Acid Reflux Disease Symptons (Part 3)

What are the symptoms of uncomplicated Acid Reflux Disease?

Heartburn

When acid refluxes back into the esophagus in patients with GERD, nerve fibers in the esophagus are stimulated. This nerve stimulation results most commonly in heartburn, the pain that is characteristic of GERD. Heartburn usually is described as a burning pain in the middle of the chest. It may start high in the abdomen or may extend up into the neck. In some patients, however, the pain may be sharp or pressure-like, rather than burning. Such pain can mimic heart pain (angina). In other patients, the pain may extend to the back. Since acid reflux is more common after meals, heartburn is more common after meals. Heartburn is also more common when individuals lie down because without the effects of gravity, reflux occurs more easily, and acid is returned to the stomach more slowly.

Episodes of heartburn may occur infrequently or frequently, but episodes tend to happen periodically. This means that the episodes are more frequent or severe for a period of several weeks or months, and then they become less frequent or severe or even absent for several weeks or months. Nevertheless, heartburn is a life-long problem, and it almost always returns.

Regurgitation

Regurgitation is the appearance of refluxed liquid in the mouth. In GERD, usually only small quantities of liquid reach the esophagus, and the liquid remains in the lower esophagus. Occasionally, and particularly in some patients, larger quantities of liquid, sometimes containing food, are refluxed and reach the upper esophagus.

At the upper end of the esophagus is the upper esophageal sphincter (UES). The UES is a circular ring of muscle that is very similar in its actions to the LES. That is, the UES prevents esophageal contents from backing up into the throat. When small amounts of refluxed liquid and/or foods breach (get through) the UES and enter the throat, there may be an acid taste in the mouth. If larger quantities breach the UES, patients may suddenly find their mouths filled with the liquid or food. What's more, frequent or prolonged regurgitation can lead to acid-induced erosions of the teeth.

Nausea

Nausea is uncommon in GERD. In some patients, however, it may be frequent or severe and may result in vomiting. In fact, in patients with unexplained nausea and/or vomiting, GERD is one of the first conditions suspected. It is not clear why some patients with GERD develop mainly heartburn and others develop mainly nausea.

What are the complications of Acid Reflux Disease?

Ulcers

The liquid from the stomach that refluxes into the esophagus damages the cells lining the esophagus. The body responds in the way that it usually responds to damage, which is with inflammation (esophagitis). The purpose of inflammation is to neutralize the damaging agent and begin the process of healing. If the damage goes deeply into the esophagus, an ulcer forms. An ulcer is simply a break in the lining of the esophagus that occurs in an area of inflammation. Ulcers and the additional inflammation they provoke may erode into the esophageal blood vessels and give rise to bleeding into the esophagus. Occasionally, the bleeding is severe and may require transfusions of blood and endoscopic (a procedure in which a tube is inserted through the mouth into the esophagus) or surgical treatment.

Strictures

Ulcers of the esophagus heal with the formation of scars (fibrosis). Over time, the scar tissue shrinks and narrows the lumen (inner cavity) of the esophagus. This scarred narrowing is called a stricture. Once the narrowing becomes severe enough (usually when it restricts the esophageal lumen to a diameter of one centimeter), swallowed food may get stuck in the esophagus. This situation may necessitate endoscopic removal of the stuck food. Then, to prevent food from sticking, the narrowing must be stretched (widened). Moreover, to prevent a recurrence of the stricture, the reflux also must be prevented.

Barrett's esophagus

Long-standing and/or severe GERD causes changes in the cells that line the esophagus. These cells then become pre-cancerous, and finally cancerous. This condition is referred to as Barrett's esophagus, which occurs in approximately 10% of patients with GERD. The type of esophageal cancer associated with Barrett's esophagus (adenocarcinoma) is increasing in frequency.

Barrett's esophagus can be recognized visually at the time of an endoscopy and confirmed by microscopic examination of biopsies of the lining cells. Then, patients with Barrett's esophagus may require periodic surveillance endoscopies with biopsies. The purpose of the surveillance is to detect pre-cancerous changes so that cancer-preventing treatment can be started. It is also believed that patients with Barrett's esophagus should receive maximum treatment for GERD to prevent further damage to the esophagus. It is not clear why some patients with GERD develop Barrett's esophagus, but most do not.

