Question

TS is 67 years old with a long history of knee osteoarthritis for which he self-medicates regularly with over-the-counter (OTC) naproxen. He is in the clinic today complaining of a swallowing difficulty that has progressively worsened over the past several months. He has otherwise been healthy and has not seen a doctor in many years. TS denies significant past medical history. A review of systems is negative except for arthritic symptoms and swallowing difficulty. He denies noticing blood in his stool and vomiting blood. He denies history of gastroesophageal reflux disease (GERD) and ulcer. He does not drink alcohol, although he drank heavily many years ago. He does not smoke. TS describes the dysphagia this way: “Food gets stuck in my throat, and I can’t get it down.” The feeling occurs only after he has ingested solid food; liquids are not a problem. There is burning chest pain associated with meals. He is scheduled for an upper gastrointestinal endoscopy.

1. What are the usual signs and symptoms of GERD? How will it be managed?

Answer 1

Gastroesophageal reflux disease, or GERD, is a digestive disorder that affects the ring of muscle between your esophagus and your stomach. This ring is called the lower esophageal sphincter (LES). If you have it, you may get heartburn or acid indigestion. Doctors think that some people may have it because of a condition called hiatal hernia. In most cases, you can ease your GERD symptoms through diet and lifestyle changes. But some people may need medication or surgery.

The most common symptom of GERD is heartburn (acid indigestion). It usually feels like a burning chest pain that starts behind your breastbone and moves upward to your neck and throat. Many people say it feels like food is coming back into the mouth, leaving an acid or bitter taste.

The burning, pressure, or pain of heartburn can last as long as 2 hours. It’s often worse after eating. Lying down or bending over can also result in heartburn. Many people feel better if they stand upright or take an antacid that clears acid out of the esophagus.

People sometimes mistake heartburn pain for the pain of heart disease or a heart attack, but there are differences. Exercise may make heart disease pain worse, and rest may relieve it. Heartburn pain is less likely to go along with physical activity. But you can’t tell the difference, so seek medical help right away if you have any chest pain.

Besides pain, you may also have

• Nausea
• Bad breath
• Trouble breathing
• A hard time swallowing
• Vomiting
• Wearing away of tooth enamel
• A lump in your throat

If you have acid reflux at night, you may also have:

• A lingering cough
• Laryngitis
• Asthma that comes on suddenly or gets worse
• Sleep problems

GERD Treatment

GERD treatment aims to cut down on the amount of reflux or lessen damage to the lining of the esophagus from refluxed materials.

Your doctor may recommend over-the-counter or prescription medications to treat your symptoms.

• Antacids: These drugs can help neutralize acid in the esophagus and stomach and stop heartburn. Many people find that nonprescription antacids provide temporary or partial relief. An antacid combined with a foaming agent helps some people. Researchers think these compounds form a foam barrier on top of the stomach that stops acid reflux.
  But long-term use of antacids can bring side effects, including diarrhea, altered calcium metabolism (a change in the way the body breaks down and uses calcium), and a buildup of magnesium in the body. Too much magnesium can be serious for people who have kidney disease. If you need antacids for more than 2 weeks, talk to your doctor.
• H2 blockers: For chronic reflux and heartburn, the doctor may recommend medications to reduce acid in the stomach. These medicines include H2 blockers, which help block acid secretion in the stomach. H2 blockers include: cimetidine (Tagamet), famotidine (Pepcid), and nizatidine.
• Proton pump inhibitors (PPIs): Also known as acid pumps, these drugs block a protein needed to make stomach acid. PPIs include dexlansoprazole (Dexilant), esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), omeprazole/sodium bicarbonate (Zegerid), pantoprazole (Protonix), and rabeprazole (Aciphex).
• Prokinetics: In rare cases, these drugs help your stomach empty faster so you don’t have as much acid left behind. They may also help with symptoms like bloating, nausea, and vomiting. But they can also have serious side effects. Many people can’t take them, and those who can should do so only for a limited time. Example of prokinetics include domperidone and metoclopramide (Clopra, Maxolon, Metozolv, Reglan)

Diet and Lifestyle Changes

There are several changes that doctors suggest you make in your lifestyle to help lessen your symptoms of GERD.

