What is esophagitis ?

What is esophagitis

Esophagitis is present when the lining of the esophagus becomes swollen, inflamed, or irritated ¹. Esophagitis is also called erosive esophagitis or ulcerative esophagitis. The esophagus is the tube that leads from the back of the mouth to the stomach. It is also called the food pipe.

Figure 1. Esophagus

Causes of Esophagitis

Esophagitis is often caused by stomach fluid that flows back into the food pipe. The fluid contains acid, which irritates the tissue. This problem is called gastroesophageal reflux (GERD). An autoimmune disorder called eosinophilic esophagitis also causes this condition.

The following increase your risk of this condition:

• Alcohol use
• Cigarette smoking
• Surgery or radiation to the chest (for example, treatment for lung cancer)
• Taking certain medicines without drinking plenty of water. These medicines include alendronate, doxycycline, ibandronate, risedronate, tetracycline, potassium tablets, and vitamin C
• Vomiting

People who have a weakened immune system may develop infections. Infections may lead to swelling of the food pipe. Infection may be due to:

• Fungi or yeast (most often Candida)
• Viruses, such as herpes or cytomegalovirus

Symptoms of Esophagitis

The infection or irritation may cause the food pipe to become inflamed. Sores called ulcers may form.

Symptoms may include:

• Cough
• Difficulty swallowing
• Painful swallowing
• Heartburn (acid reflux)
• Hoarseness
• Sore throat

Exams and Tests for Esophagitis

The doctor may perform the following tests:

• Esophageal manometry
• Esophagogastroduodenoscopy (EGD), removing a piece of tissue from the food pipe for examination (biopsy)
• Upper GI series (barium swallow x-ray)

Treatment for Esophagitis

Treatment depends on the cause. Common treatment options are:

• Medicines that reduce stomach acid in case of reflux disease
• Antibiotics to treat infections
• Medicines and diet changes to treat eosinophilic esophagitis
• Medicines to coat the lining of the food pipe to treat damage related to pills

Outlook (Prognosis) for Esophagitis

Most of the time, the disorders that cause swelling of the food pipe, respond to treatment.

Possible Complications of Esophagitis

If not treated, this condition may cause severe discomfort. Scarring (stricture) of the food pipe may develop. This can cause swallowing problems.

A condition called Barrett esophagus can develop after years of gastroesophageal reflux (GERD). Rarely, Barrett esophagus may lead to cancer of the food pipe.

What is eosinophilic esophagitis

Eosinophilic esophagitis is a disease characterized by the presence of a large number of a special type of white blood cell, called the eosinophil, that can cause inflammation in the esophagus ². This inflammation can lead to stiffening or narrowing of the esophagus, which can lead to difficulty swallowing (dysphagia) or food getting stuck in the esophagus. Reflux of stomach acid contents into the esophagus can also cause eosinophils as well as inflammation in the esophagus. In eosinophilic esophagitis, the eosinophils are present even after acid reflux has been treated. Although eosinophils may be found in the rest of the gastrointestinal tract in a healthy person, when present in the esophagus, this usually suggests an abnormal condition. While other illnesses such as gastroesophageal reflux disease (GERD), parasitic diseases or inflammatory bowel disease may cause eosinophils in the esophagus, eosinophilic esophagitis is the most common cause of large numbers of eosinophils in the esophagus.

How common is eosinophilic esophagitis in adults ?

While eosinophilic esophagitis was previously thought to be a rare disease, it has recently been recognized as one of the most common causes of difficulty swallowing and food impaction in young adults ². This has become a global trend with increased cases of eosinophilic esophagitis being reported from five continents. The cause for this rise is likely a combination of increasing occurrences of eosinophilic esophagitis and a growing awareness of the condition among gastroenterologists, allergists and pathologists. It is thought that the disease may be increasing similar to the increases seen in other allergic disorders such as asthma and allergic rhinitis. Estimated occurrences of this condition in adults may be as high as 1-3 per 10,000 people, based on information from patients in Australia and Switzerland. Although some studies suggest that the disease is more common in the Caucasian population, cases have been seen in patients of African American, Asian and Hispanic descent. Eosinophilic esophagitis affects males three times more often than females.

What is the cause of eosinophilic esophagitis ?

