Gastroesophageal reflux disease, abbreviated as GERD,
Gastro means Stomach, and Esophageal means Esophagus which is the tube connecting your
mouth to your stomach.
Reflux means that the food in your stomach re-enters into the esophagus.
This is not how it is supposed to be. Food should move from your mouth to your stomach,
and not in the opposite direction.
That’s called vomiting.
Why is this happening?
The most common reason is because the sphincter between the esophagus and the stomach is not
closing as it should. If that sphincter would close, then the food would simply not enter
the esophagus.
Now that the food enters the esophagus, it damages the wall of the esophagus.
Why?
Because the stomach content is very acidic. The stomach wall is much more resistant against
the acid, but the esophagus can not tolerate this acidity, and therefore erosions happen.
This is painful. It can cause heartburn, which is a burning painful feeling around the heart
and the upper abdomen region.
It usually gets worse if you lie down or after you eat a big meal.
The food can move up the esophagus all the way until your mouth, and this is what we
call regurgitation. You will burp, and you will have a salty acid taste in your mouth.
This can even make you feel nausea, and provoke vomiting.
Some people even have difficulties swallowing because of these problems.
We call all these symptoms, esophageal symptoms because they are all related to the esophagus.
But there can interestingly also be extra-esophageal symptoms, which are not related to the esophagus.
These are Cough, Hoarseness, Globus feeling and difficulties sleeping.
These symptoms are bad in itself, but there can unfortunately be even worse complications,
like: aspiration of the stomach content into your lungs, ulcerations, and the worst of
all, Adenocarcinoma, which is a cancer of the esophagus.
It takes 5 steps to create a cancer from GERD. The first step is that the wall of the esophagus
undergoes Gastric metaplasia. Metaplasia means that one cell changes to another cell. This
means that the esophageal cells change into gastric cells.
The second step is that these Gastric cells change into intestinal cells. This is called
intestinal metaplasia.
The third and fourth steps are Dysplasia, which means that the cells form a bad shape.
So metaplasia were a change from one cell to another cell. But dysplasia is a change
in the cell’s shape.
We can divide dysplasia into 2 types. Low-grade and High-grade based on how severely the shape
of the cells are changed.
The last step is when High-grade dysplasia form a cancer called Adenocarcinoma.
So how can we diagnose these patients to prevent this from happening?
The symptoms themselves are already indicating that this is Gastroesophageal reflux disease.
BUT a very useful tool called Endoscope can be used. This is a tube with a camera on the
tip of the tube, that we enter into the patient’s mouth, and down through the esophagus until
we reach the stomach. Here we check the gastroesophageal junction.
We will use a classification system, called Los-Angeles classification, to divide patients
into 4 groups based on how severely the esophagus is damaged.
So when we look into the esophagus with the endoscope, we will see mucosal folds. These
are foldings of the esophageal wall.
If we see erosions that are only affecting one mucosal fold then we call these grade
A or B. The only difference between A and B, is that A is having less than 5 mm erosions,
whereas B is having 5 or more mm erosions.
Grade C and D are affecting more mucosal folds, and the only difference between these are
that, in grade C, less than 75% of the circumference is affected, whereas in grade D, 75% and more
of the circumference is affected.
If we suspect that the reflux has caused an Adenocarcinoma, we need to take a biopsy of
the esophageal wall with the help of the endoscope. When we take a biopsy, we cut out a piece
of the wall, and then we look at it under a microscope to see at which step the disease
is in. These are the steps that we talked about, namely, Gastric metaplasia, Intestinal
metaplasia, Low-grade dysplasia, High-grade dysplasia, and Adenocarcinoma.
Except for endoscopy, there are other methods that we can use to diagnose patients with
GERD.
We can for example do a 24 hour pH monitoring of the esophagus. If the pH is acidic, then
we know that the stomach acid is being refluxed into the esophagus.
How do we measure the pH down in the esophagus?
We can either use a tube that we enter through the nose into the esophagus and place it 5
cm from the lower esophageal sphincter, and we keep it there for 24 hours to measure the
pH of the esophagus.
Or we can use newer techniques where we put a a capsule at this location, which is much
more convenient for the patient, than to have a tube through the nose for 24 hours. The
other benefit of using a capsule, is that we can keep it there for longer time. The
Bravo capsule can be there for 48 hours, and the OMOM capsule can be there for 92 hours.
So, now that we have diagnosed the patient with GERD, we need to treat it.
We can use 3 different methods: Lifestyle, Medications and Operation.
When the disease is mild, then lifestyle can be enough. But if there are still a lot of
symptoms despite lifestyle changes, then we can use medications. If medications does not
work, or the disease is very severe, then an operation can be done.
So which are the lifestyle changes that we can do? Lose weight, don’t eat big meals
late in the evening, don’t lie down after a meal, don’t eat sweet dishes, don’t
drink alcohol, don’t smoke, and sleep with a couple of pillows so that your upper body
is a little bit higher up, to prevent reflux during the night which could cause aspiration
of the food into your lungs.
So these are the lifestyle changes that can be used in mild disease. But if these are
not enough, and you still have symptoms, then we can take medications.
3 groups of medications are worth remembering: Antacids, H2 receptor blockers and Proton
pump inhibitors.
Antacids and H2 receptor blockers are used in mild disease without any esophagitis, which
means without any inflammation of the esophagus. The typical H2 receptor blockers are Cimetidine,
Ranitidine, and Famotidine. As you can see, these are ending with -tidine. So Cime-, Rani-,
and Famo-tidine
Whenever there are many symptoms and esophagitis, then Proton pump inhibitors can be used. The
typical Proton pump inhibitors are Pantoprazol, Rabeprazol, Omeprazol, Lansoprazol, Esomeprazol
and Dexlansoprazol. As you can see, these are ending with -prazol. So Panto-, Rabe-,
Ome-, Lanso-, Eso- and Dexlanso-prazol. To remember these, lets use a mnemonic called
PROLED. P is Pantoprazol, R is Rabeprazol, O is Omeprazol, L is Lansoprazol, E is Esomeprazol
and D is Dexlansoprazol.
If these medications does not work, or if the disease is severe, then we can do an operation
called Nissen Fundoplication. That is when we take the Fundus part of the stomach, and
wrap it around the lower esophagus to create an artificial sphincter that increase the
pressure and thereby close the connection between the esophagus and the stomach.
Thank you very much for listening!