Now and then, one may experience a burning or aching pain at the lower part of the chest, particularly after meals. This symptom known as heartburn is all too common. This is the feeling that would prompt taking antacids or other medications for relief. The process of gastroesophageal reflux disease can be simple or complex.
Pathophysiology and Symptoms
The stomach is normally closed off from the esophagus by the lower esophageal sphincter. This way, stomach acid cannot enter the esophagus. However, many factors can relax this sphincter. They include lying down too soon after a meal, fatty foods, alcohol, and tobacco. In addition, certain medications have been linked to GERD, either by relaxing the sphincter (e.g., calcium channel blockers) or directly injuring the esophagus (e.g., ibuprofen). There are also anatomical risk factors, like obesity since pressure from abdominal fat can push stomach contents upward.
The result is the symptom known as heartburn. With progression of GERD, there can be difficulty swallowing with food getting stuck and even pain with swallowing. This is because of damage to the esophageal lining by acid. In more severe cases, refluxed stomach contents can reach the throat and get into the trachea and lungs. Though uncommon, this can cause laryngitis and pneumonia.
Diagnosis and Treatment
A physician can diagnose GERD easily based on the symptoms and the presence of risk factors. Testing is rarely needed. Sometimes, the doctor can give a trial of medications for GERD to see if symptoms are relieved with them. If they are, chances are that the pain is from acid reflux.
The first step in treating acid reflux is to minimize the risk factors. Besides cutting down on foods and beverages that worsen it, one should avoid lying down within two to three hours after a meal. If lying flat doesn’t help regardless, one can try sleeping with the head of the bed elevated so that the esophagus is tilted downward and not horizontal. For obese patients, losing weight can also help.
Medications for GERD include antacids (e.g., Mylanta), histamine-receptor blockers (e.g., Pepcid, Zantac), and proton-pump inhibitors (e.g., Prilosec, Nexium). If symptoms are persistent despite medical treatment, then the last option is surgical. A surgical procedure called Nissen fundoplication can be done where the topmost part of the stomach is wrapped around the esophagus, creating a makeshift sphincter. While it can be effective, there is a risk of it working too well so that it’s difficult to belch or vomit.
Normally, the cells lining the esophagus are stratified squamous cells, which are flattened cells forming multiple layers to withstand the mechanical forces of swallowed food. The cells in the stomach are columnar, shaped like columns and able to secrete acid. When there is acid reflux, the acidic environment of the stomach is introduced into the esophagus. With chronic acid exposure, there is a process in response where the esophageal cells transform into cells similar to those in the stomach. The result is called Barrett’s esophagus.
The significance of this is its relation to esophageal cancer. The risk for transformation to adenocarcinoma of the esophagus is less than 1% every year but it can be as high as 5% or even 10% with long-term GERD. High-risk patients can be screened for esophageal cancer with endoscopy and biopsy of the esophagus. Surgery is indicated once there is adenocarcinoma or if the biopsy shows high risk of transformation into a malignant tumor.
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