Unit 5 Research Gastroesophageal Reflux Disease

Unit 5 research gastroesophageal reflux disease (GERD)? 1. GERD.COM

Gastroesophageal reflux disease, or GERD, is a condition that affects millions of people, and can cause significant health problems. ... www.gerd.com What is GERD? Your stomach is filled with acid. Its purpose is to help digest the food you eat. Believe it or not, this acid is the same acidity as battery acid. Your stomach is built to handle the acid it produces. However, your esophagus isn’t. So when acid backs up into your esophagus, it can cause the burning sensation known as heartburn. Almost everyone has occasional heartburn. But if these symptoms occur two or more days a week for at least three months, you may have GERD, or acid reflux disease. Acid reflux occurs when the lower esophageal sphincter (the valve separating the esophagus and stomach) does not close properly, allowing acid to back up into the esophagus. GERD is a chronic condition and may lead to more serious medical conditions, but is treatable. In this section, you’ll learn about the causes and common symptoms of GERD, a disease that is more common than you might think

How is GERD Treated? GERD is a treatable medical condition. If you are experiencing symptoms of GERD, you should schedule an appointment with your health care provider to discuss your symptoms and receive an official diagnosis. In order to appropriately diagnose you, your doctor may recommend lifestyle changes, a trial of a specific medical treatment, or diagnostic tests. In this section, our experts discuss lifestyle changes that can help you manage symptoms, tests that are used to diagnose GERD, and common treatment options. Diagnosing GERD Common Treatment Options Lifestyle Changes

What Can I Do? If you are concerned that you may have GERD, you should arrange to visit your doctor as soon as possible. GERD is a chronic medical condition that may lead to more serious problems, but it is treatable, and can be effectively managed through diet and lifestyle changes along with medical treatments. In this section, you will find advice that will assist you before, during, and after your doctor visit.

Helpful Tools A symptom diary helps to make the most of the time you have with your doctor. Enter symptoms into the diary starting one to two weeks before you see the doctor. Write down what you felt in the diary. An example is, “I had a burning sensation halfway down my chest.” Another example is, “I had difficulty swallowing.” Note how long the feeling lasted. Write about what you were doing that might have brought on the discomfort. If the discomfort seemed

to be related to something you ate, write that down too. Keeping track of how your heartburn symptoms affect your life will help you and your doctor decide if your treatment is working.

Heartburn-Friendly Recipes Heartburn can be caused by ordinary foods most of us eat every day. But limiting these food triggers from your diet doesn’t mean you have to sacrifice delicious meals! Remember to eat small meals… portion control is key. Here you can find recipes for flavorful dishes that limit ingredients known to trigger heartburn. We hope you will savor these flavors!

Take The Assessment Use this tool to help your doctor determine whether you have acid reflux disease, also known as GERD (gastroesophageal reflux disease).This tool may help you and your doctor find appropriate treatment.

Glossary A|B|C|D|E|F|G|H|I|J|K|L|M|N|O|P|Q|R|S|T|U|V|W|X|Y|Z Antacids Drugs used for indigestion and heartburn that neutralize stomach acid. Barium Esophagram (upper GI) A test in which the patient swallows a chalky, nonradioactive liquid containing barium. The barium coats the digestive tract and emphasizes the contours on x-ray. It can show narrowing of the esophagus and other structural abnormalities. Barrett’s Epithelium/Esophagus An abnormality of the cells lining the esophagus (esophageal epithelium) in which they are altered so that they become columnar, thus resembling the lining of the stomach. Dysphagia Difficulty in swallowing. Endoscopy A diagnostic test in which a thin, flexible tube carrying a fiberoptic cable is swallowed by the patient to allow the physician to directly inspect the lining of the upper gastrointestinal tract. Epithelium The purely cellular layer covering all the free surfaces of the body: cutaneous (skin), mucous, and serous. Erosion A shallow break in the esophagus limited to the mucosa. Esophageal pH monitoring This test determines the severity of acid reflux, including the amount of acidity and the time acid remains in the esophagus. There are two types of pH montoring tests. In the first, a tiny tube is inserted through the nose and into

the esophagus. An acid monitor at the end of the tube measures and records the acid levels in the esophagus for 24 hours. In the second, a pH monitor is clipped into the esophagus by endoscopy and records the pH up to a 48-hour period. Esophagitis Inflammation of the esophagus. Esophagus The tube that carries food from your throat to your stomach. Gastroenterologist A doctor who specializes in treating problems and diseases of the esophagus, stomach, small intestines, colon, liver, and pancreas. Gastroesophageal Reflux Regurgitation of the stomach contents into the esophagus. GERD (Gastroesophageal Reflux Disease) Chronic symptoms or mucosal damage produced by abnormal reflux of gastric contents into the esophagus. Heartburn A burning sensation, usually centered in the middle of the chest near the sternum, caused by the reflux of acidic stomach fluids that enter the lower end of the esophagus. Also called acid reflux, cardialgia, pyrosis. Histamine2-Receptor Antagonist (H2-RA) A class of medications that decrease stomach acid by preventing histamine from stimulating the stomach to produce acid. LES The lower esophageal sphincter. The muscular ring where the esophagus meets the stomach. Its function is to keep stomach juices from flowing up into the esophagus. Mucosal The inner lining of a tubular structure or hollow organ. Mucosal Protective Agents Medications that create a protective barrier on the lining of the esophagus to protect it from stomach acid. Parietal Cell A cell found within the stomach lumen that secretes hydrochloric acid. Pepsin The principal digestive enzyme of the gastric juices. Peristalsis (Esophageal) The movement of the esophagus, induced by swallowing, in which waves of alternate circular contraction and relaxation propel the contents onward.

Primary Peristalsis (Esophageal) Peristalsis that occurs in response to a swallow, and usually travels the full length of the esophagus. Promotility Agent Medications that increase the lower esophageal sphincter pressure, increase stomach emptying, and stimulate the esophagus to contract more often and with more power. Proton Pump Inhibitor A class of medications that block the final step in stomach acid production. Reflux The backflow of stomach acid into the esophagus. Regurgitation The backflow of swallowed food or drink into the throat or mouth. Secondary Peristalsis (Esophageal) Peristalsis that originates in the esophagus in response to esophageal stimulation (distention or irritation), as opposed to that initiated by swallowing. The wave of contractions originates at the site of stimulation and extends to the lower esophageal sphincter (LES). Sphincter A ring-like band of muscle that can tighten to narrow or close off a tube or an orifice. Ulcer A slow-healing open sore in which tissue breaks down. Water Brash Vagally mediated excessive salivation that results from esophageal acidification during reflux.

Site References 1.

Klauser AG, Schindlebeck NE, Muller-Lissner SA. Symptoms in gastrooesophageal reflux disease. Lancet . 1990;335:205-208.

2.

Jacob P, Kahrilas PJ, Vanagunas A. Peristaltic dysfunction associated with non-obstructive dysphagia in reflux disease. Dig Dis Sci. 1990;35(8):939-942.

