Hello and welcome to Dr Euan's TGIF Blog!
Today's blogpost is about acid reflux, which over time, can become GERD. This can lead to hoarseness and discomfort in the throat and stomach.
So let's take a look at this, shall we?
Q: What is Acid reflux and what is GERD?
Gastro-esophageal Reflux Disease (GERD) occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach (oesophagus). This backwash (acid reflux) can irritate the lining of your oesophagus, and cause troublesome symptoms.
Certain conditions can also increase your risk of GERD, such as:
Bulging of the upper part of the stomach up above the diaphragm (hiatal hernia)
Connective tissue disorders, such as scleroderma
Delayed stomach emptying, usually related to certain drugs
Factors that can aggravate acid reflux include:
Eating large meals or eating late at night eg supper or SIEW YEH (in Cantonese)
Eating certain foods (triggers) such as fatty or fried foods
Drinking certain beverages, such as alcohol or coffee
Taking certain medications, such as aspirin
People can have different foods or drinks that trigger more reflux in their diet. Being aware of your triggers can help you to avoid some discomfort.
Q: What are the symptoms of GERD?
Common symptoms include:
A burning sensation in your chest (heartburn), usually after eating, which might be worse at night or while lying down.
Backwash (regurgitation) of food or sour liquid.
Upper abdominal or chest pain.
Trouble swallowing (dysphagia)
A sensation of a lump in your throat that you cannot seem to clear (globus).
Q: Why do we feel heartburn and burning in the throat from GERD?
Acid reflux happens because a valve at the lower end of your oesophagus, called the lower oesophageal sphincter, doesn’t close properly when the food arrives in your stomach. Acid backwash then flows back up through your oesophagus into your throat and mouth, giving you heartburn and often a sour taste in your mouth.
Actually, acid reflux happens to nearly everyone at some point in life, especially after a full meal, accompanied by wine or alcohol. There are many TV and radio advertisements on such episodes.
So having acid reflux and heartburn now and then is totally normal.
However, if you have acid reflux/heartburn more than twice a week over a period of several weeks, or constantly take heartburn medications and antacids but yet your symptoms keep returning, you may have developed GERD.
Your GERD should be treated by your GP or healthcare professional: not just to relieve your symptoms, but because GERD can lead to more serious problems and complications if left untreated.
Q: What do you see when the Doctor examines the Throat and Voice Box in Clinic?
Endoscopic images of larynx (voice box) affected by GERD, & without GERD for comparison
Voice Box with features of GERD (left image): redness (erythema) & swelling (oedema) around the arytenoids, the cartilage above the vocal cords. Foamy saliva can also be seen around the vocal cords due to the acid from reflux.
To confirm a diagnosis of GERD, or to check for complications, your doctor might recommend one or more of the following tests:
Upper endoscopy. Your doctor inserts a thin, flexible tube equipped with a light and camera (endoscope) down your throat. The endoscope helps your provider see inside your oesophagus and stomach. Test results may not show problems when reflux is present, but an endoscopy may detect inflammation of the oesophagus (oesophagitis) or other complications. An endoscopy can also be used to collect a sample of tissue (biopsy) to be tested for complications such as Barrett Oesophagus. In some instances, if a narrowing is seen in the oesophagus, it can be stretched or dilated during this procedure. This is done to improve trouble swallowing (dysphagia).
Ambulatory acid (pH) probe test. A monitor is placed in your oesophagus to identify when, and for how long, stomach acid regurgitates there. The monitor connects to a small computer that you wear around your waist or with a strap over your shoulder. The monitor might be a thin, flexible tube (catheter) that's threaded through your nose into your oesophagus. Or it might be a clip that's placed in your oesophagus during an endoscopy. The clip passes into your stool after about two days.
X-ray of the upper digestive system. X-rays are taken after you drink a chalky liquid that coats and fills the inside lining of your digestive tract. The coating allows your doctor to see a silhouette of your oesophagus and stomach. This is particularly useful for people who are having trouble swallowing. You may also be asked to swallow a barium pill that can help diagnose a narrowing of the oesophagus that may interfere with swallowing.
Oesophageal manometry. This test measures the rhythmic muscle contractions in your oesophagus when you swallow. Oesophageal manometry also measures the coordination and force exerted by the muscles of your oesophagus. This is typically done in people who have trouble swallowing.
Transnasal Oesophagoscopy. This test is done to look for any damage in your oesophagus. A thin, flexible tube with a video camera is put through your nose and moved down your throat into the oesophagus. The camera sends pictures to a video screen.
Oftentimes in our ENT practice, we perform a trans-nasal flexible Naso-endoscopy to look for any telltale signs of GERD in and around your voice box, such as redness (erythema) swelling (oedema), ulcers or granulations.
Image of Dr Euan performing a Nasoendoscopy
Q: What are the longer-term risks of untreated GERD? Are there any serious complications?
Over time, chronic acid irritation and inflammation in your oesophagus can cause:
Inflammation of the tissue in the oesophagus (oesophagitis). Stomach acid can break down tissue in the oesophagus, causing inflammation, bleeding, and sometimes an open sore (ulcer). Oesophagitis can cause pain and make swallowing difficult.
Narrowing of the oesophagus (oesophageal stricture). Damage to the lower oesophagus from stomach acid causes scar tissue to form. The scar tissue narrows the food pathway, leading to problems with swallowing.
Precancerous changes to the oesophagus (Barrett Oesophagus). Damage from acid can cause changes in the tissue lining the lower oesophagus. These changes are associated with an increased risk of Oesophageal cancer.