Currently the cause of eosinophilic esophagitis in adults has not been clearly identified. Some studies have suggested an allergic reaction to environmental and food allergens. There may also be a genetic cause that may lead to eosinophilic esophagitis in some patients. A recent study has identified an increase in a gene coding for a protein called eotaxin-3 in patients with eosinophilic esophagitis. Further support that there may be a genetic link is that some adults have a family history of allergic disorders and a family history of eosinophilic esophagitis.

A history of allergic conditions such as allergic rhinitis, asthma, eczema or food allergy has been seen in up to 70% of adults with eosinophilic esophagitis either by history or positive allergy testing. In one recent study, adults with eosinophilic esophagitis treated with dietary elimination improved their eosinophilic esophagitis, but recurrence of eosinophilic esophagitis happened when certain foods were added back to the diet. This suggests that food allergens play a role in some adults with eosinophilic esophagitis.

What are common symptoms of eosinophilic esophagitis in adults ?

The most common presenting symptoms in adults are difficulty swallowing solid food and food impactions in which food gets lodged in the esophagus and is unable to pass into the stomach ². If patients develop a food impaction, an endoscopy is often needed to help relieve this obstruction. Most adults with symptoms are between the ages of 20 to 40, although there have been cases of adults presenting at much later ages. Other less common symptoms include heartburn and chest pain.

How is eosinophilic esophagitis diagnosed ?

Currently, the only way to diagnose this condition is by performing an upper endoscopy with biopsy (taking tiny pieces of tissue) of the esophagus ². During endoscopy, a thin, flexible tube with a camera, which allows the doctor to see the inside of your esophagus, is inserted into the esophagus while the patient is sedated (sleep caused by medication). Biopsies taken from the lining of the esophagus (mucosa) are later inspected under a microscope by a pathologist for characteristic changes of eosinophilic esophagitis. These changes include large numbers of eosinophils in the superficial portion of the tissue biopsy and signs of inflammation in the tissue. Sometimes scaring or fibrosis can be seen in the deeper portions of the tissue. In eosinophilic esophagitis, the eosinophils are limited to the esophagus and are not present in the stomach or duodenum.

Usually, there are characteristic features that the gastroenterologist can see in the esophagus of patients with eosinophilic esophagitis. These include linear furrows or creases in the esophagus and concentric rings of the superficial layer of the esophagus. Other features, including narrow esophagus, white spots on the esophageal tissue and short, very narrow segments of the esophagus called strictures, may also be seen. While these changes are suggestive of eosinophilic esophagitis, their presence alone does not diagnose the condition. The esophagus can also appear normal in adult patients with eosinophilic esophagitis.

Symptoms of gastroesophageal reflux disease (GERD) such as heartburn or regurgitation can overlap with symptoms of eosinophilic esophagitis. Since gastroesophageal reflux disease is much more common than eosinophilic esophagitis in the adult population and can also be a cause of eosinophils in the esophagus, it is important to distinguish the two. Therefore, if eosinophils are found on a tissue biopsy of the esophagus, it is suggested that the patient start treatment with acid reducers to see if the eosinophils go away once the reflux is treated. This requires another endoscopy. If the eosinophils are still in the tissue after reflux has been treated, then the patient most likely has eosinophilic esophagitis. Another method to identify if acid in the esophagus is contributing to the eosinophils is to complete a test called an esophageal pH test. In this test, a very thin tube is placed through the nose into the esophagus and stomach, or a temporary sensor is placed in the esophagus via endoscopy. Both allow levels of acid in the esophagus to be monitored for a period of time, usually 24 – 72 hours. If this test shows high levels of acid in the esophagus, it suggests that GERD may be the cause of the eosinophils in the esophagus. In more complicated situations, some patients have both GERD and eosinophilic esophagitis and therefore will need to have treatment for both conditions.

What are the most common treatments for eosinophilic esophagitis in adults ?

Currently, there is no one accepted therapy for all patients with eosinophilic esophagitis. Although dietary therapy is the most common treatment of pediatric eosinophilic esophagitis, this has not been widely accepted among gastroenterologists who treat adult patients. Many adult patients are initially treated with acid-blocking medications to rule out GERD. If this does not improve symptoms or tissue changes of the eosinophils, then steroids taken using an asthma inhaler, but swallowed rather than inhaled by the patient, have been tried with good, although limited results. This treatment tends to be well tolerated; side-effects of a fungal infection called thrush or candida of the esophagus are relatively rare.