Cough and asthma

Many nerves are in the lower esophagus. Some of these nerves are stimulated by the refluxed acid, and this stimulation results in pain (usually heartburn). Other nerves that are stimulated do not produce pain. Instead, they stimulate yet other nerves that provoke coughing. In this way, refluxed liquid can cause coughing without ever reaching the throat! In a similar manner, reflux into the lower esophagus can stimulate esophageal nerves that connect to and can stimulate nerves going to the lungs. These nerves to the lungs then can cause the smaller breathing tubes to narrow, resulting in an attack of asthma.

So, GERD is a common cause of unexplained coughing. Although GERD also may be a cause of asthma, it is more likely that it precipitates asthmatic attacks in patients who already have asthma. Although chronic cough and asthma are common ailments, it is not clear just how often they are aggravated or caused by GERD.

Inflammation of the throat and larynx

If refluxed liquid gets past the upper esophageal sphincter, it can enter the throat (pharynx) and even the voice box (larynx). The resulting inflammation can lead to a sore throat and hoarseness. As with coughing and asthma, it is not clear just how commonly GERD is responsible for otherwise unexplained inflammation of the throat and larynx.

Inflammation and infection of the lungs

Refluxed liquid that passes the larynx can enter the lungs. The reflux of liquid into the lungs (called aspiration) often results in coughing and choking. Aspiration, however, can also occur without producing these symptoms. With or without these symptoms, aspiration may lead to infection of the lungs and result in pneumonia. This type of pneumonia is a serious problem requiring immediate treatment. When aspiration is unaccompanied by symptoms, it can result in a slow, progressive scarring (fibrosis) of the lungs that can be seen on chest x-rays. Aspiration is more likely to occur at night because that is when the processes (mechanisms) that protect against reflux are not active and the coughing reflex that protects the lungs also is not active.

Fluid in the sinuses and middle ears

The throat communicates with the nasal passages. In small children, two patches of lymph tissue, called the adenoids, are located where the upper part of the throat joins the nasal passages. The passages from the sinuses and the tubes from the middle ears (Eustachian tubes) open into the rear of the nasal passages near the adenoids. Refluxed liquid that enters the upper throat can inflame the adenoids and cause them to swell. The swollen adenoids then can block the passages from the sinuses and the Eustachian tubes. When the sinuses and middle ears are closed off from the nasal passages by the swelling of the adenoids, fluid accumulates within them. This accumulation of fluid can lead to discomfort in the sinuses and ears. Since the adenoids are prominent in young children, and not in adults, this fluid accumulation in the sinuses and ears is seen in children and not adults.



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Acid Reflux Disease Symptons (Part 2)

Hiatal hernia

Hiatal hernias contribute to reflux, although the way in which they contribute is not clear. A majority of patients with GERD have hiatal hernias, but many do not. Therefore, it is not necessary to have a hiatal hernia in order to have GERD. Moreover, many people have hiatal hernias but do not have GERD. It is not known for certain how or why hiatal hernias develop.

Normally, the LES is located at the same level where the esophagus passes from the chest through the diaphragm and into the abdomen. (The diaphragm is a muscular, horizontal partition that separates the chest from the abdomen.) When there is a hiatal hernia, a small part of the upper stomach that attaches to the esophagus pushes up through the diaphragm. As a result, a small part of the stomach and the LES come to lie in the chest, and the LES is no longer at the level of the diaphragm.

It appears that the diaphragm that surrounds the LES is important in preventing reflux. That is, in individuals without hiatal hernias, the diaphragm surrounding the esophagus is continuously contracted, but then relaxes with swallows, just like the LES. Note that the effects of the LES and diaphragm occur at the same location in patients without hiatal hernias. Therefore, the barrier to reflux is equal to the sum of the pressures generated by the LES and the diaphragm. When the LES moves into the chest with a hiatal hernia, the diaphragm and the LES continue to exert their pressures and barrier effect. However, they now do so at different locations. Consequently, the pressures are no longer additive. Instead, a single, high-pressure barrier to reflux is replaced by two barriers of lower pressure, and reflux thus occurs more easily. So, decreasing the pressure barrier is one way that an hiatal hernia can contribute to reflux.

There is a second way in which hiatal hernias might contribute to reflux. When a hiatal hernia is present, there is a hernial sac, which is a small pouch of stomach above the diaphragm. The sac is pinched off from the esophagus above by the LES and from the stomach below by the diaphragm. What's important about this situation is that the sac can trap acid that comes from the stomach. This trap keeps the acid close to the esophagus. As a result, it is easier for the acid to reflux when the LES relaxes with a swallow or a transient relaxation.

