Synonym
GERD (gastroesophageal reflux disease), reflux disease
Definition
- Gastro-oesophageal reflux: reflux of stomach contents into the esophagus due to incomplete closure of the annular muscle at the stomach entrance.
- Physiological reflux: is a reflux of stomach contents that occasionally occurs in healthy people when they eat high-fat meals and drink wine.
- Gastroesophageal reflux disease: This disease shows changes in the mucous membrane of the esophagus due to constant reflux.
Frequency of illness
In the western population about 20% are affected by reflux disease, 60% of which show no mucous membrane changes in the endoscopic examination. However, 40% already have visible changes. 5% of people with a GERD develop a so-called beretted esophagus during their lifetime, and in 10% of these people esophageal cancer develops.
Causes
One cause of reflux can be that the lower esophageal sphincter does not close properly and the gastric juices flow back into the esophagus. This is also the most common cause of reflux. Another cause may be pregnancy, since about 50% of all expectant mothers have reflux, especially in the last trimester of pregnancy. Other reasons for reflux may be: Condition after surgical treatment of achalasia (a muscular constriction of the lower esophagus due to nerve malformation), a gastric outlet narrowing, or a scleroderma (a hardening of the connective tissue of the skin or internal organs).
Pathogenesis
An inadequate anti-reflux barrier of the lower esophageal muscle (also called lower esophageal sphincter, UÖS for short), which is located between the stomach entrance and the lower esophagus, is one of the main causes of gastroesophageal reflux disease. In a healthy person, the lower UÖS forms a pressure barrier, whereby the pressure in the esophagus at rest is about 10 – 25 mmHg higher than that in the stomach. Only during the act of swallowing does a short-lasting flaccidity of the UÖS occur.
The patient suffers from an inappropriate relaxation of the lower esophageal ring muscle outside of the act of swallowing, or the pressure is too low, so that no pressure barrier can be built up. Other factors that may contribute to an inadequate anti-reflux barrier include obesity, late evening large meals, alcohol and coffee consumption. The second major cause of GERD is a so-called aggressive reflux.
This is an acid reflux of the gastric juice. In two thirds of all patients, the main symptom is heartburn, a burning pain located behind the breastbone, which occurs particularly after meals, at night and when lying down. A feeling of pressure behind the breastbone can also occur.
In 60% of patients, air is bursting, in half of the patients swallowing difficulties occur. Soapy or salty taste after burping can occur as well as nausea and vomiting. All of these symptoms are aggravated by pressing, lying on the back, bending over, physical exertion, certain foods and medicines, and also stress.
Chronic coughing, possibly hoarseness or sleep disturbances at night can be a sign of an “extraesophageal manifestation” (manifestation lying above the esophagus) of reflux disease. Occasional reflux is just as normal and harmless in babies and children as in adults. Only if the reflux leads to further abnormalities or complications, it is in need of treatment.
Symptomatically, the consequences of pathologic reflux often show themselves in a failure to thrive. The children stand out with a lack of weight gain or a growth that does not correspond to their age. Accompanying often increased vomiting or refusal to eat can be observed (here you can find more causes for vomiting).
Reactive respiratory diseases, such as asthma (click here for symptoms of asthma), can also trigger reflux. The physical cause of reflux is the same as in adults. The lower sphincter muscle at the esophagus contracts incorrectly and as a result, gastric acid can travel up the esophagus.
In children, this phenomenon is caused in up to 80% of cases by a hernia in the diaphragm. The esophagus normally enters the abdomen through a small opening in the diaphragm. There it then flows into the stomach.This is fixed in the abdominal cavity by its larger volume and cannot pass through this constriction.
In addition, the sphincter muscle of the esophagus is located directly under the constriction and can thus control the passage of food towards the stomach. However, if the passage is enlarged, parts of the stomach may, anatomically speaking, enter the chest. The sphincter muscle loses its support just below the diaphragm and the pressure in the stomach may exceed its muscle strength.
Reflux is the result. A much rarer cause is a congenital malformation of the esophagus, which had to be corrected surgically. Any operation on the esophagus can result in reflux.
The treatment of reflux in very small children is often first conservative, in order to avoid side effects of medication. Upper body elevation during and after meals and the administration of locust bean gum should therefore be attempted for at least six months. If there is no improvement, drug therapy or even surgical treatment can be considered.
