Gastro-Oesophageal Reflux Disease (GERD): The Story Of Miss Winifred Alvin From London, England
Gastroesophageal reflux disease (GERD)
Heartburn in GERD
Miss Winifred Alvin's Story
Miss Winifred Alvin is a student of Accounting in Oxford University, England. She is also into fashion and always wear tight-fitting designer clothes. Her schedule is so tight, combining her fashion-activities with class work and so do not usually have time to eat well cooked food, nor visit the restaurant. With this, for the past 3 months, she has been feeding heavily on junks, fast foods, drinking lots of coffee, beverages and chocolates.
One night, her sleep was interrupted with heavy episodes of chokes. She was choking for about 5 minutes until her room-mate came to her rescue. It did not stop there, the following morning she began experiencing heartburn, difficulty in eating and when she bends down, she regurgitates the little food she took. She managed going to class, but her situation persisted and she noticed her salivation increased which came with pain when trying to swallow it.
That same day, she went to the hospital and after giving her a substance with meal (which she ate in difficulty), she had an X-ray. That was not all, the doctors passed a thin long tube through her mouth into her digestive tract. An hour later, the doctors responded by letting her know she had Gastro-Oesophageal Reflux disease. What is this?
The Angle of His
The Lower Oesophageal Sphincter
The Oesophageal Sphincters
Gastro-oesophageal reflux disease (GERD) develops when gastric (Stomach) or duodenal contents flow back into the Oesophagus. It is only considered a pathological condition when it causes undesirable symptoms. Normally, contents move from Oesophagus to the stomach and not the other way round. If this happens with some clinical effects, then GERD is said to occur.
Once in a while, episodes of reflux are common even in healthy individuals; particularly after eating but GERD develops when the Oesophageal mucosa is exposed to gastric contents for a long period of time, resulting to pathological symptoms. These gastric contents (stomach contents) are highly acidic and so can irritate this Oesophageal mucosa. Continuous irritation can cause symptomatic manifestations. There are four Physiological mechanisms which ensure a stable efficiency to prevent reflux and even if it occurs, they act swiftly to ensure the prevention of disease manifestation. These mechanisms are as follows:
- The alkaline nature of swallowed saliva helps neutralize Oesophageal acid.
- The angle of the diaphragm is at the angle of entry of the Oesophagus into the stomach (angle of His) [from the diagram above]. This diaphragm exerts some extrinsic pressure on the Oesophagus; thereby preventing reflux.
- Just at the junction where the Oesophagus enters the Stomach, there is a small muscle which contracts in tones and relaxes only during swallowing, for easy passage of bolus. When not swallowing, it stays constricted (close) and hence nothing from the stomach can come into the Oesophagus. Note that this muscle is called the lower Oesophageal Sphincter (LOS) which is about 3-4 cm long. It is a collection of smooth muscle fibers which maintain a resting tone of 10-30 mmHg pressure on the Esophagus of which also, is sufficient enough to withstand any reflux
- But should in case reflux do occur (especially during the Lower Oesophageal Sphincter relaxation), a wave-like movement (distal Oesophageal peristaltic wave) immediately clears the acid.
Hiatal Hernia, One Major Cause Of GERD
How Does GERD Come about?
Pathology and Causes
1. As earlier discussed, the lower Oesophageal Sphincter contracts in tones, while it relaxes only during swallowing. Some patients have a reduced or low Oesophageal Sphincter tone. In this case, when pressure within the Stomach region (intra-abdominal pressure) rises; it outweighs the normal pressure of the sphincter (10-30 mmHg), hence, permitting reflux to occur. Not only that, some patients may be in a condition where the LOS relaxes not just only during swallowing but in frequent tones and this also allows for reflux to occur.