3.

Helm JF, Dodds WJ, Hogan WJ. Salivary Response to Esophageal Acid in Normal Subjects and Patients with Reflux Esophagitis. Gastroenterology. 1987;93(6):1393-1397.

4.

Richter JE. Extraesophageal presentations of gastroesophageal reflux disease: an overview. Am J Gastroenterol . 2000;95(8 suppl):S1-S3.

5.

Richter JE. Gastroesophageal Reflux Disease. In: Yamada T, Alpers DH, Kaplowitz N, et al., eds. Textbook of Gastroenterology . 2003; Lippincott Williams & Wilkins: pp.

6.

Dent J, Brun J, Fendrick AM, et al. An evidence-based appraisal of reflux disease management: The Genval Workshop Report. Gut. 1999;44 (Suppl 2): S1-S16.

7.

American Gastroenterological Association. The Burden of Gastrointestinal Diseases. American Gastroenterological Association. Bethesda, MD. 2001.

8.

DeVault KR, Castell DO. Updated Guidelines for the Diagnosis and Treatment of Gastroesophageal Reflux Disease. Am J Gastroenterol . 1999;94 (6):1434-1442.

9.

Ward EM, DeVault KR, Bouras EP, et al. Successful oesophageal pH monitoring with a catheter-free system. Aliment Pharmacol Ther. 2004;19(4):449-454.

10. Maton PN. Profile and assessment of GERD pharmacotherapy. Cleve Clin J Med. 2003;70(suppl 5):S51-S70.

11. Hameeteman W, van de Boomgaard DM, Dekker W, et al. Sucralfate versus cimetidine in reflux esophagitis: single-blind multicenter study. J Clin Gastroenterol. 1987;9(4):390-394.

12. Simon B, Ravelli G-P, Goffin H. Sucralfate gel versus placebo in patient with non-erosive gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 1996;10(3):441-446.

13. Lambert JR, Korman MG, Nicholson L, et al. In-vivo anti-reflux and raft properties of alginates. Aliment Pharmacol Ther. 1990;4(6):615-622.

14. Ramirez B, Richter J. Review article: promotility drugs in the treatment of gastro-oesophageal reflux disease.Aliment Pharmacol Ther. 1993;7(1):5-20.

15. Smith JL, Opekun AR, Larkai E, et al. Sensitivity of the esophageal mucosa to pH in gastroesophageal reflux disease. Gastroenterology. 1989;96(3):683-689

16. Stein HJ, Barlow AP, DeMeester TR, et al. Complications of gastroesophageal reflux disease. Role of the lower esophageal

sphincter, esophageal acid and acid/alkaline exposure, and duodenogastric reflux. Ann Surg. 1992;216(1):35-43.

17. Kahrilas PJ. Gastroesophageal reflux disease. JAMA. 1996;276:983988.

18. Lipsy RJ, Fennerty B, Fagan TC. Clinical review of histamine2 receptor antagonists. Arch Intern Med. 1990;150(4):745-751.

19. Howden CW, Henning JM, Huang B, et al. Management of heartburn in a large, randomized, community-based study; comparison of four therapeutic strategies. Am J Gastroenterol. 2001;96(6):1704-1710.

20. Hatlebakk JG, Berstad A Gastro-oesophageal reflux during 3 months of therapy with ranitidine in reflux oesophagitis. Scand J Gastroenterol. 1996;31:954-958.

21. Frislid K, Berstad A. Prolonged influence of a meal on the effect of ranitidine.Scand J Gastroenterol. 1984;19:429-432.

22. Klinkenberg-Knol E, Nelis F, Dent J, et al. Long-term omeprazole treatment in resistant gastroesophageal reflux disease. Gastroenterology. 2000;118:661-669.

23. Bardhan KD, Morris P, Thompson M, et al. Omeprazole in the treatment of erosive esophagitis refractory to high dose of cimetidine and ranitidine. Gut. 1990. 31(7):745-749.

24. Huang JQ, Hunt RH. Meta-analysis of comparative trials for healing erosive esophagitis (EE) with proton pump inhibitors (PPIs) and H2receptor antagonists (H2RAs). Gastroenterology. 1998;114(4):A154 (abstract G0633).

25. Richter JE, Campbell DR, Kahrilas PJ et al. Lansoprazole compared with ranitidine for the treatment of nonerosive gastroesophageal reflux disease. Arch Intern Med. 2000;160:1803-1809.

26. Robinson M, Sahba B, Avner D et al. A comparison of lansoprazole and ranitidine in the treatment of erosive esophagitis. Aliment Pharmacol Ther. 1995;9:25-31.

27. Oberg S, Clark GW, DeMeester TR. Barrett’s esophagus. Update of pathophysiology and management. Hepatogastroenterology. 1998;45(23):1348-1356.

28. Bell NJV, Burget D, Howden CW, et al. Appropriate acid suppression for the management of gastro-oesophageal reflux disease. Digestion. 1992;51(suppl 1):59-67.

29. Castell DO, Richter JE, Robinson M, et al. Efficacy and safety of lansoprazole in the treatment of erosive reflux esophagitis. The Lansoprazole Group. Am J Gastroenterol. 1996;91(9):1749-1757.

30. Dekkers CP, Beker JA, Thjodleifsson B, et al. Double-blind comparison [correction of Double-blind, placebo controlled comparison] of rabeprazole 20 mg vs.omeprazole 20 mg in the treatment of erosive or ulcerative gastro-oesophageal reflux disease. The European Rabeprazole Study Group. Aliment Pharmacol Ther. 1999;13(1):49-57.

31. Mossner J, Holscher AH, Herz R, et al. A double-blind study of pantoprazole and omeprazole in the treatment of reflux oesophagitis; a multicentre trial. Aliment Pharmacol Ther. 1995;9(3):321-326.

32. Caro JJ, Salas M, Ward A. Healing and Relapse Rates in Gastroesophageal Reflux Disease Treated with the Newer Proton-Pump Inhibitors Lansoprazole, Rabeprazole, and Pantoprazole Compared with Omeprazole, Ranitidine, and Placebo: Evidence from Randomized Clinical Trials. Clin Ther. 2001;23(7):998-1017.

33. Vigneri S, Termini R, Leandro G, et al.: A comparison of five maintenance therapies for reflux esophagitis. N Engl J Med. 1995;333:1106-1110.

34. Katzka DA, Castell DO. Successful elimination of reflux symptoms does not ensure adequate control of acid reflux in patients with Barrett's esophagus. Am J Gastroenterol. 1994;89(7):989-991.

35. Vaezi MF, Richter JE. Role of acid and duodenogastroesophageal reflux in gastroesophageal reflux disease. Gastroenterology. 1996;111:11921199.

36. Marshall REK, Anggiansah A, Manifold DK, et al. Effect of omeprazole 20 mg twice daily on duodenogastric and gastro-oesophageal bile reflux in Barrett's esophagus. Gut. 1998;43(5):603-606.