Q: So what can you do about GERD?
Your doctor is likely to recommend that you first try lifestyle changes and nonprescription medications. If you don't experience relief within a few weeks, your doctor might recommend prescription medication and additional testing. For certain conditions, there is also the option of surgical treatment.
Non-prescription medications are available off the counter (OTC) at most pharmacies.
Antacids that neutralise stomach acid. Antacids containing calcium carbonate, such as Mylanta, Rolaids and Tums, may provide quick relief. But antacids alone won't heal an inflamed oesophagus damaged by stomach acid. Overuse of some antacids can cause side effects, such as diarrhoea or sometimes kidney problems.
Medications to reduce acid production. These medications — known as histamine (H-2) blockers — include cimetidine (Tagamet HB), famotidine (Pepcid AC) and nizatidine (Axid AR). H-2 blockers don't act as quickly as antacids, but they provide longer relief and may decrease acid production from the stomach for up to 12 hours. Stronger versions are available by prescription.
Medications that block acid production and heal the oesophagus. These medications — known as proton pump inhibitors — are stronger acid blockers than H-2 blockers and allow time for damaged oesophageal tissue to heal. Nonprescription proton pump inhibitors include lansoprazole (Prevacid 24 HR), omeprazole (Prilosec OTC) and esomeprazole (Nexium 24 HR).
If you start taking a nonprescription medication for GERD, please be sure to inform your doctor or GP.
Prescription-strength treatments for GERD include:
Prescription-strength proton pump inhibitors (PPIs). These include esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix), rabeprazole (Aciphex) and dexlansoprazole (Dexilant). Although generally well tolerated, these medications might cause diarrhoea, headaches, nausea, or in rare instances, low vitamin B-12 or magnesium levels.
Prescription-strength H-2 blockers. These include prescription-strength famotidine and nizatidine. Side effects from these medications are generally mild and well tolerated.
Surgery and other procedures
GERD can usually be controlled with lifestyle changes and medication. But if medications don't help or you wish to avoid long-term medication use, your doctor might recommend:
Fundoplication. The healthcare surgeon wraps the top of your stomach around the lower oesophageal sphincter, to tighten the muscle and prevent reflux. Fundoplication is usually done with a minimally invasive (laparoscopic) procedure. The wrapping of the top part of the stomach can be complete (Nissen fundoplication) or partial. The most common partial procedure is the Toupet fundoplication. Your surgeon will recommend the type that is best suited for you.
LINX device. A ring of tiny magnetic beads is wrapped around the junction of the stomach and oesophagus. The magnetic attraction between the beads is strong enough to keep the junction closed to refluxing acid, but weak enough to allow food to pass through. The LINX device can be implanted using minimally invasive surgery. The magnetic beads do not have an effect on airport security or magnetic resonance imaging.
Transoral incisionless fundoplication (TIF). This new procedure involves tightening the lower oesophageal sphincter by creating a partial wrap around the lower oesophagus using polypropylene fasteners. TIF is performed through the mouth by using an endoscope and requires no surgical incision. Its advantages include quick recovery time and high tolerance. However, if you have a large hiatal hernia, then TIF alone is not an option. However, TIF may be possible if it is combined with laparoscopic hiatal hernia repair.
Because obesity can be a risk factor for GERD, your healthcare provider could suggest weight-loss surgery as an option for treatment for morbid obesity. Do talk with your GP to find out if you're a candidate for this type of surgery.
Finally, lifestyle and dietary habit changes are VERY important in managing GERD:
Lifestyle and home remedies
Lifestyle changes may help reduce the frequency of acid reflux. Try to:
Maintain a healthy weight. Excess pounds put pressure on your abdomen, pushing up your stomach and causing acid to reflux into your oesophagus.
Stop smoking. Smoking decreases the lower oesophageal sphincter's ability to function properly.
Elevate the head of your bed. If you regularly experience heartburn while trying to sleep, place wood or cement blocks under the feet at the head end of your bed. Raise the head end by 6 to 9 inches. If you can't elevate your bed, you can insert a wedge between your mattress and box spring to elevate your body from the waist up. Raising your head with additional pillows isn't effective.
Start on your left side. When you go to bed, start by lying on your left side to help make it less likely that you will have reflux.
Don't lie down after a meal. Wait at least three hours after eating before lying down or going to bed.
Eat food slowly and chew thoroughly. Put down your fork after every bite and pick it up again once you have chewed and swallowed that bite.
Avoid foods and drinks that trigger reflux. Common triggers include alcohol, chocolate, caffeine, fatty foods or peppermint.
Avoid tight-fitting clothing. Clothes that fit tightly around your waist put pressure on your abdomen and the lower oesophageal sphincter.
Regular overconsumption of alcohol can also increase the risk of GERD
Some complementary and alternative therapies, such as ginger, chamomile and slippery elm, may sometimes be recommended to treat GERD. However, none have been proven to treat GERD or reverse mucosal damage to the oesophagus.
Do discuss these alternative treatments with your Doctor.
If you are experiencing discomfort in your throat, but the symptoms do not appear to align with GERD, here are some blogposts you can read on other throat-related conditions:
Consultation for GERD:
If you would like to seek treatment for GERD, please see your GP for advice,
or feel free to Contact Us at Euan's ENT Surgery & Clinic to make an appointment.
Here are some useful references if you are keen to delve deeper into GERD.
Have a good restful weekend ahead! TGIF FOLKS :-)
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