Definition

Gastroesophageal reflux is a condition where stomach fluid containing acid refluxes into the esophagus (the passage connecting the mouth and stomach) continuously. The term 'gastroesophageal' originates from 'gaster,' meaning stomach, and 'esophagus,' referring to the esophagus, while 'reflux' means backflow. Gastroesophageal reflux happens when the valve at the end of the esophagus cannot close completely when food arrives in the stomach. Consequently, stomach fluid flows back into the esophagus through the mouth, causing an acidic taste. The acid backflow will cause irritation to the esophageal surface.

Gastroesophageal reflux occurs in nearly everyone at some point in their lives. Occasional reflux that happens only once in a while is generally considered normal. However, if reflux occurs more than twice a week for several weeks and persists even after consuming stomach medication, it may indicate GERD (Gastroesophageal Reflux Disease).

Causes

The exact cause of GERD is currently unknown, but the mechanism behind its symptoms is understood to involve improper valve function in the lower part of the esophagus. This valve, known as the lower esophageal sphincter, is a ring of muscle at the end of the esophagus. When functioning properly, the valve relaxes and opens when swallowing, then tightens and closes afterward. Reflux occurs when the valve cannot tighten or close completely, causing fluid and stomach contents to flow back into the esophagus. Some possible factors that can affect the function of the lower esophageal valve include:

• Eating large portions frequently can cause the upper part of the stomach to expand, leading to improper closure of the valve below the esophagus.
• Lying down too soon after eating can overly relax the valve and cause it to open.
• Hiatal hernia, a condition where the stomach protrudes into the chest cavity through the hole in the diaphragm (the muscle below the lungs), can also impact the function of the valve below the esophagus.

Risk factor

Some risk factors that can increase the likelihood of GERD include:

• Habits of lying down or sleeping immediately after finishing a meal.
• Consumption of certain foods, such as high-fat foods (fried foods, fast food) or products with high acid content, like tomatoes, oranges, and red meat.
• Drinking beverages such as soda, coffee, dairy products, or alcohol.
• Eating large portions frequently.
• Smoking.
• Obesity.
• Increased pressure on the stomach is often experienced by pregnant women.
• Excessive use of anti-inflammatory drugs such as aspirin or ibuprofen.

Symptoms

The most common symptom of GERD is discomfort in the chest that feels like a burning pain, originating from the epigastrium and moving upward toward the neck or esophagus. Some people also experience sensations like food flowing back into the mouth, leaving an acidic or sour taste in the back of the mouth. The burning, pressure, or epigastrium pain can last up to two hours and may worsen after eating. Lying down or bending over can also exacerbate symptoms, while most people feel more comfortable when standing

In addition to chest pain, other symptoms may include:

• Nausea or vomiting
• Bad breath
• Feeling of something stuck in the throat
• Difficulty swallowing
• Trouble breathing

If reflux occurs at night, additional symptoms that may appear are:

• Persistent cough
• Sore throat
• Sudden or worsening asthma
• Sleep disturbances

Diagnosis

In diagnosing GERD, the doctor will start by interviewing you about the symptoms you're experiencing and assessing any risk factors you may have. A physical examination will follow, during which the doctor may find tenderness upon applying pressure to the upper abdomen. Depending on the circumstances, the doctor may recommend additional tests, such as:

• Endoscopy of the upper gastrointestinal tract

During this procedure, a thin, flexible cable equipped with a light and camera is inserted into your esophagus to examine the inner surfaces of the esophagus and stomach. While test results may appear normal even with a history of reflux, endoscopy can detect inflammation in the esophagus (esophagitis) or other complications. Additionally, tissue samples (biopsy) may be taken for further evaluation of complications.

• Ambulatory pH monitoring

This involves inserting a small tube through the nose into the esophagus for 24 hours. pH sensors at the tube's tip measure acid exposure in the esophagus and transmit data to a computer. This test can detect pH changes when the patient is lying down or standing and measure the number and duration of reflux episodes.

• Imaging

This may involve X-ray examinations using X-rays or barium contrast fluid. The purpose is to assess the shape and contour of the gastrointestinal tract and to identify inflammation, hernias, or tumors in the upper gastrointestinal tract.

Management

In treating and reducing the symptoms of GERD, doctors often recommend lifestyle changes such as:

• Maintaining an ideal body weight
• Quitting smoking if you smoke
• Avoiding large meals, especially at night
• Waiting a few hours after eating before lying down
• Elevating the head while sleeping (by raising the head of the bed or using a pillow 15-20 cm high)

Over-the-counter drugs can also help manage GERD, including:

• Antacids

These are useful for neutralizing stomach acid and provide quick relief. However, prolonged use may lead to side effects such as diarrhea and disruption of calcium metabolism. Consult your doctor if you need antacid medication for more than two weeks.

• H2 receptor inhibitors

These medications work by inhibiting H2 receptors in the stomach, thus reducing stomach acid production. They can be helpful for nighttime GERD symptoms and are sometimes used in conjunction with PPI medication. Examples include Cimetidine and Famotidine.

• Proton pump inhibitors (PPIs)

PPI medications are more effective than H2 receptor antagonists in healing the esophageal lining. They work by reducing the amount of acid produced by the stomach. Examples of PPI medications include Omeprazole and Lansoprazole.

Complications

In most cases, GERD does not cause serious complications. However, in rare instances, it can lead to severe health problems or even life-threatening conditions. Here are some complications that may occur:

• Esophagitis: Inflammation of the esophagus.
• Esophageal stricture: Narrowing of the esophagus.
• Barrett's esophagus: Permanent changes in the lining of the esophagus.
• Esophageal cancer: While affecting a small percentage of people with Barrett's esophagus, it is a serious concern.
• Dental problems: GERD can contribute to issues such as erosion of tooth enamel, gum disease, and other dental issues.

Prevention

To prevent GERD, you can take the following steps:

• Eat small and frequent meals instead of large ones.
• Sit upright while eating and remain upright (sitting or standing) for 45-60 minutes afterward.
• Reduce fat intake by avoiding foods high in butter, oil, fatty meats, and high-fat dairy products like cream, cheese, and whole milk.
• Avoid eating before bedtime; wait at least three hours after eating to lie down.
• Achieve and maintain an ideal body weight.
• Avoid wearing tight clothing around the abdomen, as it can compress the stomach and push stomach acid up into the esophagus.
• Quit smoking and limit alcohol consumption.

When to see a doctor?

If you experience severe GERD symptoms that persist for a long time and do not improve after using over-the-counter drugs, it's important to consult your doctor. Remember that chest pain from GERD can sometimes resemble chest pain from a heart attack. Your symptoms and medical history will be further evaluated by the doctor. Follow the recommended therapy provided by your doctor to prevent GERD from recurring or worsening.

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