Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.
Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.
The cause of GERD is complex. There probably are multiple causes, and different causes may be operative in different individuals or even in the same individual at different times. A small number of patients with GERD produce abnormally large amounts of acid, but this is uncommon and not a contributing factor in the vast majority of patients. The factors that contribute to GERD are lower esophageal sphincter
abnormalities, hiatal hernias, abnormal esophageal contractions, and slow or
prolonged emptying of the stomach.
Lower esophageal sphincter
The action of the lower esophageal sphincter (LES) is perhaps the most
important factor (mechanism) for preventing reflux. The esophagus is a muscular
tube that extends from the lower throat to the stomach. The LES is a specialized
ring of muscle that surrounds the lower-most end of the esophagus where it joins
the stomach. The muscle that makes up the LES is active most of the time. This
means that it is contracting and closing off the passage from the esophagus into
the stomach. This closing of the passage prevents reflux. When food or saliva is
swallowed, the LES relaxes for a few seconds to allow the food or saliva to pass
from the esophagus into the stomach, and then it closes again.
Several different abnormalities of the LES have been found in patients with GERD. Two
of them involve the function of the LES. The first is abnormally weak contraction of the LES, which reduces its ability to
prevent reflux. The second is abnormal relaxations of the LES, called transient
LES relaxations. They are abnormal in that they do not accompany swallows
and they last for a long time, up to several minutes. These prolonged
relaxations allow reflux to occur more easily. The transient LES relaxations
occur in patients with GERD most commonly after meals when the stomach is
distended with food. Transient LES relaxations also occur in individuals without
GERD, but they are infrequent.
The most recently-described abnormality in patients with GERD is laxity of the LES. Specifically, similar distending pressures open the LES more in patients with GERD than in individuals without GERD. At least theoretically, this would allow easier opening of the LES and/or greater backward flow of acid into the esophagus when the LES is open.
Hiatal hernia
Hiatal hernias contribute to reflux, although the way in which they
contribute is not clear. A majority of patients with GERD have hiatal hernias,
but many do not. Therefore, it is not necessary to have a
hiatal hernia in order
to have GERD. Moreover, many people have hiatal hernias but do not have GERD. It
is not known for certain how or why hiatal hernias develop.
Normally, the LES is located at the same level where the esophagus passes
from the chest through the diaphragm and into the abdomen. (The diaphragm is a
muscular, horizontal partition that separates the chest from the abdomen.) When
there is a hiatal hernia, a small part of the upper stomach that attaches to the
esophagus pushes up through the diaphragm. As a result, a small part of the
stomach and the LES come to lie in the chest, and the LES is no longer at the
level of the diaphragm.
It appears that the diaphragm that surrounds the LES is important in preventing reflux. That is, in
individuals without hiatal hernias, the diaphragm surrounding the esophagus is continuously
contracted, but then relaxes with swallows, just like the LES.
Note that the effects of the LES and diaphragm occur at the same location
in patients without hiatal hernias. Therefore, the barrier to reflux is equal to the sum
of the pressures generated by the LES and the diaphragm. When the LES moves into
the chest with a hiatal hernia, the diaphragm and the LES continue to exert
their pressures and barrier effect. However, they now do so at different
locations. Consequently, the pressures are no longer additive. Instead, a
single, high-pressure barrier to reflux is replaced by two barriers of lower
pressure, and reflux thus occurs more easily. So, decreasing the pressure
barrier is one way that a hiatal hernia can contribute to reflux.
There is a second way in which hiatal hernias might contribute to reflux.
When a hiatal hernia is present, there is a hernial sac, which is a small pouch
of stomach above the diaphragm. The sac is pinched off from the esophagus above
by the LES and from the stomach below by the diaphragm. What's important about
this situation is that the sac can trap acid that comes from the stomach. This
trap keeps the acid close to the esophagus. As a result, it is easier for the
acid to reflux when the LES relaxes with a swallow or a transient relaxation.
Finally, there is a third way in which hiatal hernias might contribute to
reflux. The esophagus normally joins the stomach obliquely, which means not
straight on or at a 90-degree angle. Due to this oblique angle of entry, a flap
of tissue is formed between the stomach and esophagus. This flap of tissue is
believed to act like a valve, shutting off the esophagus from the stomach and
preventing reflux. When there is a hiatal hernia, the entry of the esophagus
into the stomach is pulled up into the chest. Therefore, the valve-like flap is
distorted or disappears and it no longer can help prevent reflux.
