Dr. Starpoli's Blog

Refluxology: The Study of GERD

Posted by Anthony Starpoli on Jul 21, 2012 11:36:00 AM
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So, you think you have acid reflux?  What is acid reflux?  Why is it called acid reflux?

Firstly, gastroesophageal reflux disease (a.k.a. GERD) is a condition whereby the contents of the stomach that are mostly liquid travel backwards up into the esophagus or the food tube that connects the stomach and the esophagus.  Because of noxious components in this refluxed material, a person can experience pain, usually a burning, because the nerve fiber lining the esophagus are irritated.  Heartburn is that substernal (beneath the breastbone) burning sensation.  While there is acid in the stomach, there are other agents in the gastric juice that have enzymes and bile.  These substances are not acidic in nature.  

The expression acid reflux was coined by the pharmaceutical companies that developed acid lowering drugs over the past several decades.  These drug types range from simple antacids like Tums, or histamine type II blockers like brand Pepcid or Zantac, to the proton pump inhibitors (PPI), the strongest of the lot, with such names such as Nexium or Prevacid brand. These widely prescribed medications only lower acid and have no effect on the mechanical aspect of GERD.  

Lower esophageal sphincter (LES) function in the area of the lower esophagus where it borders the stomach is responsible for preventing the backwash of reflux material. Specifically, transient relaxations of the LES are mostly responsible for reflux.  In addition, the muscle sling fibers of the diaphragm (diaphragmatic crura) that surround this same level of the esophagus that contains the LES and serve as an external sphincter system that aid in preventing reflux.

When there is a widening of the diaphragmatic crura, the stomach below the diaphragm can migrate above and this is called a hiatal hernia.  A crural defect or widening can occur without and overt herniation of the stomach.  Both conditions can make one more susceptible to GERD because of their anatomical disruptions leading to the mechanically induced reflux. This reflux is not only about the acid content.  When analyzed, this refluxate contains acidic nonacid components.  In many cases, uncontrolled reflux occurs due to the fact that acid lowering drugs by themselves can not control all aspects of reflux.  There may be p

ersistent elevated acid reflux, but more likely nonacid reflux is present.  Acid lowering drugs have little or no impact on the nonacid type of reflux which explains why a failure to standard medical therapy can happen.  The symptom of regurgitation, the effortless backwash of stomach contents up into the esophagus (and sometimes into the mouth), is evidence of this type of reflux.

The continued use of medical therapy to lower acid, with the escalation of dosing, will likely have little or no effect on the management of GERD that occurs as a result of significant anatomical abnormalities as described.  In these cases the use of impedance combined pH 24 hour reflux testing can prove the presence of nonacid reflux.  There are clues from a well performed upper endoscopy that can highlight key aspects of the anatomy of the esophagus and stomach.  Very simply, a medical practioner can as his or her patient whether or not all the reflux symptoms are well controlled.

A refluxologist will take the time to ask the hard questions about why medical therapy is not working and will come up with a diagnostic and therapeutic plan.  Often, correction by way of surgery of the anatomy will be needed to control nonacid reflux.  In the case of a surgical approach, there may be an opportunity to stop all medical therapy for GERD.  Over the past year, there have been may concerns raised over the chronic use of PPI drug treatment that include: vitamin and mineral depletion such as vitamin D, iron and magnesium, interference with the function of other critical drug therapies, increase risk of bone fracture, and an increase risk for gastrointestinal infections such as that with Clostridium difficle.  If possible, a safe alternative to longterm drug therapy may be beneficial. 

Dr. Starpoli

Complicated GERD requires an in-depth review of the underlying mechanisms behind the complaints of GERD.  A physician with a focus on refluxology, or the study of reflux, will be most equipped to assess the condition at hand.

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Obesity, GERD, atypical reflux, nonacid reflux, heartburn, EsophyX, incisionless surgery, Barrett's Esophagus