37. Harris RA, Kuppermann M, Richter JE. Prevention of recurrences of erosive reflux esophagitis: a cost-effectiveness analysis of maintenance proton pump inhibition. Am J Med. 1997;102(1):78-88.

38. Goeree R, O’Brien B, Hunt R, et al. Economic evaluation of long-term management strategies for erosive oesophagitis. Pharmacoeconomics. 1999;16(6):679-697.

39. Harris RA, Kuppermann M, Richter JE. Proton pump inhibitors or histamine-2 receptor antagonists for the prevention of recurrences of erosive reflux esophagitis: a cost-effective analysis. Am J Gastroenterol. 1997;92(12):2179-2187.

40. Ladas SD, Tassios PS, Raptis SA. Selection of patients for successful maintenance treatment of esophagitis with low-dose omeprazole: use of 24-hour gastric pH monitoring. Am J Gastroenterol. 2000;95(2):374-380.

41. Inadomi JM, Jamal R, Murata GH, et al. Step-down management of gastroesophageal reflux disease. Gastroenterology. 2001;121(5):10951100.

42. Katz PO, Anderson C, Khoury R, et al. Gastro-oesophageal reflux associated with nocturnal gastric acid breakthrough on proton pump inhibitors. Aliment Pharmacol Ther. 1998;12(12):1231-1234.

43. Paoletti V, Karvois D, Greski-Rose P, et al. Lansoprazole is superior to omeprazole in increasing both 24-hour and nighttime intragastric pH in "omeprazole failure" GERD patients. Am J Gastroenterol. 1997;92:1621(Abstract).

44. DeVault KR, Castell DO. Updated Guidelines for the Diagnosis and Treatment of Gastroesophageal Reflux Disease. Am J Gastroenterol. 2005 (100):190-200.

45. Bell NJV, Burget DW, Howden CW, et al. Healing of gastro-esophageal reflux disease: regression analysis of the role of gastric acid suppression [abstract]. Am J Gastroenterol. 1992;87(9):1253 Abs 46. (Data on file)

46. Schindlbeck NE, Ippisch H, Klauser AG, et al. Which pH threshold is best in esophageal pH monitoring? Am J Gastroenterol. 1991;86:11381141. (Data on file)

47. Schindlbeck NE, Heinrich C, Konig A, et al. Optimal thresholds, sensitivity, and specificity of long-term pH metry for the detection of gastroesophageal reflux disease. Gastroenterology. 1987;93:85-90. (Data on file)

Patient Education Patients with heartburn or other gastrointestinal reflux disease (GERD) symptoms will come to you for diagnosis and treatment. Many will have already tried over the counter remedies such as antacids, alginic acid, and low-dose histamine-2 receptor antagonists (H2RAs). Providing them with a good understanding of acid reflux disease, its causes, symptoms, and treatment, may be helpful in assuring patient compliance with the treatment regimen you prescribe.

What patients want to know Patients will want information on a number of issues including: •

What is GERD?

•

What causes GERD?

•

What are the sequelae of GERD?

•

How can they get relief from their symptoms?

•

What tests will they need?

•

How often will they need to be seen by you for their GERD?

What educational materials can you give them? Providing your patients with fact sheets will allow them to review the information you discuss during the visit, assist them in complying more fully with instructions, and formulate questions for the next visit.

Acid Reflux Disease discusses, in a language patients can understand, the symptoms and cause of GERD. Symptoms described include heartburn, acid reflux, and dysphagia. The basis of GERD is explained with text and anatomic diagrams. Heartburn Facts emphasizes that GERD is a real disease and gives some epidemiological information so that patients know that this is a common disease. Heartburn Tips is a list of lifestyle modifications that they can make, including keeping a symptom diary. Food Triggers and Tips will help to remind them of foods they should avoid, to not lie down after eating, and to keep a food diary. Doctor Visits is a list of tips for patients to assist them in making the most of their visit. They are encouraged to come prepared with a list of questions to ask them at the beginning of the visit. They should be specific, keep the diary and bring it with them, and repeat instructions back to you to be sure they understand them. A Symptom Diary will aid in establishing an effective individualized regimen for each patient.

Educational Web Sites For those of you who have patients who want to know more about GERD, the following are some Web sites you could consider recommending: Medline Plus www.nlm.nih.gov/medlineplus/ This Web site is produced by the National Library of Medicine and the National Institutes of Health. It is a health information center for consumers. Patients can read about health topics, access a medical encyclopedia, read about medications, and get health news. Mayo Clinic Consumer Health www.mayoclinic.com This is a consumer health Web site produced by the Mayo Clinic. It provides information on diseases and conditions, suggestions for a healthier lifestyle, information on medications, health assessment tools, books, newsletters, essays, and more. Accent Health www.accenthealth.com This Web site has information on a variety of health and wellness topics, articles, tips, interactive tools, and support groups. GERD Diet www.gicare.com/pated/edtgs03.htm This site provides good, detailed information about diet and lifestyle changes that may help GERD symptoms. Health A to Z www.healthatoz.com

This site gives information on a variety of diseases. The digestive disease library provides information, a glossary, and suggestions for healthier eating habits. iVillage www.allhealth.com This is a general health site. There is a medical encyclopedia, special site areas for certain conditions, daily health news, chat rooms, and information on current research.

Resources Between 4.6 and 18.6 million people in the United States have GERD.7 GERD can have a significant impact on quality of life; because of this, a great deal of information is available both on the Internet, in textbooks, and in journals on this common disease.

Textbooks A number of excellent gastroenterology textbooks are available: Yamada T, Alpers DH, Laine L, et al. Atlas of Gastroenterology. 2003 Lippincott Williams and Wilkins. ISBN 07817-3081-3. 1100 pages, 3087 illustrations. http://www.lww.com/products/?0-7817-3081-3. Yamada T, Alpers DH, Laine L, et al. Atlas of Gastroenterology, Third Edition and Gastroenterology CD-ROM, package. 2003 Lippincott Williams and Wilkins. ISBN 0-7817-4720-1. 1100 pages, 3087 illustrations. http://www.lww.com/products/?0-7817-4720-1. Yamada T, Alpers DH, Laine L, et al. Textbook of Gastroenterology, Fourth Edition and Gastroenterology CDROM. 2003 Lippincott Williams and Wilkins. ISBN 0-7817-4719-8. 3900 pages, 2000 illustrations. http://www.lww.com/products/?0-7817-4719-8.

