Gastroesophageal Reflux J. David Cunningham, MD; Timothy Heffron, MD; Frances E. Marchant, MD; Ernest L. McKenna, Jr., MD Gastroesophageal reflux is a term used to describe the events in which contents within the stomach and stomach acids are able to pass up into the esophagus and throat region with resultant inflammation and injury to the lining tissue in contact with the refluxed fluid. Gastroesophageal reflux, or GE reflux, can occur with an anatomic defect in the lower esophagus called a hiatal hernia. With hiatal hernias, the lower esophageal sphincter, which acts as a valve to hold stomach contents within the stomach, is somewhat defective allowing acid from the stomach to come up into the esophagus. This can be associated with heartburn and many times occurs without the patient's knowledge at all. Symptoms: There are numerous symptoms that may occur in patients who have significant GE reflux. These include: heartburn hoarseness, which tends to be worse in the morning chronic throat clearing chronic dry cough wheezing and asthmatic-type symptoms a sensation of a “lump in your throat” All of these symptoms may occur when acid is able to come from the stomach into the esophagus and into the lower throat and voice box region. Therapy: Therapy for gastroesophageal reflux is directed toward two goals. The first is to decrease the amount of stomach contents available to reflux into the esophagus and lower throat. The second is to decrease the acidity of the gastric contents and decrease gastric emptying. The specific measures that are recommended include: Weight Loss — Obesity and weight gain tends to increase the pressure in the abdominal cavity and helps to promote reflux of the stomach contents into the esophagus. No Food Two Hours Prior to Lying Down — Eating tends to stimulate gastric acidity. When gravity is unable to help keep the stomach contents in the stomach, it is important that the stomach be empty when the patient is lying down for sleep. Allowing two hours for gastric emptying markedly decreases the amount of acidity and contents within the stomach cavity. Avoid Tight-Fitting Clothing — Tight belts and pants tend to increase abdominal pressure as does pregnancy. This will increase the amount of acid reflux accordingly. It is for this reason that many pregnant women have frequent problems with heartburn due to the increased abdominal pressure from the pregnancy itself. Raising the Head of the Bed — In order to allow for some gravitational drainage of the esophagus, sleeping with the head of the bed elevated will allow gravity to help keep the stomach contents within the abdominal cavity. This may be performed by three or four pillows underneath the head and back or may be achieved by placing blocks underneath the frame of the headboard, raising the headboard 6-8 inches. Avoid Certain Food Products — Caffeine products (colas, coffee, tea and chocolate), tobacco, alcohol, nuts and spicy food. These foods and other foods will decrease the tone of the lower esophageal sphincter and allow more food from the stomach to reflux into the esophagus. It is important, if these foods are to be used, that they be used early in the evening. Late night snacks with these foods will promote reflux when one lies down for bed. Alcohol and Tobacco — Both alcohol and tobacco decrease the tone of the lower esophageal sphincter and will promote reflux. Both products should be minimized in the late evening. Medications Antacids — These are frequently helpful prior to bedtime and we recommend a liquid antacid such as Maalox, Mylanta or Riopan to be used as the only liquid or food to be taken at bedtime to decrease the acidity of whatever acid remains in the stomach prior to lying down. Tagamet or Reglan — These medications may be prescribed to decrease the acidity in the stomach and to increase emptying of the stomach. These should be reserved for more severe problems. Surgical Therapy — Surgical therapy is generally reserved for patients with severe reflux with significant inflammation of their esophagus, resulting in narrowing of their lower esophageal sphincter and stricture formation. Patients who have such sever symptoms may require dilation of their lower esophagus with esophageal dilators or, rarely, require surgical therapy to repair the hiatal hernia and reduce the ability of acid contents from regurgitating into the esophagus.