Gastroesophageal Reflux

What is GERD?

The sensitive lining of the esophagus (“food tube. connecting the throat and stomach) cannot withstand repeated, prolonged contact with stomach acid. A special “valve” mechanism (sphincter) separating the esophagus and stomach normally prevents excessive “back flow” (reflux) of acid into the esophagus. When we’re awake and upright, gravity and frequent swallowing help move refluxed acid back into the stomach. Also, swallowed saliva neutralizes the acid. Failure of these normal mechanisms can result in pooling of acid in the esophagus–with sometimes disastrous long term consequences.

Is GERD the same thing as a hiatus hernia?

No. Severe GE reflux occurs in many people without a hiatus hernia, and not everyone with a hiatus hernia has significant reflux, so they are not the same.

Why does GE reflux tends to be more prolonged and damaging during sleep?

  • Lying flat eliminates the protective effects of gravity, and swallowing frequency is greatly reduced during sleep.
  • Sound sleep often renders us oblivious to heartburn and other symptoms, so reflux may be allowed to continue.
  • In sleep, stomach acid is much more likely to back up high in the esophagus or even the throat. Asthma-like wheezing, choking, vocal cord spasms or throat closure can result. Some people even inhale the acid into their lungs during sleep, with such drastic consequences as scarring of lung tissues and lung abscesses!

What are possible symptoms of GE reflux?

  • HEARTBURN
  • SOUR BELCHING
  • CHRONIC COUGH
  • CHEST PAIN: which can mimic pain from the heart perfectly, even improving with nitroglycerine!
  • FREQUENT USE OF ANTACIDS OR OTHER REMEDIES (ex: Rolaids®, Maalox®, Mylanta®, Pepcid AC®)
  • AWAKENINGS WITH BITTER TASTE, CHOKING. STRANGLING COUGHING, OR CHEST PAINS
  • WHEEZING, STRIDOROUS (“CROWING”) GASPS
  • VOMITING–with increased risk of inhaling stomach acid into the lungs if it occurs in sleep
  • NO SYMPTOMS WHATSOEVER!!

Doesn’t GE reflux always cause heartburn or other symptoms?

No, surprisingly not. Some people experience extraordinarily prolonged, continuous pooling of acid in the esophagus, lasting over four continuous hours in full wakefulness, without any symptoms at all!

Why not just take antacids?

  • They often aren’t sufficient to treat the problem and prevent damage.
  • Severe reflux can occur without any symptoms (particularly in sleep) means that people may not even know when they need them.

What tests are available for GE reflux?

  • X-rays (upper Gl series) are not very sensitive, and they often miss the diagnosis.
  • Endoscopy (looking at the esophageal lining with a scope) can show inflammation or damage to the esophagus once it has occurred.
  • Manometry (pressure measurements) can clarify why reflux has developed.
  • The most sensitive and specific test for GE reflux is ambulatory esophageal pH monitoring, a test very similar to 24 hour “Holter monitors” used to record heart rhythms. This powerful diagnostic tool is unique in two ways. First, it documents the actual frequency and duration of reflux episodes. Second, it is the only test that can prove whether reflux episodes correlate with specific symptoms. This safe, simple outpatient procedure can be performed in conjunction with monitoring of overnight sleep. Unfortunately, the majority of sleep centers do not offer this invaluable test. If you suffer from symptoms of GE reflux and are seeking assessment, be sure to ask sleep centers that you are considering whether they perform ambulatory esophageal pH monitoring.

Is there any relationship between GE reflux and breathing disorders during sleep?

Yes!

  • Sleep apnea can induce or aggravate GE reflux. When a person struggles to breathe in against a collapsed upper airway, a vacuum effect is created in the chest–which can pull acid up into the esophagus–much like sucking on a straw! Treatment of sleep apnea can help GE reflux during sleep, if the sleep center is equipped to monitor esophageal acidity levels.
  • Sleep-related wheezing, asthmatic symptoms and shortness of breath can be caused by GE reflux during sleep. The reflux may escape detection if pH monitoring is not performed, since heartburn and hyperacidity symptoms may not be present.
  • Both sleep apnea and GE reflux can cause arousals and frightening awakenings with choking, gasping, coughing and breathlessness. If esophageal acidity levels are not monitored in suspicious cases, it can be impossible to tell whether the patient is having reflux with or without coexisting sleep apnea.

How can GE reflux be treated?

1. ELIMINATION OF AGGRAVATING FACTORS: avoiding acidic and spicy foods, caffeine, alcohol, chocolate, peppermint and other dietary causes of reflux; not eating shortly before bedtime; weight loss; quitting smoking. Certain drugs (for example, some asthma drugs) can worsen reflux. Review your medications with your doctor, but don’t stop prescribed medicines on your own!

2. ELEVATING THE HEAD OF YOUR BED ON 6 INCH BLOCKS may help: by allowing gravity to help keep stomach acid down where it belongs. (Extra pillows are not a substitute!)

3. SPECIAL PRESCRIBED MEDICINES may help: some by decreasing acid production, and others by stimulating downward movement of acid back into the stomach.

4. TREATMENT OF SLEEP APNEA: which, if present, can aggravate GE reflux.

5. SURGERIES are used in severe cases.

If you believe you may have significant GE reflux, what should you do?

  • ELIMINATE AGGRAVATING FACTORS AND ELEVATE THE HEAD OF THE BED AS DESCRIBED, if at all possible.
  • CONSULT WITH YOUR FAMILY DOCTOR OR A GASTROENTEROLOGIST (STOMACH SPECIALIST). If they feel an ambulatory esophageal pH study would help in the evaluation of your problem and its severity and if you live in Central Ohio, they can schedule it for you directly by calling The Regional Neurology and Sleep Medicine Institute at (614)-854-0300.
  • IF YOUR SYMPTOMS OF SLEEP-RELATED GE REFLUX ARE ACCOMPANIED BY ANY INDICATIONS OF SLEEP APNEA OR OTHER MAJOR SLEEP DISORDERS, A SLEEP EVALUATION SHOULD BE DONE IN CONJUNCTION WITH ASSESSMENT OF YOUR GE REFLUX, AT A SLEEP CENTER THAT CAN PERFORM AMBULATORY ESOPHAGEAL pH MONITORING: particularly since treatment of sleep apnea may simultaneously reduce GE reflux, thereby treating two potentially serious problems in sleep for “the price of one”! Again, realize that most sleep centers do not offer ambulatory esophageal pH monitoring, such that you should verify that a given center does have the ability to perform that test before scheduling your assessment.
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