Gastroesophageal Regression
Gastroesophageal reflux is a condition in which the lower oesophageal sphincter (LES) , a muscular ring in the lower part of the oesophagus that acts as a valve between the oesophagus and the stomach, does not close properly and allows the contents of the stomach to reflux into the oesophagus.
The reflux of gastric contents, whether acidic or alkaline, irritates the inner surface of the oesophagus, and causes a burning sensation in the chest or throat called retrostatic burning. A reflux sensation is also common, in which gastric contents may be felt to rise up into the throat or at the back of the mouth. Occasional heartburn is common, but does not necessarily mean that we have GERD.
Chronic acid reflux, especially when acidic content is involved, can cause inflammation of the oesophageal lining - oesophagitis - and may be responsible for the development of peptic strictures or pre-cancerous lesions such as Barrett's oesophagus.
What are the symptoms?
The main symptoms are frequent heartburn, burning sensation in the chest, and reflux. Other symptoms resulting from acid reflux are chest pain, difficulty swallowing, or a feeling of a stuck pale throat, coughing and hoarseness. Some patients may have no symptoms, but may still have lesions of inflammation of the surface of the oesophagus.
What are the complications of gastroesophageal reflux disease?
Sometimes GERD can cause serious complications. Inflammation of the esophagus by gastric acid causes bleeding or ulcers. In addition,chronic inflammation can contribute to the formation of peptic strictures that prevent the swallowing of food and are associated with feelings of dysphagia. As a result of chronic inflammation, Barrett's esophagus, a precancerous condition that can lead to esophageal cancer over time. Finally, studies have shown that asthma, chronic cough, and pulmonary fibrosis can be exacerbated or even caused by GERD.
What are the causes?
The most common cause of gastroesophageal reflux disease is the presence of a diaphragmatic hernia in which the part of the stomach is above the diaphragm, the muscular wall that separates the stomach from the chest. The presence of a diaphragmatic hernia contributes to the inadequacy of the lower oesophageal sphincter, resulting in easier reflux of gastric contents into the oesophagus. Unfortunately, the existence of a diaphragmatic hernia is quite common and can occur in people of any age.
Other factors that may contribute to GERD include:
- The use of alcohol
- The increase in body weight
- Pregnancy
- Smoking
Eating certain foods can also aggravate acid reflux. Such foods are
- citrus
- chocolate
- drinks with caffeine
- fatty and fried
- garlic and onions
- peppermint flavourings
- spicy foods
- tomato-based foods such as pasta sauce, chili, and pizza
Investigation of gastroesophageal reflux disease
Gastroscopy is an ideal examination for the detection of lesions associated with gastroesophageal reflux disease such as esophagitis, peptic strictures, Barrett's esophagus. During the gastroscopy the physician may also take biopsies of any lesions or also perform therapeutic procedures such as for example dilatation of possible strictures.
Radiological examinations now have a limited role in the diagnosis of gastroesophageal reflux disease. Barium oesophagography is also used to diagnose oesophageal or gastric motility disorders, while CT scans are used to exclude major lesions of the thorax or mediastinum.
In recent years, other diagnostic tests such as manometry and pH measurement have also played an important role in the investigation of resistant gastroesophageal reflux disease. Manometry helps to detect esophageal motility disorders that may contribute to the occurrence of reflux symptoms, while ph metric allows the precise measurement of reflux episodes and the degree of correlation with the patient's symptoms.
What is the appropriate treatment?
Treatment may include a combination of lifestyle and dietary changes, medications or surgery. Lifestyle changes can be effective in about 20% and involve stopping smoking, losing weight, elevating the head of the bed, eating small meals frequently, and avoiding foods that may aggravate acid reflux.
Drug treatment consists of administering antacids or gastric acid secretion inhibitors that neutralise the acidic gastric fluid and help to reduce symptoms.
Antacids, such as Maalox, Simeco, Aludrox, and Riopan, are usually the first medications recommended to relieve heartburn and other mild symptoms of GERD.These can be obtained without a prescription.Many brands on the market use different combinations of the three basic salts - magnesium, calcium, and aluminum - with hydroxide or bicarbonate ions to neutralize the acid in your stomach. Antacids, however, have side effects. Magnesium salts can lead to diarrhea, and aluminum salts can cause constipation. Aluminum and magnesium salts are often combined in a single product to balance these effects.
Calcium carbonate antacids, such as Tums, Titralac, can also be a supplemental source of calcium. They can cause constipation.
Combinations of antacids and alginates, such as Algoral protect and Gaviscon, cover the contents of the stomach to prevent reflux. These medications can help those who have no damage to the esophagus.
H2 blockers, such as cimetidine , phamotidine , nizatidine , and ranitidine , inhibit acid production. These drugs provide short-term relief. They are effective for about half who have GERD symptoms. Many people benefit from taking bedtime H2 blockers in combination with a proton pump inhibitor.
Proton pump inhibitors include omeprazole , lansoprazole , pantoprazole , ramprazole , and esomeprazole . Proton pump inhibitors contribute to reduced production of gastric acid and are more effective than H2 blockers and can relieve the symptoms of almost everyone who has GERD.
In addition to the above drugs, another group of drugs, the prokinetics, are used to help strengthen stomach contractions and speed up the movement of gastric contents into the small intestine. This group includes domperidone, metoclopramide and the Prodigest complex (a combination of artichoke and ginger extracts - commercial formulation silactis prokinetic). Metoclopramide improves muscle action in the digestive system, but has frequent side effects which limits its usefulness.
Because medications work in different ways, combinations of medications can help control symptoms.
Surgery is finally a treatment option in patients with gastroesophageal reflux disease resistant to conventional drug therapy or in cases of large diaphragmatic hernia. Nissen's tholoplasty is the most common surgical procedure in which the upper part of the stomach is wrapped around the KOS to strengthen the sphincter, prevent acid reflux and repair the diaphragmatic hernia.