2. Another cause is Hiatus Hernia (diagram above). This occurs when the stomach invades the thoracic (Chest) cavity through the diaphragm. This is very common to the elderly and more common to women than men. Such occurrence alter the pressure gradient which usually exist between the abdominal and thoracic cavities and therefore allows reflux to occur. Also, the oblique angle between the Oesophagus and the stomach (Cardia) is lost in Hiatus hernia. This angle also aids in maintaining the lower Oesophageal Sphincter (LOS) pressure and since it is lost, a good platform for reflux to occur is produced.
3. Increased pressure within the stomach region (intra-abdominal pressure) is a strong factor/cause. This happens mostly in pregnancy and obesity. Also, tight fitting garments can cause an increase in such pressure, as in the case of Miss Winifred Alvin.
4. Dietary fat, chocolate, alcohol and beverages such as tea and coffee relax the LOS and may provoke symptoms. This is another practical case in Miss Winifred's situation.
5. Defective Oesophageal peristaltic activity also known as delayed Oesophageal clearance leads to an increased exposure of acid from the stomach. Also, corrosives and cigarette smoke can be causes of reflux.
6. Zollinger-Ellison syndrome: A clinical pathology whereby an increased gastrin production increases gastric acidity causing ulcers.
7. Gallstones: They alter the flow of bile into the duodenum which then affects their neutralizing ability of gastric acid.
8. Scleroderma and systemic sclerosis can both cause a negative effect of the movement of the Oesophagus (Oesophageal dysmobility)
9. The use of some non-steroidal anti-inflammatory drugs such as prednisolone.
10. Increase in gastrin production can also result in high levels of calcium in the blood (Hypercalcemia) which can also cause GERD.
11. There is a condition known as Visceroptosis or Glenard syndrome in which the stomach acid secretion and motility is altered due to its sunken location in the abdomen. It is believed that obstructive sleep apnea can also cause GERD.
Intra-abdominal Pressure Increase
Heartburn Is a Major Symptom of GERD
Symptoms And Complications
To know or suspect GERD, observe the following symptoms:
- Difficulty in eating/digestion (Dyspepsia)
- Heart burn, as in the case of Miss Winifred
- Regurgitation; which can be provoked by straining or lying down or bending (as in Winifred's case).
- Hypersalivation due to a reflex reaction from the salivary gland as acid enters the gullet. Such a symptom is called waterbrash.
- Sometimes, patients are woken at night by choking due to irritation of the larynx by reflux fluid.
- Difficulty in swallowing (dysphagia). This can be accompanied with painful swallowing (Odynophagia) and symtoms of Anemia is another possibility.
- Some patients suffer from chest pain which can be severed. This mimics angina and is probably due to constant and irregular contractions of the Oesophagus; irritated by reflux contents (reflux-induced Oesophageal spasms).
When GERD do occur and is not properly treated or even left untreated, its symptomatic manifestations persist for a very long terms, making it a chronic clinical situation. In this case, some complications (additional clinical pathologies due to its prolonged effects) can occur. Such complications are as follows:
- Esophagitis: The acidic reflux from the stomach and as well as bile from the first part of the small intestine (duodenum) can irritate the lining of the Oesophagus, causing inflammatory processes. This can result to Ulcers of the Mucose membrane and secondary fibrosis in the muscular wall.
- Accidental or suicidal ingestion of highly alkaline or acidic substances may result in injury to the Oesophagus.
- Barrett's Oesophagus: This is the result of chronic gastro-Oesophageal reflux. In this case, epithelial metaplasia of the Oesophagus takes place of which the normal squamous epithelium of the Oesophagus is replaced by the columnar epithelial cells.
- The chronic nature of the disease can cause Iron deficiency Anema.
- Benign Oesophageal stricture: This is a much more chronic complication of GERD. It is an abnormal formation of fibrous tissue that is usually at the lower end of the Oesophagus. After a long time irritation of Oesophageal lining, due to reflux; the epithelial cells are irritated; inflammation and ulcers occur (Esophagitis). When this ulcers begin healing; new cell growths/formations occur (granulations) which then result to scar formation which is a fibrous tissue. Continual scar formation not only heals the ulcers/wounds but also begin to occupy the space within the lumen of the Oesophagus and hence causing strictures.