Dietary treatment may consist of an elemental diet, a “six-food-elimination diet” or a targeted-elimination diet, usually for six weeks. After this point, if the disease improves, foods are reintroduced one at a time to help identify the food trigger. An elemental diet is another potential treatment. It is an amino-acid based formula, taken usually for six weeks. Elemental diet involve removing intact protein from the diet and replacing that with an amino acid–based formula ³. Elemental formula can have a poor taste and can be costly; therefore, a six-food-elimination diet is preferred by most patients.

A six-food-elimination diet is a diet that contains no milk protein, soy, egg, wheat, peanut/tree nuts, and seafood ⁴. These foods are the most common food allergens found in patients with eosinophilic esophagitis.

A targeted-elimination diet is a diet that is based on eliminating foods found to be positive on allergy testing.

Dietary therapy has been shown to be helpful in some adults with eosinophilic esophagitis and may be tried with motivated (willing to follow through with food avoidance) patients under the care of an experienced provider or dietician.

If patients do not respond to medical therapy or diet exclusion, an esophageal dilation or “stretching” is sometimes performed if there is narrowing of the esophagus. Although dilation may be helpful in the short term, repeated dilations may be needed to control symptoms. Because dilation alone does not affect the underlying inflammation in the esophagus, this procedure is usually performed in patients who are also being treated with medical or dietary therapy. The risks of esophageal dilation include chest pain after the procedure and in rare cases a perforation or tear of the esophagus. While dilation can be performed safely, it must be done with caution and is almost always performed after a trial of medical or dietary therapy has failed.

What is the long term consequence of having eosinophilic esophagitis ?

There is limited information about the natural history of this disease in adults. Current studies suggest that it is a chronic, reoccurring condition. Patients have continued symptoms, although esophageal eosinophil levels may change over time. Complications, including esophageal strictures and food impactions, may occur. In very rare cases, forceful vomiting, prolonged food impactions and esophageal dilations may result in a perforation or tear of the esophagus which needs immediate medical attention. Currently treatment of eosinophilic esophagitis is directed at controlling symptoms, reducing eosinophil levels in the tissue, and preventing complications of the disease, such as food impactions.

What is gastroesophageal reflux disease ?

Gastroesophageal reflux disease (GERD) is a condition in which the stomach contents leak backwards from the stomach into the esophagus (the tube from the mouth to the stomach) ⁵. This can irritate the esophagus and cause heartburn and other symptoms.

People will experience heartburn symptoms when excessive amounts of acid reflux into the esophagus. Many describe heartburn as a feeling of burning discomfort, localized behind the breastbone, that moves up toward the neck and throat ⁶. Some even experience the bitter or sour taste of the acid in the back of the throat ⁶. The burning and pressure symptoms of heartburn can last for several hours and often worsen after eating food ⁶.

More than 60 million Americans experience heartburn at least once a month and some studies have suggested that more than 15 million Americans experience heartburn symptoms each day. Symptoms of heartburn, also known as acid indigestion, are more common among the elderly and pregnant women. Frequent heartburn (two or more times a week), food sticking, blood or weight loss may be associated with a more severe problem known as gastroesophageal reflux disease or GERD ⁶.

• Heartburn or GERD if left untreated, longstanding, severe and chronic heartburn has been linked with esophageal cancer. Don’t ignore frequent heartburn — instead consult with your physician regarding an endoscopy and treatment to achieve early symptom resolution. So don’t ignore frequent heartburn — instead consult with your physician regarding an endoscopy and treatment to achieve early symptom resolution.

• GERD has a significant role in asthma, chronic cough and ear, nose and throat problems — all referred to as extra-esophageal manifestations (EEM) although this connection may often go unrecognized. GERD should be actively considered in physician evaluations of these conditions, or it could go undetected.

• With effective treatment, using the range of prescription medications and other treatments available today, you can become symptom free, avoid potential complications and restore the quality of life you deserve.

Do you have GERD ?

Here’s a simple self-test developed by a panel of experts from the American College of Gastroenterology ⁷.

Take this “Acid Test” to see if you’re a GERD sufferer and are taking the right steps to treat it.

