Gastroesophageal Reflux Disease and Its Implications - Case Study Example

GASTROESOPHAGEAL REFLUX DISEASE AND ITS IMPLICATIONS The digestive system is a series of hollow organs joined in a long, twisting tube starting with the mouth and ending with the anus. This is also called the gastrointestinal (GI) tract and is protected with a lining called the mucosa. In the mouth, stomach and small intestine, the mucosa contains glands that produce juices to help digest food. The liver and the pancreas are the two important organs which produce digestive juices that reach the intestine through small tubes and helps in the process of digestion. The nervous and the circulatory systems play a major role in supporting the digestive system [1]. The gut modifies food physically and chemically and disposes of unusable waste. Physical and chemical modification (digestion) depends on exocrine and endocrine secretions and controlled movement of food through the gastrointestinal tract [2]. The large, hollow organs of the digestive system contain muscle that enables their walls to move. The movement of organ walls helps to propel food and liquid and also mix the contents within each organ. Typical movement of the esophagus, stomach and intestine is called peristalsis. The esophagus is the organ into which the swallowed food is pushed. It connects the throat above with the stomach below. During swallowing the upper esophagus sphincter relaxes to enable the food to be propelled rapidly into the esophagus without entering the respiratory tract. At the junction of the esophagus and stomach, there is a ringlike valve also called the Lower Esophagus Sphincter (LES) closing the passage between the stomach and the esophagus. The malfunctioning of LES results in the disease called the Gastroesophagal Reflux Disease (GERD). There are several types of disorders associated with the digestive system that interfere with the normal digestion. If food is not properly digested, several problems such as acid reflux and heartburn symptoms, bloating of the stomach, nausea and vomiting, etc. may develop. This paper focuses mainly on GERD and its implications as Gastroesophageal reflux (GER) is a highly prevalent disease. One in seven Americans suffers with heartburn daily while one in five has weekly symptoms [3]. Gastroesophageal reflux disease (GERD) is a condition in which the acids from the stomach move backward into the esophagus (an action called reflux). The band of muscle tissue called lower esophageal sphincter (LES) responsible for closing and opening the lower end of the esophagus are essential for maintaining a pressure barrier against contents from the stomach [4]. GERD occurs when the normal function of the lower esophageal sphincter (LES) is compromised. This occurs primarily when gastric pressure is greater than esophageal pressure, and also due to inappropriate LES relaxation and contraction [5]. LES is a complex area of smooth muscles and various hormones. If it weakens and loses tone, the LES cannot close up completely after food empties into the stomach [4]. The predominant symptoms of GERD are Heartburn and Regurgitation. Other symptoms include chest pain, pain with or difficulty in swallowing, chronic recurrent cough, or excess salivation. However, most often, GERD is asymptomatic and patient or doctor cannot assess the extent of the disease from symptoms. Individual may experience GER at one time or another, with or without symptoms. Prolonged GER damages the esophagus lining [5]. Anyone can have mild and temporary heartburn caused by overeating acidic foods. This is especially true when bending over, taking a nap, or engaging in lifting anything heavy after a large fatty and acidic meal. Persistent GERD, however, may be due to various conditions, including abnormal biological or structural factors [4]. Some pharmacological agents such as theophylline (anti-asthmatic), anticholinergics (anesthesia), calcium channel blockers (anti-hypertensive), beta-adrenergic agents (anti-hypertensive), diazepam (anti-anxiety), meperidine (narcotic) and progesterone (hormone) can cause incompetence of LES. There are a number of secondary factors promoting esophageal injury, including: a higher volume of gastric contents, delayed gastric emptying, hydrochloric acid, impaired peristalsis and diminished flow of saliva [5]. Lifestyle contributors to GERD may include being overweight, overeating, and consuming certain foods, such as citrus, peppermint, chocolate, fatty and spicy foods, caffeine, alcohol, smoking, use of nonsteroidal anti-inflammatory (NSAIDs) drugs such as Aspirin and Ibuprofen [6]. Hiatal hernia may impair LES muscle function. The hiatus is a small hole in the diaphragm through which the esophagus passes into the stomach. It normally fits very snugly, but it may weaken and enlarge. When this happens, part of the stomach muscles may protrude into it producing a condition called hiatal hernia. It is very common, occurring in over half of people over 60 years old, and is rarely