Esophageal contractions
As previously mentioned, swallows are important in eliminating acid in the
esophagus. Swallowing causes a ring-like wave of contraction of the esophageal
muscles, which narrows the lumen (inner cavity) of the esophagus. The
contraction, referred to as peristalsis, begins in the upper esophagus and
travels to the lower esophagus. It pushes food, saliva, and whatever else is in
the esophagus into the stomach.
When the wave of contraction is defective, refluxed acid is not pushed back
into the stomach. In patients with GERD, several abnormalities of contraction
have been described. For example, waves of contraction may not begin after each
swallow or the waves of contraction may die out before they reach the stomach.
Also, the pressure generated by the contractions may be too weak to push the
acid back into the stomach. Such abnormalities of contraction, which reduce the
clearance of acid from the esophagus, are found frequently in patients with
GERD. In fact, they are found most frequently in those patients with the most
severe GERD. The effects of abnormal esophageal contractions would be expected to be worse at night when gravity is not helping to return refluxed acid to the stomach. Note that
smoking also substantially reduces the clearance of acid
from the esophagus. This effect continues for at least 6 hours after the last
cigarette.
Emptying of the stomach
Most reflux during the day occurs after meals. This reflux probably is due to
transient LES relaxations that are caused by distention of the stomach with
food. A minority of patients with GERD, about 20%, has been found to have
stomachs that empty abnormally slowly after a meal. The slower emptying of the
stomach prolongs the distention of the stomach with food after meals. Therefore,
the slower emptying prolongs the period of time during which reflux is more
likely to occur.
In addition to the above, some medications may cause or worsen GERD. Some common medications that may have this effect include anticholinergics, antihypertensives such as
beta blockers or
calcium channel blockers, bronchodilators, dopamine-active drugs, progestin, sedatives, and
tricyclic antidepressants.
Individuals should not stop taking these or any drugs that are prescribed until the prescribing doctor has discussed the potential GERD situation with the
them.
GERD - Proton Pump InhibitorsQuestion: Heartburn symptoms caused by GERD are usually relieved by drugs called proton pump inhibitors (Prilosec, Prevacid, Aciphex, Protonix, Nexium, Zegerid); however, proton pump inhibitors sometimes do not work well. If your symptoms were not relieved by treatment with proton pump inhibitors, can you please describe your GERD symptoms that did not improve? If you have other treatments that have been effective, please comment on those.
Abdominal pain is pain in the belly and can be acute or chronic. Causes include inflammation, distention of an organ, and loss of the blood supply to an organ. Abdominal pain can reflect a major problem with one of the organs in the abdomen such as the appendix, gallbladder, large and small intestine, pancreas, liver, colon, duodenum, and spleen.
There are many symptoms involved in the 1st, 2nd and 3rd trimesters of pregnancy. The first early pregnancy symptom is typically a missed period, but others include breast swelling and tenderness, nausea and sometimes vomiting, fatigue and bloating. Second trimester symptoms include backache, weight gain, itching, and possible stretch marks. Third trimester symptoms are additional weight gain, heartburn, hemorrhoids, swelling of the ankles, fingers, and face, breast tenderness, and trouble sleeping. Read more to learn about recommended procedures and tests for each stage of a healthy pregnancy.
Bronchitis is a disease of the respiratory system in which the bronchial passages become inflamed. There are two types of bronchitis, acute and chronic. Symptoms of acute bronchitis include frequent cough with mucus, lack of energy, wheezing, and possible fever. Treatment may require medication such as bronchial inhalers and predinsone. Supportive treatment is focused on relieving the symptoms with fever reducers, cough suppressants, and rest. Treatment may be more aggressive in patients with pre-existing conditions such as empyema, COPD, or cigarette smoking.
Allergic rhinitis symptoms include an itchy, runny nose, sneezing, itchy ears, eyes, and throat. Seasonal allergic rhinitis (also called hay fever) is usually caused by pollen in the air. Perennial allergic rhinitis is a type of chronic rhinitis and is a year–round problem, often caused by indoor allergens, such as dust, animal dander, and pollens that may exist at the time. Treatment of chronic rhinitis and post nasal drip are dependant upon the type of rhinitis condition.