1. Do you frequently have one or more of the following:
   + an uncomfortable feeling behind the breastbone that seems to be moving upward from the stomach?
   + a burning sensation in the back of your throat?
   + a bitter acid taste in your mouth?
2. Do you often experience these problems after meals?
3. Do you experience heartburn or acid indigestion two or more times per week?
4. Do you find that antacids only provide temporary relief from your symptoms?
5. Are you taking prescription medication to treat heartburn, but still having symptoms?

If you said yes to two or more of the above, you may have GERD. To know for sure, see your doctor or a gastrointestinal specialist. They can help you live pain free.

Figure 2. Gastroesophageal reflux disease (GERD) 

What causes heartburn and GERD ?

To understand gastroesophageal reflux disease or GERD, it is first necessary to understand what causes heartburn.

When you eat, food passes from the throat to the stomach through the esophagus. A ring of muscle fibers in the lower esophagus prevents swallowed food from moving back up. These muscle fibers are called the lower esophageal sphincter (LES) — keeps the acid in the stomach and out of the esophagus.

In gastroesophageal reflux disease or GERD, the lower esophageal sphincter relaxes too frequently or does not close all the way, stomach acid contents can reflux or flow backward into the esophagus. This is called reflux or gastroesophageal reflux. Reflux may cause symptoms. Harsh stomach acids can also damage the lining of the esophagus.

Most people will experience heartburn if the lining of the esophagus comes in contact with too much stomach juice for too long a period of time. This stomach juice consists of acid, digestive enzymes, and other injurious materials. The prolonged contact of acidic stomach juice with the esophageal lining injures the esophagus and produces a burning discomfort.

The risk factors for gastroesophageal reflux include:

• Use of alcohol (possibly)
• Hiatal hernia (a condition in which part of the stomach moves above the diaphragm, which is the muscle that separates the chest and abdominal cavities)
• Obesity
• Pregnancy
• Scleroderma
• Smoking

Heartburn and gastroesophageal reflux can be brought on or made worse by pregnancy.

Symptoms can also be caused by certain medicines, such as:

• Anticholinergics (for example, seasickness medicine)
• Bronchodilators for asthma
• Calcium channel blockers for high blood pressure
• Dopamine-active drugs for Parkinson disease
• Progestin for abnormal menstrual bleeding or birth control
• Sedatives for insomnia or anxiety
• Tricyclic antidepressants

Talk to your health care provider if you think one of your medicines may be causing heartburn. Never change or stop taking a medicine without first talking to your provider.

Symptoms of gastroesophageal reflux disease

Common symptoms of GERD include:

• Feeling that food is stuck behind the breastbone
• Heartburn or a burning pain in the chest
• Nausea after eating

Less common symptoms are:

• Bringing food back up (regurgitation)
• Cough or wheezing
• Difficulty swallowing
• Hiccups
• Hoarseness or change in voice
• Sore throat

Symptoms may get worse when you bend over or lie down, or after you eat. Symptoms may also be worse at night.

How is GERD diagnosed ?

You may not need any tests if your symptoms are mild.

Your doctor or gastroenterologist may wish to evaluate your symptoms with additional tests when it is unclear whether your symptoms are caused by acid reflux, or if you suffer from complications of GERD such as dysphagia (difficulty in swallowing), bleeding, choking, or if your symptoms fail to improve with prescription medications. Your doctor may decide to conduct one or more of the following tests.

Endoscopy

If your symptoms are severe or they come back after you have been treated, your doctor may perform a test called an upper endoscopy.

This is a test to examine the lining of the esophagus, stomach, and first part of the small intestine. It is done with a small camera (flexible endoscope) that is inserted through the mouth into the esophagus and stomach to examine for abnormalities. The test is usually performed with the aid of sedatives. It is the best test to identify esophagitis and Barrett’s esophagus.

Upper GI Series

For the upper GI series, you will be asked to swallow a liquid barium mixture (sometimes called a “barium meal”). The radiologist uses a fluoroscope to watch the barium as it travels down your esophagus and into the stomach.

You will be asked to move into various positions on the X-ray table while the radiologist watches the GI tract. Permanent pictures (X-ray films) will be made as needed.

Esophageal Manometry or Esophageal pH

Esophageal Manometry: this test involves passing a small flexible tube through the nose into the esophagus and stomach in order to measure pressures and function of the esophagus.