Finally, there is a third way in which hiatal hernias might contribute to reflux. The esophagus normally joins the stomach obliquely, which means not straight on or at a 90-degree angle. Due to this oblique angle of entry, a flap of tissue is formed between the stomach and esophagus. This flap of tissue is believed to act like a valve, shutting off the esophagus from the stomach and preventing reflux. When there is a hiatal hernia, the entry of the esophagus into the stomach is pulled up into the chest. Therefore, the valve-like flap is distorted or disappears and it no longer can help prevent reflux.

Esophageal contractions

As previously mentioned, swallows are important in eliminating acid in the esophagus. Swallowing causes a ring-like wave of contraction of the esophageal muscles, which narrows the lumen (inner cavity) of the esophagus. The contraction, referred to as peristalsis, begins in the upper esophagus and travels to the lower esophagus. It pushes food, saliva, and whatever else is in the esophagus into the stomach.

When the wave of contraction is defective, refluxed acid is not pushed back into the stomach. In patients with GERD, several abnormalities of contraction have been described. For example, waves of contraction may not begin after each swallow or the waves of contraction may die out before they reach the stomach. Also, the pressure generated by the contractions may be too weak to push the acid back into the stomach. Such abnormalities of contraction, which reduce the clearance of acid from the esophagus, are found frequently in patients with GERD. In fact, they are found most frequently in those patients with the most severe GERD. The effects of abnormal esophageal contractions would be expected to be worse at night when gravity is not helping to return refluxed acid to the stomach. Note that smoking also substantially reduces the clearance of acid from the esophagus. This effect continues for at least 6 hours after the last cigarette.

Emptying of the stomach

Most reflux during the day occurs after meals. This reflux probably is due to transient LES relaxations that are caused by distention of the stomach with food. A minority of patients with GERD, about 20%, has been found to have stomachs that empty abnormally slowly after a meal. The slower emptying of the stomach prolongs the distention of the stomach with food after meals. Therefore, the slower emptying prolongs the period of time during which reflux is more likely to occur.

Acid Reflux Disease Symptons

Gastroesophageal Reflux Disease (GERD)

GERD (gastroesophageal reflux disease) is a condition in which the acidified liquid contents of the stomach backs up into the esophagus. The symptoms of uncomplicated GERD are heartburn, regurgitation, and nausea. Effective treatment is available for most patients with Acid Reflux Disease Symptons.

What causes Acid Reflux Disease?

The cause of GERD is complex. There probably are multiple causes, and different causes may be operative in different individuals or even in the same individual at various times. A small number of patients with GERD produce abnormally large amounts of acid, but this is uncommon and not a contributing factor in the vast majority of patients. The factors that contribute to causing GERD are the lower esophageal sphincter, hiatal hernias, esophageal contractions, and emptying of the stomach.

What are the symptoms of uncomplicated Gastroesophageal Reflux Disease?

The symptoms of uncomplicated GERD are primarily heartburn, regurgitation, and nausea. Other symptoms occur when there are complications of GERD and will be discussed with the complications.

Lower esophageal sphincter

The action of the lower esophageal sphincter (LES) is perhaps the most important factor (mechanism) for preventing reflux. The esophagus is a muscular tube that extends from the lower throat to the stomach. The LES is a specialized ring of muscle that surrounds the lower-most end of the esophagus where it joins the stomach. The muscle that makes up the LES is active most of the time. This means that it is contracting and closing off the passage from the esophagus into the stomach. This closing of the passage prevents reflux. When food or saliva is swallowed, the LES relaxes for a few seconds to allow the food or saliva to pass from the esophagus into the stomach, and then it closes again.

Several different abnormalities of the LES have been found in patients with GERD. Two of them involve the function of the LES. The first is abnormally weak contraction of the LES, which reduces its ability to prevent reflux. The second is abnormal relaxations of the LES, called transient LES relaxations. They are abnormal in that they do not accompany swallows and they last for a long time, up to several minutes. These prolonged relaxations allow reflux to occur more easily. The transient LES relaxations occur in patients with GERD most commonly after meals when the stomach is distended with food. Transient LES relaxations also occur in individuals without GERD, but they are infrequent.

The most recently-described abnormality in patients with GERD is laxity of the LES. Specifically, similar distending pressures open the LES more in patients with GERD than in individuals without GERD. At least theoretically, this would allow easier opening of the LES and/or greater backward flow of acid into the esophagus when the LES is open.