What is gastroesophageal reflux (GER)?
GER is when the acid present in the stomach backs up into the esophagus, the tube connecting the mouth to the stomach. That can happen to a limited degree normally after a meal. However, when its intensity and duration increase, it may lead to symptoms and/or complications. In this case the condition is called gastroesophageal reflux disease (GERD).
What causes GERD?
At the lower end of the esophagus, there is a circular muscle called the lower esophageal sphincter (LES). After swallowing, the LES relaxes to allow food to enter the stomach and then contracts to prevent the back-up of food particles and acid into the esophagus. However, sometimes the LES gets weak leading to frequent and long lasting acid reflux and associated symptoms.
What are predisposing factors for GERD?
Predisposing factors include increased body weight, presence of a hiatal hernia (part of the stomach having slid up into the chest), dietary and lifestyle factors (large or fatty meals, intake of caffeine, chocolate, alcohol, carbonated beverages), and pregnancy.
What are the symptoms of GERD?
Most commonly GERD is associated with heartburn (burning in the chest) or regurgitation (return of food and/or fluids up to the chest or mouth). Other symptoms include chest or upper abdominal pain, and difficulty swallowing. Sometimes GERD causes symptoms outside the esophagus, such as chronic cough, laryngitis, asthma, sinusitis, dental problems, or a sense of lump in the throat.
Are there any possible complications?
The most common complication is esophagitis (erosions in the lower esophagus, seen endoscopically, Figure). Long-standing GERD may rarely lead to Barrett’s esophagus, which is a change in esophagus epithelium. In that case, your gastroenterologist will recommend the appropriate therapeutic and follow-up plan (see Barrett’s esophagus).
How is GERD diagnosed?
GERD is typically diagnosed based on symptoms and response to treatment. The gastroenterologist will recommend an endoscopy in case of long-lasting symptoms, symptoms that do not get better with treatment, or in the presence of worrisome complaints, including difficulty swallowing, anemia, vomiting and weight loss. In rare cases, specific functional tests such as pH-metry or manometry may be indicated.
How is GERD treated?
GERD treatment includes lifestyle and dietary modifications (weight loss, elevation of the head of the bed while sleeping, avoidance of smoking, alcohol, fatty foods, excess caffeine, large and late meals and tight fitting clothing), and drugs aiming to reduce gastric acidity. These are very effective and safe. The duration of treatment varies from several weeks to life-long according to disease’s severity. Of note, symptoms may recur after discontinuation of the medication, necessitating its re-initiation. In rare cases endoscopic or surgical management might be suggested.
What is Barrett’s esophagus (BE)?
Barrett’s esophagus is a change in the cells of the lower part of the esophagus (Figure) caused by chronic acid reflux (see under Gastroesophageal reflux).
Is BE associated with a high risk of esophageal cancer development?
Confirmed BE is linked to a very low cancer risk, less than 0,5% per year. In patients with BE without dysplasia we recommend upper endoscopy every 3-5 years, along with medicines to reduce acid reflux (“proton pump inhibitors”). Those with dysplastic BE should undergo more frequent follow-up and perhaps specific endoscopic treatments.
It is very important to reassure patients that the overall cancer risk is very low and no need for excessive endoscopic procedures exists.
Is there a treatment for BE?
There is no easy way to abolish BE. However, measures can be taken to prevent BE from progressing. The most important step is to control acid reflux (see under Gastroesophageal reflux). Cases with dysplastic BE need more attention. Low grade dysplasia is followed with endoscopy and biopsies once a year, while high-grade dysplasia should be referred to a gastroenterologist specialized in endoscopic treatment of BE.
What can be done to prevent esophageal cancer development?
People suffering from long-standing GERD symptoms should undergo upper endoscopy, especially if they are men, and older than 45 years. If no BE is found, its future development is rather infrequent thus no regular endoscopic follow-up is indicated.
On the other hand, esophageal cancer is extremely rare in those without GERD symptoms. Therefore, no recommendation for screening with upper endoscopy exists in people without reflux symptoms. This is contrary to colorectal cancer screening with colonoscopy, which is mandatory for all asymptomatic individuals at the age of 50.
What is eosinophilic esophagitis (EoE)?
EoE is a chronic condition of the esophagus (the tube leading from the mouth to the stomach) characterized by an increase in the number of a cell type called the eosinophil. It usually affects young-middle aged men and its cause is not clearly specified. An association with allergic disorders has been proposed.
What are the symptoms of EoE?
People with EoE experience difficulty in swallowing solid foods. They may also present with food stuck in their throat or chest. Other symptoms include pain or burning in the chest.
How is EoE diagnosed?
EoE is diagnosed with endoscopy (esophagoscopy) with biopsies form different parts of the esophagus (Figure).
How is EoE treated?
EoE management includes dietary modifications and medicines like “proton pump inhibitors” and steroids. In case of a tight stricture in the esophagus that does not respond to treatment, dilation during endoscopy is indicated.
What is the prognosis of EoE?
EoE is a benign condition that has no relationship to cancer. By following the doctor’s instructions, symptoms can be controlled to a great extent. It is also of great importance to avoid hard foods and to chew thoroughly before swallowing.