Esophageal pH: a test that measures how often stomach acid enters the tube that leads from the mouth to the stomach can be measured over 24 hours.

A positive stool occult blood test may diagnose bleeding that is coming from the irritation in the esophagus, stomach, or intestines.

Treatment Options for Gastroesophageal reflux disease

GERD is a problem that is symptomatic by day but in which much damage is done by night.

Treatment should be designed to:

1. Eliminate symptoms;
2. Heal esophagitis; and
3. Prevent the relapse of esophagitis or development of complications in patients with esophagitis.

In many patients, GERD is a chronic, relapsing disease. Long-term maintenance is the key to therapy; therefore, continuous long-term therapy, possibly life-long therapy, to control symptoms and prevent complications is appropriate. Maintenance therapy will vary in individuals ranging from mere lifestyle modifications to prescription medication as treatment.

All treatments are based on attempts to a) decrease the amount of acid that refluxes from the stomach back into the esophagus, or b) make the refluxed material less irritating to the lining of the esophagus.

For infrequent heartburn

In many cases, doctors find that infrequent heartburn can be controlled by lifestyle modifications and proper use of over-the-counter medicines.

Lifestyle Modification

In order to decrease the amount of gastric contents that reach the lower esophagus, certain simple guidelines should be followed:

• Raise the Head of the Bed. The simplest method is to use a 4″ x 4″ piece of wood to which two jar caps have been nailed an appropriate distance apart to receive the legs or casters at the upper end of the bed. Failure to use the jar caps inevitably results in the patient being jolted from sleep as the upper end of the bed rolls off the 4″ x 4″.
• Alternatively, one may use an under-mattress foam wedge to elevate the head about 6-10 inches. Pillows are not an effective alternative for elevating the head in preventing reflux.
• Change Eating and Sleeping Habits. Avoid lying down for two hours after eating. Do not eat for at least two hours before bedtime. This decreases the amount of stomach acid available for reflux.
• Avoid Tight Clothing. Reduce your weight if obesity contributes to the problem.
• Avoid foods and beverages that contribute to heartburn: chocolate, fats, coffee, peppermint, greasy or spicy foods, citrus juice, tomato products, peppers and alcoholic beverages.
• Avoid drugs such as aspirin, ibuprofen (Advil, Motrin), or naproxen (Aleve, Naprosyn). Take acetaminophen (Tylenol) to relieve pain.
• Stop smoking. Tobacco inhibits saliva, which is the body’s major buffer. Tobacco may also stimulate stomach acid production and relax the muscle between the esophagus and the stomach, permitting acid reflux to occur.
• Reduce weight if too heavy. Obesity is linked to GERD, so maintaining a healthy body weight may help prevent the condition.
• Do not eat 2-3 hours before sleep.
• For infrequent episodes of heartburn, take an over-the-counter antacid or an H2 blocker, some of which are now available without a prescription.

Over-the-Counter Medications

Large numbers of Americans use over-the-counter antacids and other agents that are available without a prescription to treat minor gastrointestinal discomforts and infrequent heartburn. In 1995, the U.S. Food and Drug Administration (FDA) approved the non-prescription availability of important acid blockers, also called H2 blockers, for treatment of infrequent heartburn with dosage levels below the prescription strength formulations. It is anticipated that the FDA will approve the non-prescription availability of another distinct class of drugs, known as proton pump inhibitors (PPIs), for the treatment of infrequent heartburn, also at dosage levels below the prescription strength formulations. While these reduced strength formulations have been approved for relief of symptoms/discomfort from occasional heartburn, they are not recognized by FDA as promoting actual healing of esophagitis, whereas FDA does recognize the healing benefits of some prescription strength medications, e.g. proton pump inhibitors, when taken regularly at prescription dosages.

Over-the-counter medications have a significant role in providing relief from heartburn and other occasional gastrointestinal discomforts. More frequent episodes of heartburn or acid indigestion may be a symptom of a more serious condition that could worsen if not treated.

• If you are using an over-the-counter product more than twice a week, you should consult a physician who can confirm a specific diagnosis and develop a treatment plan with you, including the use of stronger medicines that are only available with a prescription.