Links to Internet Web Sites The National Institute of Diabetes and Digestive and Kidney Diseases www.niddk.nih.gov This site offers disease information on a variety of diseases, statistics on digestive diseases in the United States, and links to other useful government Web sites. It also provides information about clinical trials and practice guidelines. NIDDK publications can be ordered from the Web site. PubMed www.pubmed.com A service of the National Library of Medicine, includes over 14 million citations for biomedical articles back to the 1950's. These citations are from MEDLINE and additional life science journals. PubMed includes links to many sites providing full text articles and other related resources. eMedicine.com, Inc. www.emedicine.com The eMedicine Clinical Knowledge Base contains articles on 7,000 diseases and disorders (including many with CME

credit). The evidence-based content is updated daily and provides the latest practice guidelines in 62 medical specialties. eMedicine's professional content undergoes four levels of physician peer review plus an additional review by a PharmD. The Clinical Knowledge Base contains 30,000 multimedia files and features the largest online repository of medical education credits for physicians, nurses, pharmacists, and optometrists. Medscape www.medscape.com This Web site provides medical information for physicians and other health care professionals. There are sections for news, treatment updates, clinical management, practice guidelines, CME, and conference information. A daily, specialty-specific e-mail newsletter is available. The Cleveland Clinic Medical Education Web Site www.clevelandclinicmeded.com This Web site offers access to CME including Selected Topics in Gastrotherapy. The Disease Management project provides current information on treating 120 commonly seen diseases. The “One Minute Consult” comprises brief answers to questions on current clinical controversies. The site also offers information on pharmaceuticals, a pharmacy newsletter, and more. MDlinx www.mdlinx.com MDlinx has both a professional and a patient section. The professional section is a network of 34 medical specialty Web sites, including a GI Web site, http://www.mdlinx.com/GILinx/ . There are daily updates on specialty news, daily e-mail newsletters for each specialty, e-mail discussion lists, and CME. MDlinx will also help you set up your own Web site for free. Doctor’s Guide www.docguide.com Doctor's Guide is a comprehensive source for peer-reviewed literature, case studies, Webcasts/CME, and more. It provides a daily update on news and can be customized for your personal interests. Feldman’s GastroAtlas www.gastroatlas.com Feldman’s GastroAtlas is the ultimate online gastroenterology image resource. It contains over 4,000 clinical, radiologic, pathologic, and histologic images. You can create and maintain your own named files of slides based on the Feldman Atlas image collection. These files become part of the central GastroAtlas database and can be accessed, on login, from any computer anywhere in the world. The Visible Human Project www.nlm.nih.gov/research/visible/visible_human.html The Visible Human Project® is an outgrowth of the National Library of Medicine's 1986 Long-Range Plan. It is the creation of complete, anatomically detailed, three-dimensional representations of the normal male and female human bodies. Acquisition of transverse CT, MR, and cryosection images of representative male and female cadavers has been completed. Information on the site includes how to get image data, an update of the Virtual Human’s initiatives,

information on other National Library of Medicine initiatives, information from the contractors for the Project proceedings from project conferences, and publications. MediClicks www.MediClicks.net MediClicks is a free e-mail medical newsletter sent every two weeks. It provides information about the latest trends in technology and how they relate to the field of medicine. Insights about health care as it relates to the Internet are provided, as are tips on how to use the Internet, computers, and other electronic devices. There is an original cartoon that illustrates the lighter side of medicine with each issue. For links to medical journals including GI-specific journals, professional organizations Web sites, and CME sites click here.

GERD Articles The American Gastroenterological Society’s Report on the Burden of Gastrointestinal Disease:(Membership is required to view the articles) http://www.gastro.org/clinicalRes/burdenReport.html. The American Gastroenterological Society’s GERD monograph:(Membership is required to view the articles) http://www.gastro.org/edu/GERDmonograph.pdf. The American College of Gastroenterology’s Updated Guidelines for the Diagnosis and Treatment of Gastroesophageal Reflux Disease available at: http://www.acg.gi.org/physicians/guidelines/GERDTreatment.pdf

Site References 1.

Klauser AG, Schindlebeck NE, Muller-Lissner SA. Symptoms in gastrooesophageal reflux disease. Lancet . 1990;335:205-208.

2.

Jacob P, Kahrilas PJ, Vanagunas A. Peristaltic dysfunction associated with non-obstructive dysphagia in reflux disease. Dig Dis Sci. 1990;35(8):939-942.

3.

Helm JF, Dodds WJ, Hogan WJ. Salivary Response to Esophageal Acid in Normal Subjects and Patients with Reflux Esophagitis. Gastroenterology. 1987;93(6):1393-1397.

4.

Richter JE. Extraesophageal presentations of gastroesophageal reflux disease: an overview. Am J Gastroenterol . 2000;95(8 suppl):S1-S3.

5.

Richter JE. Gastroesophageal Reflux Disease. In: Yamada T, Alpers DH, Kaplowitz N, et al., eds. Textbook of Gastroenterology . 2003; Lippincott Williams & Wilkins: pp.

6.

Dent J, Brun J, Fendrick AM, et al. An evidence-based appraisal of reflux disease management: The Genval Workshop Report. Gut. 1999;44 (Suppl 2): S1-S16.

7.

American Gastroenterological Association. The Burden of Gastrointestinal Diseases. American Gastroenterological Association. Bethesda, MD. 2001.

8.

DeVault KR, Castell DO. Updated Guidelines for the Diagnosis and Treatment of Gastroesophageal Reflux Disease. Am J Gastroenterol . 1999;94 (6):1434-1442.

9.

Ward EM, DeVault KR, Bouras EP, et al. Successful oesophageal pH monitoring with a catheter-free system. Aliment Pharmacol Ther. 2004;19(4):449-454.

10. Maton PN. Profile and assessment of GERD pharmacotherapy. Cleve Clin J Med. 2003;70(suppl 5):S51-S70.

11. Hameeteman W, van de Boomgaard DM, Dekker W, et al. Sucralfate versus cimetidine in reflux esophagitis: single-blind multicenter study. J Clin Gastroenterol. 1987;9(4):390-394.

12. Simon B, Ravelli G-P, Goffin H. Sucralfate gel versus placebo in patient with non-erosive gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 1996;10(3):441-446.

13. Lambert JR, Korman MG, Nicholson L, et al. In-vivo anti-reflux and raft properties of alginates. Aliment Pharmacol Ther. 1990;4(6):615-622.

14. Ramirez B, Richter J. Review article: promotility drugs in the treatment of gastro-oesophageal reflux disease.Aliment Pharmacol Ther. 1993;7(1):5-20.

15. Smith JL, Opekun AR, Larkai E, et al. Sensitivity of the esophageal mucosa to pH in gastroesophageal reflux disease. Gastroenterology. 1989;96(3):683-689

16. Stein HJ, Barlow AP, DeMeester TR, et al. Complications of gastroesophageal reflux disease. Role of the lower esophageal sphincter, esophageal acid and acid/alkaline exposure, and duodenogastric reflux. Ann Surg. 1992;216(1):35-43.

17. Kahrilas PJ. Gastroesophageal reflux disease. JAMA. 1996;276:983988.

18. Lipsy RJ, Fennerty B, Fagan TC. Clinical review of histamine2 receptor antagonists. Arch Intern Med. 1990;150(4):745-751.

19. Howden CW, Henning JM, Huang B, et al. Management of heartburn in a large, randomized, community-based study; comparison of four therapeutic strategies. Am J Gastroenterol. 2001;96(6):1704-1710.

