Digestion begins in the mouth, as food is broken down by chewing into smaller pieces.
And by saliva releasing digestive enzymes such as; alpha-amylase and lingual lipase
When food is swallowed, it enters the esophagus
A muscular tube, that carries food from the mouth to the stomach for further digestion.
Contractions called ‘peristalsis’ push the food down the esophagus.
At the bottom of the esophagus food passes through a muscular valve
Called the 'Lower Esophageal Sphincter' or 'LES' and into the stomach.
The digestive juices secreted by the stomach are highly acidic.
When the stomach contracts to move the food into the intestine,
The ‘LES’ closes tightly in order to prevent these acidic juices
From moving back into the esophagus where they can cause damage.
A breathing muscle called the 'diaphragm' separates the chest from the abdomen.
To reach the stomach the esophagus passes through the diaphragm,
At a point called the ‘hiatal ring’.
If the patient has gastroesophageal reflux disease or GERD,
Their LES does not close properly allowing acidic stomach contents,
To flow backward into the esophagus.
If GERD is not treated it can lead to variety of esophageal problems
Including; ulcers, bleeding, stricter and narrowings
And Barrett's esophagus, in which the normal
Stratified squamous epithelium lining of the esophagus,
Is replaced by simple columnar epithelium
Which are usually found lower in the GI tract.
If the patient has hiatal hernia
A portion of their stomach
Is protruding into their chest cavity
Through the opening in their diaphragm.
A Hiatal hernia can effect the LES
And increase the risk and severity of GERD.
Some of the factors that can contribute to GERD are;
Hiatal hernia, as we have already mentioned,
Obesity
Zollinger-Ellison syndrome, which can present with
Increase gastric acidity, due to increase 'gastrin' production,
Hypercalcemia, which can also increase gastrin production
Leading to increase acidity.
Scleroderma and Systemic sclerosis,
which can feature esophageal dysmotility.
Signs and symptoms of GERD includes;
Epigastric burning pain traveling up into the chest
known as 'heartburn'
Which can sometimes spread to the throat
Along with a sour metallic taste in the mouth.
Difficulty swallowing
Dry cough
Sore throat
Hoarseness
Which is due to the acid damaging the larynx or the voice box.
Regurgitation of food or sour liquids
And, a sensation of a lump in the throat.
GERD is most often diagnosed based on
the patient's history and symptoms.
In some patients in whom the diagnosis is not clear
24 hour pH monitoring is done to confirm the etiology
Endoscopy is not routinely needed,
if the case is typical and responds to treatment.
It is however recommended,
when people either do not respond well to treatment
or have alarming symptoms including;
dysphagia,
anemia,
blood in the stool,
wheezing,
weight loss or voice changes.
Some physicians encourage either once in a life time,
or 5 to 10 yearly endoscopy
for people with long-lasting GERD
to evaluate the possible presence of dysplasia
or Barrett's esophagus.
The treatment for GERD includes; lifestyle modification
medications and possibly surgery.
All patients should lose weight if obese,
Avoid alcohol, nicotine, spicy food, caffeine and peppermint
They should also avoid eating 3-4 hours before sleeping
And of course elevate their head off the bed while sleeping.
The primary medications used for GERD are;
Proton pump inhibitors or PPI's
Such as 'Omeprazole' Which is also the first-line medication.
Others include;
H2 receptor blockers such as 'Cimetidine'
And antacids.
For those patients who do not respond to medical therapy
Surgery may be required
The standard surgical treatment for severe GERD is 'fundoplication'
In this procedure,
The upper part of the stomach is wrapped around
The lower esophageal sphincter
To reenforce the sphincter and prevent acid reflux
And to repair the hiatal hernia.
Endocinch can also be done
Which, by using a scope
a suture is placed around the lower esophageal sphincter to make it tighter.