Why GERD can lead to more serious conditions

When symptoms of heartburn are not controlled with modifications in lifestyle, and over-the-counter medicines are needed two or more times a week, or symptoms remain unresolved on the medication you are taking, you should see your doctor. You may have GERD.

When GERD is not treated, serious complications can occur, such as:

• severe chest pain that can mimic a heart attack,
• esophageal stricture (a narrowing or obstruction of the esophagus),
• bleeding, or
• a pre-malignant change in the lining of the esophagus called Barrett’s esophagus.

A 1999 study reported in the New England Journal of Medicine showed that patients with chronic, untreated heartburn of many years duration were at substantially greater risk of developing esophageal cancer, which is one of the fastest growing, and among the more lethal forms of cancer in this country ⁶.

Symptoms suggesting that serious damage may have already occurred include:

• Dysphagia: difficulty swallowing or a feeling that food is trapped behind the breast bone.
• Bleeding: vomiting blood, or having tarry, black bowel movements.
• Choking: sensation of acid refluxed into the windpipe causing shortness of breath, coughing, or hoarseness of the voice.
• Weight Loss

 

What are the medications often prescribed for GERD ?

Prescription medications to treat GERD include drugs called H2 receptor antagonists (H2 blockers) and proton pump inhibitors (PPIs), which help to reduce the stomach acid that tends to worsen symptoms, and work to promote healing, as well as promotility agents that aid in the clearance of acid from the esophagus.

H2 Receptor Antagonists

Since the mid 1970’s, acid suppression agents, known as H2 receptor antagonists or H2 blockers, have been used to treat GERD. H2 blockers improve the symptoms of heartburn and regurgitation and provide an excellent means of decreasing the flow of stomach acid to aid in the healing process of mild-to-moderate irritation of the esophagus, known as “esophagitis.” Symptoms are eliminated in up to 50% of patients with twice a day prescription dosage of the H2 blockers. Healing of esophagitis may require higher dosing. These agents maintain remission in about 25% of patients.

H2 blockers are generally less expensive than proton pump inhibitors and can provide adequate initial treatment or serve as a maintenance agent in GERD patients with mild symptoms. Current treatment guidelines also recognize the appropriateness and in some cases desirability of using proton pump inhibitors as first-line therapy for some patients, particularly those with more severe symptoms or esophagitis on endoscopy. Proton pump inhibitors will be required to achieve effective long-term maintenance therapy in a significant percentage of heartburn/GERD patients.

Proton Pump lnhibitors

Proton pump inhibitors (PPIs), have been found to heal erosive esophagitis (a serious form of GERD) more rapidly than H2 blockers. Proton pump inhibitors provide not only symptom relief, but also elimination of symptoms in most cases, even in those with esophageal ulcers. Studies have shown proton pump inhibitor therapy can provide complete endoscopic mucosal healing of esophagitis at 6 to 8 weeks in 75% to 100% of cases. Although healing of the esophagus may occur in 6 to 8 weeks, it should not be misunderstood that gastroesophageal reflux can be cured in that amount of time. The goal of therapy for GERD is to keep symptoms comfortably under control and prevent complications. As noted above, current guidelines recognize that heartburn and GERD are typically relapsing, potentially chronic conditions, that symptoms and mucosal injury will often reoccur when medications are withdrawn, and hence that a strategy for long-term maintenance therapy is generally required. Occasionally, a health care plan seeks to limit use of proton pump inhibitors to a fixed duration of perhaps 2-3 months and others have even cited FDA’s approval of proton pump inhibitors for up to one year, as if that means that this therapy should be withdrawn after one year. There is no well-established scientific reason that supports withdrawing proton pump inhibitors after one year as these patients will invariably relapse. All gastroenterologists have patients who continue to do very well on proton pump inhibitors after many years’ use without adverse side effects. Efforts by payors to limit access to these medications are generally a cost-saving initiative. Daily proton pump inhibitor treatment provides the best long-term maintenance therapy of esophagitis, particularly in keeping symptoms and the disease in remission for those patients with moderate to severe esophagitis, plus this form of treatment has been shown to retain remission for up to five years.