20. Hatlebakk JG, Berstad A Gastro-oesophageal reflux during 3 months of therapy with ranitidine in reflux oesophagitis. Scand J Gastroenterol. 1996;31:954-958.

21. Frislid K, Berstad A. Prolonged influence of a meal on the effect of ranitidine.Scand J Gastroenterol. 1984;19:429-432.

22. Klinkenberg-Knol E, Nelis F, Dent J, et al. Long-term omeprazole treatment in resistant gastroesophageal reflux disease. Gastroenterology. 2000;118:661-669.

23. Bardhan KD, Morris P, Thompson M, et al. Omeprazole in the treatment of erosive esophagitis refractory to high dose of cimetidine and ranitidine. Gut. 1990. 31(7):745-749.

24. Huang JQ, Hunt RH. Meta-analysis of comparative trials for healing erosive esophagitis (EE) with proton pump inhibitors (PPIs) and H2receptor antagonists (H2RAs). Gastroenterology. 1998;114(4):A154 (abstract G0633).

25. Richter JE, Campbell DR, Kahrilas PJ et al. Lansoprazole compared with ranitidine for the treatment of nonerosive gastroesophageal reflux disease. Arch Intern Med. 2000;160:1803-1809.

26. Robinson M, Sahba B, Avner D et al. A comparison of lansoprazole and ranitidine in the treatment of erosive esophagitis. Aliment Pharmacol Ther. 1995;9:25-31.

27. Oberg S, Clark GW, DeMeester TR. Barrett’s esophagus. Update of pathophysiology and management. Hepatogastroenterology. 1998;45(23):1348-1356.

28. Bell NJV, Burget D, Howden CW, et al. Appropriate acid suppression for the management of gastro-oesophageal reflux disease. Digestion. 1992;51(suppl 1):59-67.

29. Castell DO, Richter JE, Robinson M, et al. Efficacy and safety of lansoprazole in the treatment of erosive reflux esophagitis. The Lansoprazole Group. Am J Gastroenterol. 1996;91(9):1749-1757.

30. Dekkers CP, Beker JA, Thjodleifsson B, et al. Double-blind comparison [correction of Double-blind, placebo controlled comparison] of rabeprazole 20 mg vs.omeprazole 20 mg in the treatment of erosive or ulcerative gastro-oesophageal reflux disease. The European Rabeprazole Study Group. Aliment Pharmacol Ther. 1999;13(1):49-57.

31. Mossner J, Holscher AH, Herz R, et al. A double-blind study of pantoprazole and omeprazole in the treatment of reflux oesophagitis; a multicentre trial. Aliment Pharmacol Ther. 1995;9(3):321-326.

32. Caro JJ, Salas M, Ward A. Healing and Relapse Rates in Gastroesophageal Reflux Disease Treated with the Newer Proton-Pump Inhibitors Lansoprazole, Rabeprazole, and Pantoprazole Compared with Omeprazole, Ranitidine, and Placebo: Evidence from Randomized Clinical Trials. Clin Ther. 2001;23(7):998-1017.

33. Vigneri S, Termini R, Leandro G, et al.: A comparison of five maintenance therapies for reflux esophagitis. N Engl J Med. 1995;333:1106-1110.

34. Katzka DA, Castell DO. Successful elimination of reflux symptoms does not ensure adequate control of acid reflux in patients with Barrett's esophagus. Am J Gastroenterol. 1994;89(7):989-991.

35. Vaezi MF, Richter JE. Role of acid and duodenogastroesophageal reflux in gastroesophageal reflux disease. Gastroenterology. 1996;111:11921199.

36. Marshall REK, Anggiansah A, Manifold DK, et al. Effect of omeprazole 20 mg twice daily on duodenogastric and gastro-oesophageal bile reflux in Barrett's esophagus. Gut. 1998;43(5):603-606.

37. Harris RA, Kuppermann M, Richter JE. Prevention of recurrences of erosive reflux esophagitis: a cost-effectiveness analysis of maintenance proton pump inhibition. Am J Med. 1997;102(1):78-88.

38. Goeree R, O’Brien B, Hunt R, et al. Economic evaluation of long-term management strategies for erosive oesophagitis. Pharmacoeconomics. 1999;16(6):679-697.

39. Harris RA, Kuppermann M, Richter JE. Proton pump inhibitors or histamine-2 receptor antagonists for the prevention of recurrences of erosive reflux esophagitis: a cost-effective analysis. Am J Gastroenterol. 1997;92(12):2179-2187.

40. Ladas SD, Tassios PS, Raptis SA. Selection of patients for successful maintenance treatment of esophagitis with low-dose omeprazole: use of 24-hour gastric pH monitoring. Am J Gastroenterol. 2000;95(2):374-380.

41. Inadomi JM, Jamal R, Murata GH, et al. Step-down management of gastroesophageal reflux disease. Gastroenterology. 2001;121(5):10951100.

42. Katz PO, Anderson C, Khoury R, et al. Gastro-oesophageal reflux associated with nocturnal gastric acid breakthrough on proton pump inhibitors. Aliment Pharmacol Ther. 1998;12(12):1231-1234.

43. Paoletti V, Karvois D, Greski-Rose P, et al. Lansoprazole is superior to omeprazole in increasing both 24-hour and nighttime intragastric pH in "omeprazole failure" GERD patients. Am J Gastroenterol. 1997;92:1621(Abstract).

44. DeVault KR, Castell DO. Updated Guidelines for the Diagnosis and Treatment of Gastroesophageal Reflux Disease. Am J Gastroenterol. 2005 (100):190-200.

45. Bell NJV, Burget DW, Howden CW, et al. Healing of gastro-esophageal reflux disease: regression analysis of the role of gastric acid suppression [abstract]. Am J Gastroenterol. 1992;87(9):1253 Abs 46. (Data on file)

46. Schindlbeck NE, Ippisch H, Klauser AG, et al. Which pH threshold is best in esophageal pH monitoring? Am J Gastroenterol. 1991;86:11381141. (Data on file)

47. Schindlbeck NE, Heinrich C, Konig A, et al. Optimal thresholds, sensitivity, and specificity of long-term pH metry for the detection of gastroesophageal reflux disease. Gastroenterology. 1987;93:85-90. (Data on file)

48. Reflux Laryngitis ...throat clearing, swallowing problems, asthma, chronic cough, and more. Typical symptoms of reflux laryngitis include heartburn,...MD Why does reflux laryngitis occur? What are the typical symptoms of...

Source: MedicineNet Medical Author: John P. Cunha, DO, FACOEP Medical Editor: Jay W. Marks, MD

• •

What are the typical symptoms of reflux laryngitis?

• • • •

Why does reflux laryngitis occur?

How are reflux laryngitis evaluated?

What is the conservative therapy of reflux?

What types of medications are used to treat reflux? What are the difficulties in diagnosing reflux laryngitis?