• Avoid foods and beverages triggers: Stay away from foods that can relax the LES, including chocolate, peppermint, fatty foods, caffeine, and alcoholic beverages. You should also avoid foods and beverages that can irritate a damaged esophageal lining if they cause symptoms, such as citrus fruits and juices, tomato products, and pepper.
• Eat smaller servings: Eating smaller portions at mealtime may also help control symptoms. Also, eating meals at least 2 to 3 hours before bedtime lets the acid in your stomach go down and your stomach partially empty.
• Eat slowly: Take your time at every meal.
• Chew your food thoroughly: It may help you remember to do this if you set your fork down after you take a bite. Pick it up again only when you’ve completely chewed and swallowed that bite.
• Stop smoking: Cigarette smoking weakens the LES. Stopping smoking is important to reduce GERD symptoms.
• Elevate your head: Raising the head of your bed on 6-inch blocks or sleeping on a specially designed wedge lets gravity lessen the reflux of stomach contents into your esophagus. Don’t use pillows to prop yourself up. That only puts more pressure on the stomach.
• Stay at a healthy weight: Being overweight often worsens symptoms. Many overweight people find relief when they lose weight.
• Wear loose clothes: Clothes that squeeze your waist put pressure on your belly and the lower part of your esophagus.
• Acupuncture: In one study, treatment with acupuncture stopped reflux in the test group better than PPIs, with results that lasted longer. We need more large studies to confirm this, but early results are promisin

Severe GERD Diagnosis

If you have severe, lasting esophageal reflux, or if your symptoms don’t get better with treatment, you may need tests for a better diagnosis. Your doctor may use one or more procedures to do this:

• Endoscopy: Your doctor will put a small lighted tube with a tiny video camera on the end (endoscope) into your esophagus to look for inflammation or irritation of the tissue (esophagitis). If the results are abnormal or questionable, they may remove a small tissue sample for more testing (biopsy).
• Upper GI series: This may be one of the first tests your doctor does. It’s a special X-ray that shows your esophagus, stomach, and the upper part of your small intestine (duodenum). It gives limited information about possible reflux, but it can help rule out other conditions, such as peptic ulcers.
• Esophageal manometry and impedance study: This test checks for low pressure in your esophagus. It can also show defects in how your esophageal muscles contract.
• pH testing: If it’s hard to make a definite diagnosis, your doctor may measure the acid levels inside your esophagus through this test. It tracks how much acid is in your esophagus during meals, activity, and sleep. Newer techniques of long-term pH tracking have made this a more effective too

Surgery for Severe GERD

If you need regular high doses of PPIs to control your symptoms, have damage to your esophagus even with medication, and a hiatal hernia, you may need surgery for GERD. But you should try all the other treatments you can first.

Fundoplication: This is a procedure that raises the pressure in your lower esophagus. The doctor will wind the top of your stomach around the LES. This tightens the muscle and raises pressure in your lower esophagus to stop reflux. They’ll do this either through a laparoscope (small holes through the belly) or through open surgery.

Transoral incisionless fundoplication (TIF): A newer from of this surgery uses an endoscope (a small tube with a camera) to wrap the stomach around the LES with plastic fasteners. It’s less invasive than standard fundoplication.

Stretta procedure: Your doctor puts a small tube down the esophagus that uses low-radiofrequency heat to reshape your LES.

LINX surgery: Your doctor wraps a band of magnetic titanium beads around the place where your stomach and esophagus meet. The magnetic attraction of the beads keeps it loose enough to let food pass through into the stomach, but tight enough to stop reflux

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