A hiatal hernia is an anatomical abnormality in which part of the stomach protrudes through the diaphragm and up into the chest. Causes of hiatal hernia are a larger than normal esophageal hiatus. There are two types of hiatal hernias, sliding, or para-esophageal. When symptoms of hiatal hernia appear, they are similar to GERD symptoms. Hiatal hernia treatment is generally surgery.
Sjögren's syndrome is an autoimmune disease involving the abnormal production of extra antibodies that attack the glands and connective tissue. Sjögren's syndrome with gland inflammation (resulting dry eyes and mouth, etc.) that is not associated with another connective tissue disease is referred to as primary Sjögren's syndrome. Sjögren's syndrome that is also associated with a connective tissue disease, such as rheumatoid arthritis, systemic lupus erythematosus, or scleroderma, is referred to as secondary Sjögren's syndrome. Though there is no cure for Sjögren's syndrome, the symptoms may be treated by using lubricating eye ointments, drinking plenty of water, humidifying the air, and using glycerin swabs. Medications are also available to treat dry eye and dry mouth.
Chronic cough is a cough that does not go away and is generally a symptom of another disorder such as asthma, allergic rhinitis, sinus infection, cigarette smoking, GERD, postnasal drip, bronchitis, pneumonia, medications, and less frequently tumors or other lung disease. Treatment of chronic cough is dependant upon the cause.
Esophageal cancer is a disease in which malignant cells form in the esophagus. Risk factors of cancer of the esophagus include smoking, heavy alcohol use, Barrett's esophagus, being male and being over age 60. Severe weight loss, vomiting, hoarseness, coughing up blood, painful swallowing, and pain in the throat or back are symptoms. Treatment depends upon the size, location and staging of the cancer and the health of the patient.
Chest pain is a common complaint by a patient in the ER. Causes of chest pain include broken or bruised ribs, pleurisy, pneumothorax, shingles, pneumonia, pulmonary embolism, angina, heart attack, costochondritis, pericarditis, aorta or aortic dissection, and reflux esophagitis. Diagnosis and treatment of chest pain depends upon the cause and clinical presentation of the patient's chest pain.
Dyspepsia (indigestion) is a functional disease in which the gastrointestinal organs, primarily the stomach and first part of the small intestine, function abnormally. It is a chronic disease in which the symptoms fluctuate infrequency and intensity. Symptoms of dyspepsia include upper abdominal pain, belching, nausea, vomiting, abdominal bloating, early satiety, and abdominal distention (swelling). These symptoms are most often provoked by eating.
Scleroderma is an autoimmune disease of the connective tissue. It is characterized by the formation of scar tissue (fibrosis) in the skin and organs of the body, leading to thickness and firmness of involved areas. Scleroderma is also referred to as systemic sclerosis, and the cause is unknown. Treatment of scleroderma is directed toward the individual features that are most troubling to the patient.
Laryngitis is an inflammation of the voice box (vocal cords). The most common cause of acute laryngitis is infection, which inflames the vocal cords. Symptoms may vary from degree of laryngitis and age of the patient. Common symptoms include croup, hoarse cough, fever, cold, runny nose, dry cough, and loss of voice. Chronic laryngitis generally lasts more than three weeks. Causes other than infection include smoking, excess coughing, GERD, and more. Treatment depends on the cause of laryngitis.
Asthma is a common disorder in which
chronic inflammation of the bronchial tubes (bronchi) makes them swell, narrowing the airways. Signs and symptoms include shortness of breath, chest tightness,
cough and wheezing.
Eosinophilic esophagitis is an inflammation of the esophagus. Eosinophilic esophagitis has many causes including acid reflux, heartburn, viruses, medications that become stuck in the esophagus, allergy, asthma, hay fever, allergic rhinitis, and atopic dermatitis. Eosinophilic esophagitis symptoms include difficulty swallowing food, abdominal pain, chest pain, and heartburn.
Dysphagia or difficulty in swallowing, swallowing problems. Dysphagia is due to problems in nerve or muscle control. It is common, for example, after a stroke. Dysphagia compromises nutrition and hydration and may lead to aspiration pneumonia and dehydration.
Esophagitis is caused by an infection or irritation of the esophagus. Infections that cause esophagitis include candida yeast infection of the esophagus as well as herpes.
Barrett's esophagus occurs as a complication of chronic gastroesophageal reflux disease (GERD), primarily in white males. GERD refers to the reflux of acidic fluid from the stomach into the esophagus (the swallowing tube), and is classically associated with heartburn.