Promotility Agents

Promotility drugs are effective in the treatment of mild to moderately symptomatic GERD. These drugs increase lower esophageal sphincter pressure, which helps prevent acid reflux, and improves the movement of food from the stomach. They can decrease heartburn symptoms, especially at night, by improving the clearance of acid from the esophagus. Recent developments have greatly limited the availability of one of these agents, i.e. cisapride. Cisapride had been used widely for several years in treating night-time heartburn and was also used by some practitioners in the treatment of GERD symptoms in children. More recently, rare but potentially serious complications have been reported in some patients taking cisapride. These complications seem to be related to usage in patients on contraindicated medications or in patients with contraindicated medical conditions, such as underlying heart disease. In March of 2000, the manufacturer announced that it had reached a decision in consultation with the FDA to discontinue the marketing of the drug. The product will remain available only through a limited-access program. This program has been established for patients who fail other treatment options and who meet clearly defined eligibility criteria.

Table 1. Summary of Effectiveness of Therapies for GERD

Class of Drugs	How It Works	Eliminate Symptoms	Heal Esophagitis	Manage or Prevent Complications	Maintain Remission
Antacids	neutralize acid	+1	0	0	0
H2 Blockers Over-the-counter	mildly suppress acid	+1	0	0	0
Promotility	increase LES pressure; move acid from esophagus and stomach	+2	+1	0	+1
H2 Blockers Prescription	moderately suppress acid	+2	+2	+1	+1
H2 Blockers + Promotility	moderately suppress acid; move acid from esophagus to stomach	+3	+3	+1	+1
High Dose H2 Blockers	moderately suppress acid	+3	+3	+2	+2
Proton Pump Inhibitors	markedly suppress acid	+4	+4	+3	+4
Surgery	improve barrier between stomach and esophagus to prevent acid reflux	+4	+4	+3	+4

Rating Scale: 0 (no effect) to +4 (nearly 100%)

[Source ⁶]

Surgery for GERD

Surgical measures to prevent reflux can be considered if other measures fail or complications occur such as bleeding, recurrent stricture, or metaplasia (abnormal transformation of cells lining the esophagus), which is progressive. The surgical technique improves the natural barrier between the stomach and the esophagus that prevents acid reflux from occurring. Consultation with both a gastroenterologist and a surgeon is recommended prior to such a decision.

There are always new treatments and possibilities looming on the horizon.

There are two new endoscopic techniques for treating GERD — suturing and the Stretta radio frequency technique — which have recently been approved by the FDA for use with patients. Because these treatments are so new, doctors do not have any real information concerning their long-term effectiveness. They were approved by the FDA largely based on data showing that they could help reduce GERD for at least six months after treatment. At least in the foreseeable future, until long-term outcomes can be evaluated, most patients and physicians will likely be sticking with the treatment options about which there is a much greater wealth of experience, e.g. medical treatment with proton pump inhibitors and other acid suppression medications, and surgery.

GERD can masquerade as other diseases

Increasingly, doctors are becoming aware that the irritation and damage to the esophagus from continual presence of acid can prompt an entire array of symptoms other than simple heartburn. Experts recognize that often the role of acid reflux has been overlooked as a potential factor in the diagnosis and treatment of patients with chronic cough, hoarseness and asthma-like symptoms. In some instances, patients have never reported heartburn, and in others the potential causal link between reflux and the onset of these so-called “extra-esophageal manifestations” has not been fully recognized. Physicians are increasingly becoming aware that it is good clinical practice to evaluate the possible presence of reflux in patients with chronic cough and asthma-like symptoms, as well as the importance that acid suppression and treating underlying reflux can have in potentially improving the symptoms in these patients.

• Chest Pain: Patients with GERD may have chest pain similar to angina or heart pain. Usually, they also have other symptoms like heartburn and acid regurgitation. If your doctor says your chest pain is not coming from the heart, don’t forget the esophagus. On the other hand, if you have chest pain, you should not assume it is your esophagus. All chest pain should be checked by a doctor !
• Asthma: Acid reflux may aggravate asthma. Recent studies suggest that the majority of asthmatics have acid reflux. Clues that GERD may be worsening your asthma include: 1) asthma that appears for the first time during adulthood; 2) asthma that gets worse after meals, lying down or exercise; and 3) asthma that is mainly at night. Treatment of acid reflux may cure asthma in some patients and decrease the need for asthmatic medications in others.
• Ear, Nose and Throat Problems: Acid reflux may be a cause of chronic cough, sore throat, laryngitis with hoarseness, frequent throat clearing, or growths on the vocal cords. If these problems do not get better with standard treatments, think about GERD.

