Reflux tends to be progressive in that the more a person refluxes the more damage will be caused to the oesophagus and airways which in turn will cause further reflux. It is this worsening cycle that leads to the patient experiencing symptoms and thereby noticing the condition. The good news is that recovery should follow the opposite pathway – if the damaging agents can be removed the body’s natural defences will progressively improve the oesophagus and airways thus reducing reflux and eventually leading to the reduction of symptoms.
Some people may be genetically predisposed to reflux but we know that over-eating, late-night eating, eating fatty foods, fried foods, carbonated drinks, smoking, and alcohol all have a role in causing reflux. It is thought that chemicals in these foods and drinks act by directly relaxing the LOS thus allowing gastric contents to be more easily released from the stomach.
A hiatal hernia may also contribute to Reflux. A hiatal hernia occurs when the upper part of the stomach is above the diaphragm, the muscle wall that separates the stomach from the chest. The diaphragm helps the LOS keep acid from coming up into the oesophagus. When a hiatal hernia is present, it is easier for the gastric contents to come up. In this way, a hiatal hernia can cause reflux. A hiatal hernia can happen in people of any age; many otherwise healthy people over 50 have a small one.
Other factors that may contribute to GORD include:
Lower Oesophageal Sphincter (LOS)
About one in four people with GORD have a weakened LOS valve. This allows for more frequent reflux, but little is known about how or why it occurs, it is known that it is more common in older people and is often associated with obesity.
Heartburn and regurgitation symptoms are common in pregnancy. The hormonal changes during the first trimester of pregnancy seem to weaken and relax the LOS. But during the later stages of pregnancy, pressure is the big problem. The pressure on a woman’s abdomen during pregnancy may be enough to throw the valve out of its proper position.
Research has demonstrated a link between obesity and reflux symptoms. One theory is that if you are carrying extra weight around your stomach this can put extra pressure on your stomach, forcing the lower esophageal sphincter open and pushing gastric juice into your esophagus. Another interpretation is that the fat cells in our bodies cause inflammation, which loosens up the valve and makes it harder to do its job.
A small group of people with chronic heartburn may have what is called delayed gastric emptying.
Many GORD sufferers will associate their symptoms with a particular dietary trigger or over-indulgence. Common trigger foods are:
- Citrus fruits
- Drinks with caffeine
- Fatty and fried foods tend to relax the lower oesophageal sphincter (LOS) muscle.
- Garlic and onions
- Mint flavourings
- Spicy foods
- Tomato-based foods, like spaghetti sauce, chilli, and pizza
How is Reflux currently diagnosed?
A barium swallow typically does not take more than a few minutes to perform and in essence is an x-ray (fluoroscopy) exam taken while a patient is actively swallowing a thick milkshake (barium). It is also the first test that is often obtained when working up possible non-acid LPR.
Upper Endoscopy (EGD or oesophagogastroduodenoscopy)
Upper endoscopy or EGD is a procedure commonly performed by GI specialists that uses a lighted, flexible endoscope inserted through the mouth (or nose by some ENTs with special training) to see inside the upper GI tract.
EGD is good for evaluating the presence of mucosal damage (erosive oesophagitis and Barrett’s Oesophagus) which can not be seen on barium swallow as well as presence of any anatomic abnormalities like hiatal hernia. However, only 40% of GORD sufferers will have endoscopic evidence of erosive oesophagitis.
A small capsule, about the size of a gel cap, is temporarily attached to the wall of the oesophagus during EGD. The capsule measures pH levels in the esophagus and transmits readings via a small radio transmitter in the capsule. A receiver is worn on the belt that allows the patient to record symptoms of GORD, such as heartburn. Patients maintain a diary to record information such as when you start and stop eating and drinking, when you lie down, and when you get back up.
BRAVO can only detect acid reflux that reaches the mid-chest region and not what actually reaches the throat level where a patient may have symptoms. This means it has limited use for diagnosing LPR.
The same disadvantages found with BRAVO also holds true for single or dual-probe pH studies: inability to detect non-acid reflux events and absent sensors at the throat level.
24 Hour Multichannel pH and Impedance Testing with Manometry
Multichannel intraluminal impedance (MII) is a technique designed to detect bolus movement within the oesophagus without the use of radiation. It is generally performed in combination with:
- Manometry, to provide information on the functional (i.e., bolus transit) component of manometrically detected contractions.
- pH testing, for detection of gastroesophageal reflux independent of pH (i.e., both acid and non-acid reflux)
Proper 24 hour reflux testing needs to be a multi-channel pH and impedance testing. Make sure “impedance” testing is included as this is the only test that can detect non-acid (typically defined as pH > 4.0) reflux events. Make sure the test is “multi-channel” to ensure there are sensors that go all the way up to the throat level.