Reflux is the involuntary movement of stomach contents back into the esophagus. This process is normal and occurs several times a day without symptoms or damage to the lining of the esophagus in healthy individuals. But in some people, the reflux can cause symptoms such as burning or pain in the chest, and cause bitter or sour stomach contents to back up into the throat, which may even affect the vocal cords or lungs. When people develop symptoms or damage to the esophagus, pharynx, or respiratory tract because of reflux, then they are considered to have a "disease" called gastroesophageal reflux disease (GERD). It is a common condition, occurring in approximately 20 percent of the population in the United States.
Most GERD is not life threatening. The most common complications are esophagitis, or inflammation of the esophagus; esophageal strictures, or narrowing of the esophagus because of inflammation and scarring, which makes swallowing difficult; and Barrett's esophagus, a condition in which the lower part of the esophagus is covered with abnormal cells similar to those lining the intestines. Only 10 to 20 percent of patients with chronic GERD will develop Barrett's esophagus; this condition is associated with an increased risk of esophageal cancer.
Symptoms of GERD can be treated effectively by a combination of diet and life-style changes and drug therapy. But because GERD is generally a chronic condition, some form of treatment must be continued indefinitely. The wide availability of histamine blockers, such as Zantac, and proton pump inhibitors, like Prilosec, has allowed many individuals to effectively treat occasional pain from GERD themselves.
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The esophagus transports food from the mouth to the stomach and prevents gastric or esophageal contents from moving backward into the mouth. It is a hollow tube, roughly 10 inches long; the length of the esophagus correlates with an individual's height. It is usually longer in men than in women.
The esophagus is closed at the upper and lower ends by two rings of muscle, called "sphincters." These sphincters open to allow food through and then close to prevent the food from backing up. The upper esophageal sphincter, near the throat, prevents swallowed food from re-entering the throat. The lower esophageal sphincter, near the opening to the stomach, stops stomach acid and digested food from moving back up into the esophagus, throat, and mouth. This lower esophageal sphincter, or LES, plays a critical role in GERD.
The hollow walls of the esophagus are lined with a three-layer mucosa. The first layer is composed of soft, scalelike cells. Underneath is a supporting layer of connective tissue and then a thin layer of muscle fiber. There are two layers of muscle tissue below the mucosa that work voluntarily and involuntarily to move food from the mouth to the stomach.
The esophagus passes through the hiatus, an opening in the diaphragm, to join up with the stomach in the abdominal cavity at the lower esophageal sphincter. The diaphragm muscle contracts and helps to enhance the strength of the lower esophageal sphincter, which creates a barrier to the transfer of stomach contents back into the esophagus. Sometimes a weakening of the diaphragm muscle at the hiatus will cause the top part of the stomach to slip through the hiatus into the chest, and this is called a hiatal hernia.
No one knows for certain why some people suffer from GERD and others do not. Studies show that most healthy people experience brief, spontaneous episodes of reflux daily. These occur almost exclusively after meals, are caused by a sudden relaxation of the lower esophageal sphincter, and do not produce symptoms.
Among GERD patients, the central cause of reflux is a weak barrier between the esophagus and stomach. The muscle ring at the junction of the stomach and the esophagus—the lower esophageal sphincter—relaxes or fails to close properly under pressure from stomach contents, which leak backward. A hiatal hernia may be partially responsible: When part of the stomach protrudes above the diaphragm, which ordinarily helps the sphincter keep stomach contents back, it's easier for leakage to occur. Severe symptoms of GERD are more likely when both abnormalities occur in the same individual.
Other factors affect the severity of reflux. Weak or uncoordinated esophageal contractions (perhaps occurring in response to irritation from reflux) delay clearance of refluxed material. This prolongs esophageal contact with acids and bitter digestive stomach contents.
Saliva is an effective natural antacid—and reflux often stimulates salivation, a beneficial response that enhances neutralization of the offending substances. But many people have a low rate of salivation or are unable to swallow their saliva; in them, refluxed material remains in the esophagus for prolonged periods. This increases the severity of esophageal irritation and the probability of damage and complications.
The severity of esophageal damage correlates fairly well with the amount of time the esophagus is bathed in refluxed acid. Patients with higher gastric acid secretion and those who reflux bile (which has entered the stomach from the small intestine) are more likely to have severe esophageal damage than those with lower acid secretion and no bile in the stomach contents.
An additional factor in determining reflux severity is the amount of pressure placed on the anti-reflux barrier. Symptoms are more likely to occur after eating, while lying down, and when there is delayed emptying of the stomach.
A number of factors increase the likelihood or severity of a flare-up:
Food. Many foods increase stomach acidity, including caffeinated beverages, coffee (even decaffeinated), tomato-based dishes and sauces, citrus juices and drinks, chocolate, and spicy foods. Some, such as chocolate, peppermint, spearmint, and carbonated beverages, decrease the lower esophageal sphincter pressure. Others, coffee among them, affect the esophagus's ability to move food to the stomach. Fatty foods slow the passage of food from the stomach into the intestines. Reflux is generally worse after large meals, because overeating increases pressure in the stomach. And lying down or going to bed shortly after eating often brings on burning and other GERD symptoms.
Smoking. Smoking decreases esophageal motor function and increases the swallowing of air, which results in frequent belching. Both effects can worsen symptoms of GERD.
Weight gain. Reflux symptoms often increase with weight gain. They also tend to decrease with weight loss.
Alcohol use. Frequent use of alcohol increases stomach acidity and decreases movement of the esophagus.
Pregnancy. Added pressure on the stomach and the normal hormones of pregnancy, such as progesterone, can make reflux more likely.
Age. GERD is common—yet often overlooked—in children and infants. The condition can cause coughing, vomiting, and other symptoms. Many children outgrow GERD in their first year, but some continue to suffer discomfort. Consult a pediatrician on the best way for dealing with GERD in infants.
Last reviewed on 7/23/09
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