•

Reflux Laryngitis At A Glance

Why does reflux laryngitis occur? Reflux is caused by weakness in the muscle at the junction of the esophagus with the stomach. Normally, this muscular valve, or sphincter, functions to keep food and stomach acid from moving upward from the stomach to the esophagus and larynx. This valve opens to allow food into the stomach and closes to keep the stomach's contents from coming back up. The backward movement of stomach contents (gastric contents) up into the esophagus is referred to as gastroesophageal reflux. Additionally, any increase in abdominal pressure (such as obesity), which can push acid back from the stomach up the esophagus, or a patient with a hiatal hernia, will have an increased risk for reflux. When it causes symptoms, it is referred to as gastroesophageal reflux disease (or GERD). When the acid backs up into the voice box (larynx), the condition is referred to as reflux laryngitis. Stomach acid can cause irritation of the lining of the esophagus, larynx, and throat. This can lead to:

•

erosion of the lining of the esophagus (erosive esophagitis),

•

narrowing of the esophagus (stricture),

• •

chronic throat clearing,

• •

chronic hoarseness,

difficulty swallowing,

foreign body sensation in the throat,

• •

asthma or cough,

spasms of the vocal cords,

• •

sinusitis, and

growths on the vocal cords (granulomas).

Rarely, reflux can lead to cancers of the esophagus or larynx.

Gastroesophageal Reflux Disease (GERD) (cont.) In this Article

•

What is GERD (acid reflux)?

• •

What are the symptoms of uncomplicated GERD?

• •

What are the complications of GERD? How is GERD diagnosed and evaluated? •

•

What causes GERD?

How is GERD treated?

What is a reasonable approach to the management of GERD?

•

What are the unresolved issues in GERD?

• • •

GERD At A Glance

Patient Discussions: GERD - Proton Pump Inhibitors Gastroesophageal Reflux Disease (GERD) Glossary

•

Gastroesophageal Reflux Disease (GERD) Index

How is GERD treated? Life-style changes One of the simplest treatments for GERD is referred to as life-style changes, a combination of several changes in habit, particularly related to eating. As discussed above, reflux of acid is more injurious at night than during the day. At night, when individuals are lying down, it is easier for reflux to occur. The reason that it is easier is because gravity is not opposing the reflux, as it does in the upright position during the day. In addition, the lack of an effect of gravity allows the refluxed liquid to travel further up the esophagus and remain in the esophagus longer. These problems can be overcome partially by elevating the upper body in bed. The elevation is accomplished either by putting blocks under the bed's feet at the head of the bed or, more conveniently, by sleeping with the upper body on a wedge. These maneuvers raise the esophagus above the stomach and partially restore the effects of gravity. It is important that the upper body and not just the head be elevated. Elevating only the head does not raise the esophagus and fails to restore the effects of gravity.

Elevation of the upper body at night generally is recommended for all patients with GERD. Nevertheless, most patients with GERD have reflux only during the day and elevation at night is of little benefit for them. It is not possible to know for certain which patients will benefit from elevation at night unless acid testing clearly demonstrates night reflux. However, patients who have heartburn, regurgitation, or other symptoms of GERD at night are probably experiencing reflux at night and definitely should use upper body elevation. Reflux also occurs less frequently when patients lie on their left rather than their right sides. GERD Diet Several changes in eating habits can be beneficial in treating GERD. Reflux is worse following meals. This probably is so because the stomach is distended with food at that time and transient relaxations of the lower esophageal sphincter are more frequent. Therefore, smaller and earlier evening meals may reduce the amount of reflux for two reasons. First, the smaller meal results in lesser distention of the stomach. Second, by bedtime, a smaller and earlier meal is more likely to have emptied from the stomach than is a larger one. As a result, reflux is less likely to occur when patients with GERD lie down. Certain foods are known to reduce the pressure in the lower esophageal sphincter and thereby promote reflux. These foods should be avoided and include: •

•

chocolate,

•

peppermint,

•

alcohol, and caffeinated drinks.

Fatty foods (which should be decreased) and smoking (which should be stopped) also reduce the pressure in the sphincter and promote reflux. In addition, patients with GERD may find that other foods aggravate their symptoms. Examples are spicy or acidcontaining foods, like citrus juices, carbonated beverages, and tomato juice. These foods should also be avoided. One novel approach to the treatment of GERD is chewing gum. Chewing gum stimulates the production of more bicarbonate-containing saliva and increases the rate of swallowing. After the saliva is swallowed, it neutralizes acid in the esophagus. In effect, chewing gum exaggerates one of the normal processes that neutralizes acid in the esophagus. It is not clear, however, how effective chewing gum actually is in treating heartburn. Nevertheless, chewing gum after meals is certainly worth a try. Antacids Despite the development of potent medications for the treatment of GERD, antacids remain a mainstay of treatment. Antacids neutralize the acid in the stomach so that there is no acid to reflux. The problem with antacids is that their action is brief. They are emptied from the empty stomach quickly, in less than an hour, and the acid then reaccumulates. The best way to take antacids, therefore, is approximately one hour after meals or just before the symptoms of reflux begin after a meal. Since the food from meals slows the emptying from the stomach, an antacid taken after a meal stays in the stomach longer and is effective longer. For the same reason, a second dose of

antacids approximately two hours after a meal takes advantage of the continuing post-meal slower emptying of the stomach and replenishes the acid-neutralizing capacity within the stomach. Antacids may be aluminum, magnesium, or calcium based. Calcium-based antacids (usually calcium carbonate), unlike other antacids, stimulate the release of gastrin from the stomach and duodenum. Gastrin is the hormone that is primarily responsible for the stimulation of acid secretion by the stomach. Therefore, the secretion of acid rebounds after the direct acid-neutralizing effect of the calcium carbonate is exhausted. The rebound is due to the release of gastrin, which results in an overproduction of acid. Theoretically at least, this increased acid is not good for GERD. Acid rebound, however, has not been shown to be clinically important. That is, treatment with calcium carbonate has not been shown to be less effective or safe than treatment with antacids not containing calcium carbonate. Nevertheless, the phenomenon of acid rebound is theoretically harmful. In practice, therefore, calcium-containing antacids such as Tums and Rolaids are not recommended. The occasional use of these calcium carbonatecontaining antacids, however, is not believed to be harmful. The advantages of calcium carbonate-containing antacids are their low cost , the calcium they add to the diet, and their convenience as compared to liquids. Aluminum-containing antacids have a tendency to cause constipation, while magnesium-containing antacids tend to cause diarrhea. If diarrhea or constipation becomes a problem, it may be necessary to switch antacids or alternately use antacids containing aluminum and magnesium. Histamine antagonists Although antacids can neutralize acid, they do so for only a short period of time. For substantial neutralization of acid throughout the day, antacids would need to be given frequently, at least every hour. The first medication developed for more effective and convenient treatment of acid-related diseases, including GERD, was a histamine antagonist, specifically cimetidine (Tagamet). Histamine is an important chemical because it stimulates acid production by the stomach. Released within the wall of the stomach, histamine attaches to receptors (binders) on the stomach's acid-producing cells and stimulates the cells to produce acid. Histamine antagonists work by blocking the receptor for histamine and thereby preventing histamine from stimulating the acid-producing cells. (Histamine antagonists are referred to as H2 antagonists because the specific receptor they block is the histamine type 2 receptor.) Because histamine is particularly important for the stimulation of acid after meals, H2 antagonists are best taken 30 minutes before meals. The reason for this timing is so that the H2 antagonists will be at peak levels in the body after the meal when the stomach is actively producing acid. H2 antagonists also can be taken at bedtime to suppress nighttime production of acid. H2 antagonists are very good for relieving the symptoms of GERD, particularly heartburn. However, they are not very good for healing the inflammation (esophagitis) that may accompany GERD. In fact, they are used primarily for the treatment of heartburn in GERD that is not associated with inflammation or complications, such as erosions or ulcers, strictures, or Barrett's esophagus.

