Gastroesophageal reflux disease or GERD (UK ~ gastro-oesophageal reflux disease, GORD) is a chronic condition characterized by constant or recurrent episodes of acid reflux. The persistent backward flow of the acidic stomach contents up into the esophagus eventually leads to a host of complications and therefore proper treatment and management of GERD is essential.
While most of us will experience the odd episode of acid reflux after overindulging in food and/or alcohol, sleeping or exercising after a large meal, in GERD the reflux is persistent. It may be exacerbated by the same factors that contribute to acute acid reflux but due to other causative factors, GERD will not resolve spontaneously and will inadvertently recur even after the symptoms ease.
Causes of Chronic Reflux
In order to understand the cause of chronic acid reflux it is important to look at the relevant anatomy and physiology. Food travels down the esophagus during swallowing and then empties into the stomach. Thickened muscles in the wall of the lower esophagus controls the passage of contents between the esophagus and stomach. This is known as the lower esophageal sphincter (LES) and it is contracted at all times.
When eating, the LES relaxes slightly to allow food to enter the stomach. It also prevents to acidic stomach contents from traveling up into the esophagus. While the stomach, and even the duodenum to some extent, is equipped to deal with the acid, the esophagus lacks these abilities. When acidic stomach contents enter the esophagus, strong peristaltic waves pushes down the acid back into the stomach while large amounts of alkaline saliva are secreted so that it can neutralize the acid.
In acid reflux, the LES is unable to prevent the backward flow of acid into the stomach and the body’s limited mechanisms to deal with the incoming acid in the esophagus is insufficient. This causes the host of signs and symptoms that is common to acid reflux – heartburn (burning chest pain), regurgitation and nausea. In addition, a person may also experience stomach bloating (a sensation of fullness) and excessive belching (burping).
The causes of chronic reflux includes (refer to diagram) :
- LES dysfunction
- Hiatal hernia
- Intra-abdominal pressure
- Delayed gastric emptying
In these cases, the tone of the contracted LES muscles are lower than normal. Slight changes in intra-abdominal pressure can then allow the stomach contents to overcome the LES resistance and the stomach acidic contents can rise up into the esophagus. Another occurrence is where the LES relaxes for no known reason for short periods of time – this tends to occur as frequent episodes in GERD.
Here a portion of the stomach protrudes through the diaphragmatic opening into the chest cavity. The support offered to the LES by the surrounding diaphragmatic muscle is affected and the pressure difference between the thoracic and abdominal cavities is also disrupted.
The increased pressure within the abdomen, especially on the stomach, may push gastric contents up into the esophagus. This is seen in obese people or pregnant women. Wearing very tight clothing, especially in a person with abdominal obesity, may also increase the intra-abdominal pressure.
Delayed Gastric Emptying
The stomach contents may stay in the stomach for longer than it should due to a number of reasons. Apart from a possible mechanical obstruction, disturbances in gut motility which can extend up from the esophagus, may also be responsible.
Treating and Managing Chronic Reflux
Factors such as overeating, exercising and sleeping after meals, and certain foods and drinks like spicy foods, fatty foods, alcohol, chocolate and acidic foods do NOT cause chronic acid reflux (GERD). Instead these are contributing factors to acute attacks. Unless the causes above are not addressed, chronic reflux will persist for years or even decades. In the chronic state, the reflux often goes unnoticed (silent acid reflux) except for acute attacks and complications such as LPR reflux.
Medication is essential in treating and managing chronic acid reflux. Acid suppressing drugs like proton pump inhibitors (PPIs) and H2-blockers reduces gastric acid secretion. Antacids help to neutralize the stomach acid and provides quick symptomatic relief. Sucralfates help to protect the lining of the esophagus. Prokinetic drugs speed up gastric emptying and esophageal clearance. This is discussed further under Stomach Acid Medication.
Conservative measures are however essential for the long term management of chronic reflux. This includes the eating guidelines and meals tips outlined in the acid reflux diet. Elevating the head of the bed by a few inches will also help with night time flare ups. Weight loss is an important component of management in overweight and obese patients.
In the event that medication and conservative management does not provide a person with significant relief and complications arise, surgical measures may be considered for chronic reflux. Anti-reflux surgery like fundoplication are not commonly conducted unless a patient does not respond to other measures.