- Other atypical symptoms such as: Pharyngitis, Laryngitis (throat clearing, hoarseness), Asthma, Globus Pharingeus and globus hystericus (Condition of feeling of choking, foreign object in throat), Erosion of dental enamel and Dentine hypersensitivity.
GERD Management Chart
Diagnosis And Management
From Miss Winifred's story, a think tube run through the mouth, then Oesophagus is performed to reveal the contents/make up of the Oesophagus. This procedure is known as Endoscopy.
24-Hour pH monitoring is done when the diagnosis after endoscopy is unclear and especially when surgical intervention is considered.
Barium Swallow and X-ray examination: From Miss Winifred's story, she was given a substance with meal to eat and then examined through the X-ray procedure. That substance is Barium. In this procedure, Barium is swallowed or taken with meal and then the Oesophagus is examined using an X-ray. This is done in complicated cases such as ulcers, Oesophagitis or corrosives. pathological effects on Oesophagus where Endoscopy is contra-indicated warrant the use of Barium Swallow/meal to avoid the risk of perforation.
- Behavioural modifications of patients: avoidance of food items which worsen clinical situation, avoidance of late meals, cessation of smoking, avoidance of tight-fitting garments, elevation of bed-head in those who experience nocturnal symptoms.
- Antacids, for example: Gestid, Almagel (combined drug which contains gel of Aluminium hydroxide, magnesium oxide and D-Sorbit); Maalox (combined gel of aluminium hydroxide and magnesium oxide); Sucralfate; De-nol. They produce protective mucosal 'raft' over the Oesophageal mucosa.
- H2-receptor antagonist drugs eg, Cimentidine (Tagamet); famotidine (Pepcid); Nizatidine (Axid) and Ranitidine (Zantac). They reduce gastric acid secretion; help symptoms without healing Oesophagitis.
- Proton Pump inhibitors: Treatment of choice for severe symptoms and for complicated reflux disease e.g Raberprazole (Aliphen); Dexilant (dexlansoprazole); Nexium (Esomeprazole); prevacid (lansoprazole); prilosec (Omeprazole); Protonix (Pantroprazole). These drugs irreversibly inhibit the proton pump. Reducing the transport of hydrogen ions out of parietal cells. Symptoms almost invariably resolve and Oesophagitis heals in the majority of patient.
- Recurrence of symptoms is almost inevitable when therapy is stopped and some patients require lifelong treatment. Patients who fail to respond to medical therapy, those who are unwilling to take long-term proton pump inhibitors and those whose major symptom is severe regurgitation are considered for anti-reflux surgery.
These treatment plans were carefully followed on Miss Winifred and she recovered. Let's digest this awareness to save us from the risk of GERD.
A Guideline To Your Own Personal GERD Diet
Apples (fresh and dried), apple juice, bananas, pears, peaches, melons, strawberries, grapes
Oranges and orange juice, lemons and lemonade, grapefruit and grapefruit juice, tomato and tomato juice, cranberries and cranberry juice
Baked potato, broccoli, cabbage, carrots, green beans, peas, asparagus, lettuce, sweet potatoes
Raw onions, peppers, radishes, french fries, mashed potatoes
Extra lean ground beef, steak (London Broil), skinless chicken breast, egg whites or substitute, fish (with no added fat), white turkey meat
Fatty ground beef, marbled sirloin, chicken nuggets, buffalo wings, fried meat
Cereal (bran or oatmeal), corn bread, graham crackers, pretzels, rice (brown or white), rice cakes, millet, quinoa
High fat grain products (cheese bread or products made with whole milk)
Low fat salad dressing, herbs ( basil, thyme, sage, oregano), hummus, mild sauces
Strong mustard, chili sauces, creamy salad dressing, black pepper, vinegar, curries, pickles, mint
Water, herbal teas, non-citrus drinks, skimmed milk
Caffeinated beverages, whole milk, alcohol, carbonated beverages
© 2014 Funom Theophilus Makama