What is Gastroesophageal Reflux Disease?

Gastroesophageal Reflux Disease, or GERD, is the most common upper gastrointestinal disorder in Western society affecting about 360 people per 100,000 population.  In the United States, this accounts for more than 100,000 cases per year.  About 75% of patients present with mild symptoms that are easily treated with dietary or lifestyle modifications while the other 25% go on to chronic recurrent forms of the disease which may  result in severe complications as to be described below.  It is the latter group of people that this discussion will focus upon.

Finally, a complete discussion of GERD is not possible without understanding the lower esophageal sphincter. Recent work has shown that although no true muscle thickening is evident on inspection of the LES, on microscopic analysis, a discreet sphincter mechanism does exist. Moreover, it is responsive to certain GI tract hormones, which may partially explain how the sphincter is regulated. The LES maintains a certain resting pressure which decreases in a coordinated fashion during swallowing to allow passage of the food bolus. The pressure may increase with food in the stomach, during the gastric phase of digestion, to prevent reflux. A normally functioning LES does permit some reflux but this is not clinically significant.

Patients with obstruction of the gastric outlet from severe ulcer disease or tumor may also develop reflux because of the inability of the stomach to empty itself normally.  Obviously, correction of the cause of the gastric outlet obstruction is necessary to correct reflux.

The vast majority of patients with gastroesophageal reflux have no underlying cause or associated condition.  However, not all patients with gastroesophageal reflux are considered to have Gastroesophageal Reflux Disease.  This diagnosis is reserved for those patients who have symptomatic reflux (to be defined below) as a primary condition.  Though other conditions causing reflux may warrant surgical intervention, correction of the underlying medical condition must first be accomplished prior to contemplating surgery.  Additionally, careful evaluation of each individual patient is necessary in order to select the correct type of surgical procedure to be undertaken.

The primary symptom of Gastroesophageal Reflux disease for which patients seek treatment is pain.  The pain is usually located in the mid upper abdomen and radiates into the mid chest.  It is usually described as burning, constant but waxing and waning.  The pain is worsened after eating, particularly  after a large meal and is typically most severe at night or early morning when the patient is in a reclining position.  In fact, many GERD sufferers sleep sitting up to minimize their symptoms.  

Occasionally, the pain of GERD can be mistaken for pain of cardiac origin.  In fact, some patients will first undergo a full cardiac work up before their symptoms are attributed to esophageal pathology and attention is turned in that direction.

Patients with asthma will often find their symptoms exacerbated by GERD and in some patients this may be the primary symptom.  On occasion the primary symptom may be an unexplained chronic cough which often has been treated for a protracted period with antihistamines, antibiotics and cough suppressants without relief.  If the diagnosis of GERD is made, intensive treatment of the reflux may suppress these symptoms.

As always, correct treatment of any condition first requires proper diagnosis.   Patients with symptoms of frequent heartburn and typical symptoms of reflux should undergo upper endoscopy to assess the entire GI tract for evidence of peptic ulcer disease.  Gastric and duodenal ulcers should be treated accordingly and a full discussion of these conditions will not be attempted here.   The level of the squamo-columnar junction should be ascertained and if Barrett's Esophagus is present, biopsies need to be taken.  If esophageal ulcers are present they should be graded by severity so that later response to treatment can be assessed.  Several types of pathology may be encountered at endoscopy and these need to be discussed.

If following biopsy of Barrett's Esophagus, dysplasia or early invasive cancer of the esophagus is encountered, esophagectomy is indicated.  The mere presence of Barrett's Esophagus does not warrant esophagectomy but may warrant an anti-reflux procedure.   This is a subject of controversy because though it has been shown that, following an anti-reflux procedure changes of Barrett’s Esophagus may regress, this is not guaranteed.  Even if the changes are reversed the later risk of developing esophageal cancer may not revert to normal.  Research on this particular phenomenon is ongoing.  Presently, many if not most surgeons would agree that Barrett’s Esophagus without dysplasia is an indication for an anti-reflux procedure.

Many patients with reflux will have various types of esophageal webs and strictures which are caused by the chronic irritation of the esophagus with gastric acid.   These may cause difficulty swallowing or dysphagia and may require pneumatic dilatation with specially designed balloons.   Patients with hiatal hernia and long standing reflux may have a shortened esophagus which presents a particular challenge to a surgeon contemplating anti-reflux surgery.   However, the results of endoscopy can be misleading in this regard and for this reason, if anti-reflux surgery is being considered, an upper GI barium swallow needs to be performed.  In addition, information about ulcers, esophageal length, presence and nature of hiatal hernia can be gained.

Patients with minor esophageal ulceration yet severe symptomatology should be evaluated with a 24 pH probe to assess the time and duration of reflux during a 24 hour period.  Patients are required to keep a log during this period to record when they have symptoms, what they are doing at the time and what position they are in.  Clinically significant reflux is demonstrated when reflux is present greater than 4% of the time and particularly when reflux is documented at time a patient is having symptoms.  This test is also particularly useful in the above described patients who have atypical symptoms of other disease processes yet fail to respond to treatment and in whom appropriate work up fails to demonstrate a cause.

Finally,  if one is considering performing anti-reflux surgery or if the patient has a component of dysphagia, Esophageal Manometry is warranted.  This test involves placement of a probe at various locations in the esophagus and assessing pressure changes during swallowing.  This test is very useful in diagnosing many types of esophageal motility disorders.  In the context of GERD, this test is used to assess the integrity of the lower esophageal sphincter. Additionally, if one is to undergo an anti-reflux operation, knowledge of the presence of a concomitant motility disorder is essential as this may contraindicate this type of surgery or necessitate alteration of the procedure to accommodate for the additional disorder.

Medical management of GERD requires lifestyle changes such as weight loss, changes in diet, and medications.  Many patients sleep upright in bed or at least with the head of the bed elevated if the symptoms are exacerbated at night or in a reclining position. Limitation of dietary intake of fat, meat and caffeine, cessation of smoking, and other modifications of lifestyle practices that are known to increase gastric acid secretion and reflux, all help to diminish symptoms.  Medications such as propulcid, (cisapride) is used to aid peristalsis of the GI tract while prilosec (omeprazole), inhibits the cellular proton pump which is directly responsible for the secretion of gastric acid.  The combination of these treatments is very effective at reducing symptoms of reflux and in reversing low grade esophagitis in most patients.