Everyone occasionally has heartburn. This occurs when stomach acid flows backward into the esophagus, the food pipe that carries food to the stomach. People usually experience heartburn after meals as a burning sensation or pain behind the breast bone. Often, regurgitation of food and bitter-tasting stomach acid accompanies heartburn. Antacids or milk temporarily relieves heartburn for most people.
Why Does Heartburn Occur?
To understand heartburn, let us look at the body's anatomy. The esophagus carries food and liquid to the stomach. A sphincter, or muscular valve, is located at the end of the esophagus at the border between the esophagus and stomach. Known as the lower esophageal sphincter (LES) this muscle contracts much the same as the anus does. The sphincter should maintain a certain pressure to keep the end of the esophagus closed so that stomach juices are not admitted. The LES muscle should only open when food is passed into the stomach.
However, the LES muscle does not always work perfectly. It is felt that the problem is with inappropriate, transient relaxations of this sphincter valve that result in reflux. Sphincter function can be easily overcome by a number of factors, the most common being eating a large meal. Along with swallowed air, a large meal causes an upward pressure in the stomach to rise, thereby overpowering the LES muscle. Other factors that reduce the LES pressure and allow reflux are:
- Nicotine (cigarettes)
- Fried or fatty foods
- Chocolate
- Coffee
- Citrus fruits and juices
- Peppermint
- Pregnancy
- Lying flat
- Hiatus hernia
- Certain prescription medications
Swallowing difficulty, medically termed dysphagia, can arise for a variety of reasons. Firstly, reflux alone can disturb the muscular contraction or motility of the esophagus and interfere with the passage of liquids and solids. Often, when reflux is controlled, these symptoms will disappear.
The inflammatory response of the esophagus from chronic reflux can lead to the formation of a ring of scar tissue at the end of the esophagus where it meets the stomach, an area know as the gastroesophageal junction (the location of the LES), that can lead to a mechanical obstruction causing difficultywith swallowing solids. This entity is known as an esophageal ring or a Schatzki Ring. In some cases the ring needs to be disrupted in order to resolve the blockage.
Of course with chronic reflux comes the risk of esophageal cancer and although the risk is low, it is very real. Such tumors can cause significant blockage and bleeding. The cancers are diagnosed most often by way of video upper endoscopy. A person presenting with new-onset swallowing trouble, a history of reflux, bleeding, and weight loss should seek a medical evaluation immediately.
There are a variety of primary esophageal motility disorders that cause swallowing trouble. Achalasia is a disorder that can be quite insidious and involves that loss of motility in the body of the esophagus and the lower esophageal sphincter (LES)fails to relax. The physical presentation can look like reflux because the patient does not clear contents of the esophagus and those materials can backwash into the upper esophagus and mimic GERD. The diagnosis of Achalasia is made by way of esophageal manometry whereby the wave forms of the esophagus are measured to make the diagnosis. Achalasia can be treated surgically (laparoscopically) or by balloon dilation of the lower sphincter.
There are other esophageal motility disorders that can be described by esophageal manometry and they include diffuse esophageal spasm that is often associated wit noncardiac chest pain, the Nutcracker esophagus, and Ineffective Esophageal Motility. Esophageal motility studies ( manometry) will require the passage of a small caliber tube into the esophagus through a nasal passage. The test takes about 20-30 minutes to complete and is well-tolerated. It is performed as an out-patient.