Chronic bronchitis is a cough that occurs daily with production of sputum that lasts for at least three months, two years in a row. Causes of chronic bronchitis include cigarette smoking, inhaled irritants, and underlying disease processes (such as asthma, or congestive heart failure). Symptoms include cough, shortness of breath, and wheezing. Treatments include bronchodilators and steroids. Complications of chronic bronchitis include COPD and emphysema.
Hoarseness (abnormal deep, harsh, raspy voice) is caused by a variety of conditions in which the larynx (voice box and vocal chords) are irritated or injured. Examples of causes of hoarseness include: laryngitis, straining the vocal cords by yelling or screaming, infections, GERD, allergies, and more. Treatment of hoarseness depends on the cause.
Insomnia is the perception or complaint of inadequate or poor-quality sleep because of difficulty falling asleep; waking up frequently during the night with difficulty returning to sleep; waking up too early in the morning; or unrefreshing sleep. Secondary insomnia is the most common type of insomnia. Treatment for insomnia include lifestyle changes, cognitive behavioral therapy, and medication.
Connective tissue diseases are disorders featuring abnormalities involving the collagen and elastin.
Connective tissue diseases that are strictly inheritable include Marfan syndrome and Ehlers-Danlos syndrome. The classic immune-related connective tissue diseases include systemic lupus erythematosus, rheumatoid arthritis, scleroderma, polymyositis, and dermatomyositis. Treatment is often directed at suppressing the inflammation present in the tissues by using anti-inflammatory and immunosuppressive medications.
Hiccups are a sudden, involuntary contraction of the diaphragm muscle. In general hiccups are just a temporary condition. Some of the causes of hiccups include certain medications, surgery, eating or drinking too much, spicy foods, diseases or conditions that irritate the nerves controlling the diaphragm, strokes, brain tumors, liver failure, and noxious fumes.
Asthma, the main cause of chronic illness in children, has signs and symptoms in children that include frequent coughing spells, low energy while playing, complaints of chest "hurting," wheezing while breathing, shortness of breath, and feelings of tiredness. Treatment will involve a doctor creating an asthma action plan which will describe the use of asthma medications and when to seek emergency care for the child.
Burning mouth syndrome (BMS) is a condition that causes pain in the mouth. BMS may be caused by menopause, dry mouth or allergies. Signs and symptoms include tingling or numbness of the tip of the tongue, bitter or metallic taste, and dry or sore mouth. Treatment depends upon the cause of your burning mouth syndrome.
Iron is a mineral our bodies need. Iron deficiency is a condition resulting from not enough iron in the body. It is the most common nutritional deficiency and the leading cause in the US. Iron deficiency is caused due to increased iron deficiency from diseases, nutritional deficiency, or blood loss and the body's inability to intake or absorb iron. Children, teen girls, pregnant women, and babies are at most risk for developing iron deficiency. Symptoms of iron deficiency include feeling weak and tired, decreased work or school performance, slow social development, difficulty maintaining body temperature, decreased immune function, and an inflamed tongue. Blood tests can confirm an iron deficiency in an individual. Treatment depends on the cause of the deficiency. Proper diet that includes recommended daily allowances of iron may prevent some cases of iron deficiency.
Schatzki (Schatzki's) ring, is a narrow ring of tissue located just above the junction of the esophagus and stomach. The cause of Schatzki ring is not clearly known, however, some doctors believe they are caused by long term acid reflux. The symptoms of a Schatzki ring is primarily poorly chewed food that stays in chunks becoming stuck in the esophagus. Diagnosis of Schatzki's ring is barium x-ray or endoscopy. Treatment is generally a procedure to stretch or fracture the rings.
Heartburn is a burning sensation experienced from acid reflux (GERD). Symptoms of heartburn include chest pain, burning in the throat, difficulty swallowing, the feeling of food sticking in the throat, and a burning feeling in the chest. Causes of heartburn include dietary habits, lifestyle habits, and medical causes. Treatments for heartburn include lifestyle changes, OTC medication, prescription medication, and surgery.
There are many unusual symptoms of asthma, including sighing, difficulty sleeping, anxiety, chronic cough, recurrent walking pneumonia, and rapid breathing. These symptoms may vary from individual to individual. These asthma complexities make it difficult to accurately diagnose and treat asthma.
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