2005-08-27 / Columnists

Stomach Acid Reflux Disease — a Common Malady

Maintaining Your Health on Mackinac
By Yvan Silva, M.D.

Maintaining Your Health
on Mackinac

Medically termed Gastro-esophageal Reflux Disease (GERD), recurring reflux of acid up from the stomach into the esophagus can result in potentially serious complications.

Stomach upsets are common. There is rampant advertising of products suggesting that if you kill acid production before or soon after you eat, you can eat or overeat any kind of food that would ordinarily give you heartburn without concern. Is it the acid you produce by eating spicy foods? Do they get your stomach to overproduce acid?

The physiology of the human stomach is well known. In fact, the earliest in vivo experiments were done right here on Mackinac Island by Doctor William Beaumont. It’s not the acid, it’s what it does when it refluxes into your esophagus that causes the problems. The lining of the stomach is compatible with acid, but the lining of flat cells, called squamous cells, in the esophagus just cannot stand acid. Acid burns off cells, causing damage that requires the body to try to regenerate the lining. Over time, repeated episodes of reflux will alter the lining, thickening and narrowing the esophagus, leading to constriction and eventual obstruction and what is now known as a pre-cancerous state predisposing to cancer of the esophagus.

Now, while an attack of dyspepsia or stomach upset is well known to most, reflux should only be occasional, but those with repeated episodes and long-standing symptoms have GERD, Gastroesophageal Reflux Disease. The problem lies in an innate dyscoordination of motility of the esophagus, which propels food down into the stomach, and the valve between the two, which when normal, prevents reflux upward. The Lower Esophageal Sphincter (LES) is now better understood. Its function can be measured by computer-based testing and the whole problem can be assessed by X-rays and endoscopy, direct visualization of the interior of the pharynx, esophagus, stomach, and duodenum.

GERD can mimic heart attacks and this little-known disease is driving hundreds of thousands of Americans to emergency departments every year. A recent Harris survey indicates that 19 million Americans have symptoms of GERD, including heartburn at least twice a week, and that relief is obtained by taking stomach medication. Experts believe that this figure is underestimated because the disease can often be non-symptomatic. As a society, we believe that heartburn and indigestion are trivial and many live with the disease with constant attention to diet and medications, often at considerable cost. Because the public continues to suffer needlessly and is unaware of effective treatments, large numbers get to an emergency room complaining of crushing chest pain with fear of the consequences of coronary disease.

More than 6 million patients are admitted to the emergency departments with chest-related symptoms. It is estimated that about 20 percent of them have serious heartburn or reflux disease. Indeed, about 75,000 to 150,000 heart catheterizations turn out to be normal. Patients get stress tests, EKGs, and other expensive tests before a heart attack is ruled out. About $3 billion is spent per year to care for patients who enter emergency departments and are needlessly admitted to cardiac care units for treatment. A broad estimate of the cost of these misdiagnoses attributable to non-cardiac causes is around $750 million. Reflux disease can cause or contribute to other conditions. Some studies have shown that of the nation’s 12 million asthmatics, 70 to 80 percent have reflux and the same is true in cases of people with chronic hoarseness of voice.

In the past 15 years, new knowledge on how the stomach produces acid, what causes ulcers, and how the LES protects the esophagus from acid has revolutionized treatment. Drug treatments of stomach ulcers have tremendously lowered the numbers of patients submitted to surgery. Now, over-the-counter medications, known as H2 blockers, the ones referred to in television advertisements, are heavily sought after by people who suffered in silence, believing their symptoms resulted from tensions with their bosses, spouses, or too much spice in their diet. Others are being widely prescribed, after direct-to-the-public marketing by manufacturers, a class of drugs known as proton-pump inhibitors that work through a different mechanism by preventing acid production. More patients are being selected for surgery when it is evident that the valve between the stomach and esophagus is weak or incompetent leading to repeated episodes of reflux through the day and increasingly during the night.

Reflux can be silent, that is, there are no recognized episodes of heartburn. Silent reflux also causes repeated throat infections, can damage the vocal cords resulting in hoarseness or chronic cough, and can even damage teeth.

Carefully selected patients, on the basis of history and relevant tests, a trial of diet and medications, when indicated, are offered surgery to prevent ongoing reflux. The so-called fundoplication operation can be done through a laparoscope when the stomach is wrapped around the lower end of the esophagus, a collar-like segment results and reflux is permanently ameliorated. Some cases require open surgery to achieve this objective. Severe reflux disease, when diagnosed and treated, still requires a lifetime of medical follow-up.

GERD is mostly related to the aging process although the condition is seen in children and adolescents who are born with a weak gastroesophageal valve mechanism. Commonly associated with a hiatal hernia, reflux can occur with this condition or even without it.

The hiatal hernia is an anatomical condition where the upper portion of the stomach is able to enter the lower chest, sliding in and out of the opening where the esophagus enters the abdominal cavity.

GERD is best evaluated and assessed by a qualified gastroenterologist. Referral to a surgeon specializing in these types of procedures becomes relevant when there are indicators that surgery will be necessary.

Dr. Silva is a professor of surgery at Wayne State University and a resident of Woodbluff on Mackinac Island.

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