serious. Until recent years, it was commonly believed that most cases of persistent heartburn were caused by a hiatal hernia. Studies also suggest an inherited risk exists in many cases of GERD, possibly because of inherited muscular or structural problems in stomach or esophagus [4]. Genetic factors may especially play a strong role in susceptibility to Barretts esophagus, a precancerous condition caused by very severe gastroesophageal reflux [4]. GERD is a common problem in patients with asthma. Gastroesophageal reflux is an important pathogenetic factor of chronic respiratory diseases. Many symptoms and diseases of the upper and lower respiratory tract, such as chronic cough, recurrent pneumonia, bronchial asthma, pulmonary fibrosis, chronic sinusitis, inflammation, ulceration or granuloma of the vocal cords, can be caused and maintained by GER [7]. Some experts speculate that the coughing and sneezing accompanying asthmatic attacks cause changes in pressure in the chest that can trigger reflux. Certain asthmatic drugs that dilate the airways may relax the LES and contribute to GERD. On the other hand, GERD has been associated with a number of other upper respiratory problems and may be a cause of asthma, rather than a result. People with asthma are at very high risk for GERD. Studies indicate that patients with chronic obstructive pulmonary diseases (e.g., emphysema or chronic bronchitis) were more likely to have GERD. Crohns disease is another chronic ailment that causes inflammation and injury in the colon and other parts of the gastrointestinal tract, including the esophagus. Other disorders that may affect areas that can contribute to GERD include diabetes, any gastrointestinal disorder, peptic ulcers, lymphomas and cancer [4]. Nonsteroidal anti−inflammatory drugs (NSAIDs) including aspirin, ibuprofen, and many prescription agents, common causes of peptic ulcers, may also cause GERD and increase severity in people who already have GERD. Many other drugs can cause GERD, including but not limited to the following: calcium channel blockers (used to treat high blood pressure and angina), anticholinergics (used in drugs that treat urinary tract disorders, allergies, and glaucoma), beta adrenergic agonists (used for asthma and obstructive lung diseases), dopamine (used in Parkinsons disease), bisphosphonates (used to treat osteoporosis), sedatives, antibiotics, potassium, or iron pills [4]. Fatty meals, candy, chocolates, citrus juices, and carbonated beverages are believed to provoke GER. Some data suggests that large meal volumes may cause GER [8]. Several studies were conducted by various organizations to analyze the impact of high caloric meals, fat content, meal volume, postprandial physical activity and ingestion of acidic food are associated with the risk of GERD symptoms. A study noted that high dietary fat intake was associated with an increased risk of GERD symptoms and erosive esophagitis, while high fibre intake correlated with a reduced risk of GERD symptoms [9]. However, in yet another study it was observed that changing the fat content of equicaloric meals has no effect on GER over a 3 hour postprandial period. High-fat foods, such as a slice of cake or an ice cream, may not be detrimental to GER, provided they are eaten on their own and not added to a meal [10]. It is essential that dietary habits in patients with GER disease should be concentrated on decreasing the caloric load of meals rather than their fat content [10]. The finding of this study was in line with another study that was conducted to find the effect of a high fat meal compared with an equal energy balanced meal on GER and on the main variables of lower esophageal sphincter (LES) competence. The results revealed that increasing fat intake does not affect GER or esophagogastric competence for at least three hours after a meal [11]. This study was contradicting with another set of studies on healthy individuals, which showed that reducing the caloric density of a meal neither influences postprandial lower esophageal sphincter pressure nor decreases GER. Thus, the amount of GER induced by ingestion of a meal seems to depend on the volume but not on the caloric density of a meal. Hence patients with reflux disease should avoid large volume meals while no restrictions of caloric density and fat content of a meal need to be proposed [12]. The extent of reflux might be influenced by several factors including the volume of refluxate, abdomino-thoracic pressure gradient, compliance of the esophago-gastric junction, and esophageal body motor response. Compared to fasting, reflux episodes occurring after the meals are more likely to reach higher proximal extend, particularly so during early postprandial period. This suggested that by reducing meal volume and early postprandial physical activity might contribute to decrease proximal extend of reflux and postprandial GERD symptoms [13]. In another study it was seen that ingestion of acidic foods may produce drops in pH to Read More