Four different H2 antagonists are available by prescription, including cimetidine (Tagamet), ranitidine (Zantac), nizatidine (Axid), and famotidine, (Pepcid). All four are also available over-the-counter (OTC), without the need for a prescription. However, the OTC dosages are lower than those available by prescription. Proton pump inhibitors The second type of drug developed specifically for acid-related diseases, such as GERD, was a proton pump inhibitor (PPI), specifically, omeprazole (Prilosec). A PPI blocks the secretion of acid into the stomach by the acid-secreting cells. The advantage of a PPI over an H2 antagonist is that the PPI shuts off acid production more completely and for a longer period of time. Not only is the PPI good for treating the symptom of heartburn, but it also is good for protecting the esophagus from acid so that esophageal inflammation can heal. PPIs are used when H2 antagonists do not relieve symptoms adequately or when complications of GERD such as erosions or ulcers, strictures, or Barrett's esophagus exist. Five different PPIs are approved for the treatment of GERD, including omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), pantoprazole (Protonix), and esomeprazole (Nexium). A fifth PPI product consists of a combination of omeprazole and sodium bicarbonate (Zegerid). PPIs (except for Zegarid) are best taken an hour before meals. The reason for this timing is that the PPIs work best when the stomach is most actively producing acid, which occurs after meals. If the PPI is taken before the meal, it is at peak levels in the body after the meal when the acid is being made. Pro-motility drugs Pro-motility drugs work by stimulating the muscles of the gastrointestinal tract, including the esophagus, stomach, small intestine, and/or colon. One pro-motility drug, metoclopramide (Reglan), is approved for GERD. Pro-motility drugs increase the pressure in the lower esophageal sphincter and strengthen the contractions (peristalsis) of the esophagus. Both effects would be expected to reduce reflux of acid. However, these effects on the sphincter and esophagus are small. Therefore, it is believed that the primary effect of metoclopramide may be to speed up emptying of the stomach, which also would be expected to reduce reflux. Pro-motility drugs are most effective when taken 30 minutes before meals and again at bedtime. They are not very effective for treating either the symptoms or complications of GERD. Therefore, the pro-motility agents are reserved either for patients who do not respond to other treatments or are added to enhance other treatments for GERD. Foam barriers Foam barriers provide a unique form of treatment for GERD. Foam barriers are tablets that are composed of an antacid and a foaming agent. As the tablet disintegrates and reaches the stomach, it turns into foam that floats on the top of the liquid contents of the stomach. The foam forms a physical barrier to the reflux of liquid. At the same time, the antacid bound to the foam neutralizes acid that comes in contact with the foam. The tablets are best taken after meals (when the stomach is distended) and when lying down, both times when reflux is more likely to occur. Foam barriers are not often used as the first or only treatment for GERD. Rather, they are added to other drugs for GERD when the other drugs are not adequately effective in relieving symptoms. There is only one foam barrier, which is a combination of aluminum hydroxide gel, magnesium trisilicate, and alginate (Gaviscon). Surgery

The drugs described above usually are effective in treating the symptoms and complications of GERD. Nevertheless, sometimes they are not. For example, despite adequate suppression of acid and relief from heartburn, regurgitation, with its potential for complications in the lungs, may still occur. Moreover, the amounts and/or numbers of drugs that are required for satisfactory treatment are sometimes so great that drug treatment is unreasonable. In such situations, surgery can effectively stop reflux. The surgical procedure that is done to prevent reflux is technically known as fundoplication and is called reflux surgery or anti-reflux surgery. During fundoplication, any hiatal hernial sac is pulled below the diaphragm and stitched there. In addition, the opening in the diaphragm through which the esophagus passes is tightened around the esophagus. Finally, the upper part of the stomach next to the opening of the esophagus into the stomach is wrapped around the lower esophagus to make an artificial lower esophageal sphincter. All of this surgery can be done through an incision in the abdomen (laparotomy) or using a technique called laparoscopy. During laparoscopy, a small viewing device and surgical instruments are passed through several small puncture sites in the abdomen. This procedure avoids the need for a major abdominal incision. Surgery is very effective at relieving symptoms and treating the complications of GERD. Approximately 80% of patients will have good or excellent relief of their symptoms for at least 5 to 10 years. Nevertheless, many patients who have had surgery—perhaps as many as half—will continue to take drugs for reflux. It is not clear whether they take the drugs because they continue to have reflux and symptoms of reflux or if they take them for symptoms that are being caused by problems other than GERD. The most common complication of fundoplication is swallowed food that sticks at the artificial sphincter. Fortunately, the sticking usually is temporary. If it is not transient, endoscopic treatment to stretch (dilate) the artificial sphincter usually will relieve the problem. Only occasionally is it necessary to re-operate to revise the prior surgery. Endoscopy Very recently, endoscopic techniques for the treatment of GERD have been developed and tested. One type of endoscopic treatment involves suturing (stitching) the area of the lower esophageal sphincter, which essentially tightens the sphincter. A second type involves the application of radio-frequency waves to the lower part of the esophagus just above the sphincter. The waves cause damage to the tissue beneath the esophageal lining and a scar (fibrosis) forms. The scar shrinks and pulls on the surrounding tissue, thereby tightening the sphincter and the area above it. A third type of endoscopic treatment involves the injection of materials into the esophageal wall in the area of the LES. The injected material is intended to increase pressure in the LES and thereby prevent reflux. In one treatment the injected material was a polymer. Unfortunately, the injection of polymer led to serious complications, and the material for injection is no longer available. Another treatment involving injection of expandable pellets also was discontinued. Limited information is available about a third type of injection which uses gelatinous polymethylmethacrylate microspheres. Endoscopic treatment has the advantage of not requiring surgery. It can be performed without hospitalization. Experience with endoscopic techniques is limited. It is not clear how effective they are, especially long-term. Because

the effectiveness and the full extent of potential complications of endoscopic techniques are not clear, it is felt generally that endoscopic treatment should only be done as part of experimental trials. Prevention of transient LES relaxation Transient LES relaxations appear to be the most common way in which acid reflux occurs. Although there are available drugs that prevent relaxations, they have too many side effects to be generally useful. Much attention is being directed at the development of drugs that prevent these relaxations without accompanying side effects

1. Discussion 2Digestive System

Digestive System. KidsHealth> Teens> Diseases & Conditions> Body Basics Library> Digestive System ... The digestive system is made up of the alimentary canal ... kidshealth.org/teen/.../body_basics/digestive_system.html

Food Is the Body's Fuel Source What's the first step in digesting food? Believe it or not, the digestive process starts even before you put food in your mouth. It begins when you smell something irresistible or when you see a favorite food you know will taste good. Just by smelling that homemade apple pie or thinking about how delicious that ice cream sundae is going to taste, you begin to salivate — and the digestive process kicks in, preparing for that first scrumptious bite.

