation. It can be done in the privacy of your home and, best of all, it is administered by you.
Heartburn Status Test
Symptoms, rate each from 0-5:
- Sensation of sticking in back of throat
- Heartburn, chest pain, acid in back of throat
- Excess mucous and post-nasal drip
You should use your judgment to determine if you have these symptoms and give your best guess on the severity using the numbers 0-5. Of course 0 represents no symptoms at all and 5 means that symptoms are very bad and negatively impact your lifestyle. Add all the scores up and a score greater than 10 indicates that you should seek medical attention for further work-up.
What Should I Do Next?
If you have identified that you may be at risk for GERD, it is time to consider next steps to obtain a diagnosis. Once again, we have to revisit the two types of symptoms that can present with GERD. If you have silent reflux symptoms, the first step would be a nasopharyngoscopy. This will allow your physician to see your vocal cords and the area around the vocal cords called the pharynx. New technology, such as the small, flexible scope from Vision Sciences allows the painless and cost-effective initial evaluation to be performed in the office without sedation or heavy anesthesia. According to J. Scott Magnuson, MD and Hilliary White, MD of Celebration Hospital in Orlando, Florida, ENT specialists are the first to evaluate the silent symptom presentation. But, with increased awareness and training, the New Vision technology will let your family physician or internist start your diagnosis journey right away. If any abnormalities are found, you will then be referred to your gastroenterologist. Today, gastroenterologists on the cutting edge will seek to establish a definitive diagnosis right away rather than treat you with anti-acid therapy blindly. It is important to identify what you are treating first. GERD can mimic other conditions from gastric ulcers to heart attacks.
Also, once the diagnosis is made and the proper medication at the right dose taken at the right time is prescribed, documentation of the results of treatment has to be established. The diagnosis is usually made by an esophagogastroduodenoscopy (EGD) with or without biopsy. The biopsy can provide definitive evidence of inflammation or tissue change caused by acid reflux. Frequently, there is evidence of erosions, ulcers or strictures that represent aggressive disease that cannot be cured by medicines. These patients should be strongly considered for surgery very early in their treatment. Once the diagnosis is made, many gastroenterologists will immediately try to determine if your form of GERD is amenable to a surgical approach. A 24-48 hour exam to determine the quantity of acid reflux is ordered. This can be done by an older method that places a catheter down your nose and a newer method that leaves a capsule in place at the same time of your EGD. If the acid level (DeMeester Score) is two to three times the normal amount, medication may not be effective and surgery is indicated early.
An esophageal strength and motility study is also usually ordered. It gives the physician a suggestion of the pumping power of the food tube. This can determine what type of operation will be offered (Nissen-Full wrap, Toupet-partial wrap, or the Linx Reflux Management System). It also can give you the strength of the door between your stomach and food tube. If it is less than 6 mm of mercury of pressure, medicines are not going to affect a cure.
It is very important for you to choose your physicians carefully. If you have a tentative, non-aggressive physician, you may have a different treatment plan. The promotion of this more aggressive strategy has also been secondary to the discovery that the “miracle meds” are fraught with very significant side effects with long-term use that had not been previously appreciated.
It should be noted that X-rays (Upper GI series) have only a limited and specialized use in the diagnosis of GERD. It is very useful in determining if you have a specialized hernia, called a paraesophageal hernia, that is famous for causing an upside down stomach to reside in the chest. This procedure’s greatest use is for follow-up for surgical reflux procedures.
How Do I Take Care of the Problem?
The bad news so far is that you may have a problem. The good news is that there are things that can be done to cure or help you live with the problem. First, let’s talk about lifestyle changes.
Changing your usual and customary way of conducting your life can make a big impact on your GERD. It can be something as simple as changing your diet. When it comes to GERD and food, there is good food and bad food. Below is a listing of both categories:
Good GERD Foods
- Grilled and baked meat
- All veggies
- Breads, rice, oatmeal
- Alkaline water, soy and coconut milk
- Chamomile tea
- Manuka honey
Bad GERD Foods
- Corrosive Cs
- Carbonated and citrus beverages
- Canned foods
- Whopper Woes
- Raw tomatoes
- Breath mints
Other lifestyles changes can be very important in your efforts to take control of this disease. It should be remembered that it is not just what you eat that can be important, but when you eat. Try to eat a lighter meal in the evening and limit consuming large amounts of food near bedtime. Also, remember to sleep with your head elevated on multiple pillows. All of this fits in well with an overall weight-loss program, which can also be very pivotal in controlling symptoms.
Clothing should not be tight-fitting as it can increase the pressure in the stomach and cause an increase in reflux. Finally, decreasing smoking can significantly assist in the control of your symptoms because it decreases the pressure of the lower esophageal sphincter. The lower the pressure of the lower esophageal sphincter, the more acid is allowed to come from the stomach and into the food tube (esophagus).
Medicines can also play a significant role in curing and controlling reflux. Some of the more important ones are Nexium, Prevacid, Prilosec, Protonix, and Aciphex. Remember they have different names but the same game: The reduction in the release of acid in the stomach. Less acid in the stomach means less acid to reflux into the esophagus. When first introduced, these medicines were touted as being the “magic pill” – “take one everyday and keep reflux and heartburn away.” The fact is 45% of patients properly diagnosed and treated with these meds will be treated, cured and not have this problem again.
Unfortunately, this type of treatment behavior has now been shown to be in error. Twenty percent of patients with the disease that are treated properly will still have treatment failures. Furthermore, there are increasing reports and academic evidence of side effects of the medication and evidence that “the magic pill” cannot be taken forever. The following are some of the side effects of GERD drug therapy:
- Nexium, Prevacid, Prilosec, Protonix, Aciphex are all included
- Increase in the rate of hip fractures
- Anemia (Iron, B12)
- C. Difficile colitis
- Increased risk of community -acquired pneumonia
- Extremely expensive
- $13 billion spent on these meds in 2006
What Is the Next Step If Lifestyle Changes and Medicines Do Not Work?
The treatment of GERD usually follows a stair-step approach that goes from the simple to the complex. Lifestyle changes and medicines make up the simple, less aggressive arm of the treatment options. If these fail, invasive treatment must be considered. There are degrees to the level of invasiveness ranging from endoscopic procedures that do not require incisions, all the way to procedures that require full-blown open surgery (incisions may be 12 inches or more).
Regardless, all of the procedures that are involved with the treatment of GERD are meant to correct the continuous or episodic incompetence of the lower esophageal sphincter.