Gastroesophageal reflux disease (GERD)

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!

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