Possible Complications of Gastroesophageal reflux disease

Complications may include:

• Worsening of asthma
• A change in the lining of the esophagus that can increase the risk of cancer (Barrett esophagus)
• Bronchospasm (irritation and spasm of the airways due to acid)
• Chronic cough or hoarseness
• Dental problems
• Ulcer in the esophagus
• Stricture (a narrowing of the esophagus due to scarring)

Peptic Stricture

This results from chronic acid injury and scarring of the lower esophagus. Patients complain of food sticking in the lower esophagus. Heartburn symptoms may actually lessen as the esophageal opening narrows down preventing acid reflux. Stretching of the esophagus and proton pump inhibitor medication are needed to control and prevent peptic strictures.

Barrett’s Esophagus

A serious complication of chronic GERD is Barrett’s esophagus. Here the lining of the esophagus changes to resemble the intestine. Patients may complain of less heartburn with Barrett’s esophagus — that’s the good news. Unfortunately, this is a pre-cancerous condition: patients with Barrett’s esophagus have approximately a 30-fold increased risk of developing esophageal cancer. These patients should be followed by endoscopy by a trained gastroenterologist familiar with this disease.

Esophageal Cancer

Recent scientific reports have confirmed that if GERD is left untreated for many years, it could lead to this most serious complication — Barrett’s esophagus and esophageal cancer. Frequent heartburn symptoms with a duration of several years cannot simply be dismissed — there can be severe consequences of delaying diagnosis and treatment. This increased risk of chronic, longstanding GERD sufferers to develop cancer demonstrates the true severity of heartburn. In patients with chronic heartburn, an endoscopy will often be recommended to visually monitor the condition of the lining of the esophagus and identify or confirm the absence of any suspicious or pre-malignant lesions, such as Barrett’s esophagus. So, do not ignore your heartburn. If you are having heartburn two or more times a week, it is time to see your physician and in all likelihood a gastrointestinal specialist. In most cases an endoscopy should be performed to evaluate the severity of GERD and identify the possible presence of the pre-malignant condition — Barrett’s esophagus. The preventative strategy is to treat GERD. If it goes untreated and cancer does develop, the survival rate for esophageal cancer, at this time, is dismal.

Study links duration of heartburn to severity of esophageal disease

Esophageal disease may be perceived in many forms, with heartburn being the most common. The severity of heartburn is measured by how long a given episode lasts, how often symptoms occur, and/or their intensity. Since the esophageal lining is sensitive to stomach contents, persistent and prolonged exposure to these contents may cause changes such as inflammation, ulcers, bleeding and scarring with obstruction. A pre-cancerous condition called Barrett’s esophagus may also occur. Barrett’s esophagus causes severe damage to the lining of the esophagus when the body attempts to protect the esophagus from acid by replacing its normal lining with cells that are similar to the intestinal lining.

Research was conducted to determine whether the duration of heartburn symptoms increases the risk of having esophageal complications. The study found that inflammation in the esophagus not only increased with the duration of reflux symptoms, but that Barrett’s esophagus likewise was more frequently diagnosed in these patients. Those patients with reflux symptoms and a history of inflammation in the past were more likely to have Barrett’s esophagus than those without a history of esophageal inflammation.

Study links chronic heartburn to esophageal cancer

Over the past 20 years, the incidence of esophageal cancer, a highly fatal form of cancer, has rapidly increased in the United States. A recent research study has linked chronic, longstanding, untreated heartburn with an increased risk of developing esophageal cancer. As reported by Lagergren et al. in the study that was published in the New England Journal of Medicine, patients who experienced chronic, unresolved heartburn markedly increase the risk of esophageal cancer, a rare but often deadly malignancy. According to the study, the incidence of adenocarcinoma of the esophagus was nearly eight times more likely among frequent heartburn sufferers (two times a week or more) compared to individuals without symptoms, while among patients with longstanding, severe and unresolved heartburn (e.g. frequent symptoms 20 years duration), the risk of developing esophageal cancer was 43.5 times as great as for those without chronic heartburn.

Persistent symptoms of heartburn and reflux should not be ignored. By seeing your doctor early, the physical cause of GERD can be treated and more serious problems avoided.

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