If it's been a while since your last meal or if you even think about something tasty, you feel hungry. You eat until you're satisfied and then go about your business. But for the next 20 hours or so, your digestive system is doing its job as the food you ate travels through your body.

Food is the body's fuel source. The nutrients in food give the body's cells the energy and other substances they need to operate. But before food can do any of these things, it has to be digested into small pieces the body can absorb and use.

Almost all animals have a tube-type digestive system in which food enters the mouth, passes through a long tube, and exits as feces (poop) through the anus. The smooth muscle in the walls of the tube-shaped digestive organs rhythmically and efficiently moves the food through the system, where it is broken down into tiny absorbable nutrients.

During the process of absorption, nutrients that come from the food (including carbohydrates, proteins, fats, vitamins, and minerals) pass through channels in the intestinal wall and into the bloodstream. The blood works to distribute these nutrients to the rest of the body. The waste parts of food that the body can't use are passed out of the body as feces.

What Is the Digestive System and What Does It Do? Every morsel of food we eat has to be broken down into nutrients that can be absorbed by the body, which is why it takes hours to fully digest food. In humans, protein must be broken down into amino acids, starches into simple sugars, and fats into fatty acids and glycerol. The water in our food and drink is also absorbed into the bloodstream to provide the body with the fluid it needs.

The digestive system is made up of the alimentary canal and the other abdominal organs that play a part in digestion, such as the liver and pancreas. The alimentary canal (also called the digestive tract) is the long tube of organs — including the esophagus, the stomach, and the intestines — that runs from the mouth to the anus. An adult's digestive tract is about 30 feet long.

Digestion Begins in the Mouth The process of digestion starts well before food reaches the stomach. When we see, smell, taste, or even imagine a tasty snack, our salivary glands, which are located under the tongue and near the lower jaw, begin producing saliva. This flow of saliva is set in motion by a brain reflex that's triggered when we sense food or even think about eating. In response to this sensory stimulation, the brain sends impulses through the nerves that control the salivary glands, telling them to prepare for a meal.

As the teeth tear and chop the food, saliva moistens it for easy swallowing. A digestive enzyme called amylase (pronounced: ah-meh-lace), which is found in saliva, starts to break down some of the carbohydrates (starches and sugars) in the food even before it leaves the mouth.

Swallowing, which is accomplished by muscle movements in the tongue and mouth, moves the food into the throat, or pharynx. The pharynx (pronounced: fair-inks), a passageway for food and air, is about 5 inches long. A flexible flap of tissue called the epiglottis (pronounced: ep-ih-glah-tus) reflexively closes over the windpipe when we swallow to prevent choking.

From the throat, food travels down a muscular tube in the chest called the esophagus (pronounced: ih-sah-fuh-gus). Waves of muscle contractions called peristalsis (pronounced: per-uh-stall-sus) force food down through the esophagus to the stomach. A person normally isn't aware of the movements of the esophagus, stomach, and intestine that take place as food passes through the digestive tract.

BackContinue

Food Is the Body's Fuel Source What's the first step in digesting food? Believe it or not, the digestive process starts even before you put food in your mouth. It begins when you smell something irresistible or when you see a favorite food you know will taste good. Just by smelling that homemade apple pie or thinking about how delicious that ice cream sundae is going to taste, you begin to salivate — and the digestive process kicks in, preparing for that first scrumptious bite.

If it's been a while since your last meal or if you even think about something tasty, you feel hungry. You eat until you're satisfied and then go about your business. But for the next 20 hours or so, your digestive system is doing its job as the food you ate travels through your body.

Food is the body's fuel source. The nutrients in food give the body's cells the energy and other substances they need to operate. But before food can do any of these things, it has to be digested into small pieces the body can absorb and use.

Almost all animals have a tube-type digestive system in which food enters the mouth, passes through a long tube, and exits as feces (poop) through the anus. The smooth muscle in the walls of the tube-shaped digestive organs rhythmically and efficiently moves the food through the system, where it is broken down into tiny absorbable nutrients.

During the process of absorption, nutrients that come from the food (including carbohydrates, proteins, fats, vitamins, and minerals) pass through channels in the intestinal wall and into the bloodstream. The blood works to distribute these nutrients to the rest of the body. The waste parts of food that the body can't use are passed out of the body as feces.

Continue

What Is the Digestive System and What Does It Do? Every morsel of food we eat has to be broken down into nutrients that can be absorbed by the body, which is why it takes hours to fully digest food. In humans, protein must be broken down into amino acids, starches into simple sugars, and fats into fatty acids and glycerol. The water in our food and drink is also absorbed into the bloodstream to provide the body with the fluid it needs.

The digestive system is made up of the alimentary canal and the other abdominal organs that play a part in digestion, such as the liver and pancreas. The alimentary canal (also called the digestive

tract) is the long tube of organs — including the esophagus, the stomach, and the intestines — that runs from the mouth to the anus. An adult's digestive tract is about 30 feet long. Digestion Begins in the Mouth The process of digestion starts well before food reaches the stomach. When we see, smell, taste, or even imagine a tasty snack, our salivary glands, which are located under the tongue and near the lower jaw, begin producing saliva. This flow of saliva is set in motion by a brain reflex that's triggered when we sense food or even think about eating. In response to this sensory stimulation, the brain sends impulses through the nerves that control the salivary glands, telling them to prepare for a meal.

As the teeth tear and chop the food, saliva moistens it for easy swallowing. A digestive enzyme called amylase (pronounced: ah-meh-lace), which is found in saliva, starts to break down some of the carbohydrates (starches and sugars) in the food even before it leaves the mouth.

Swallowing, which is accomplished by muscle movements in the tongue and mouth, moves the food into the throat, or pharynx. The pharynx (pronounced: fair-inks), a passageway for food and air, is about 5 inches long. A flexible flap of tissue called the epiglottis (pronounced: ep-ih-glah-tus) reflexively closes over the windpipe when we swallow to prevent choking.

From the throat, food travels down a muscular tube in the chest called the esophagus (pronounced: ih-sah-fuh-gus). Waves of muscle contractions called peristalsis (pronounced: per-uh-stall-sus) force food down through the esophagus to the stomach. A person normally isn't aware of the movements of the esophagus, stomach, and intestine that take place as food passes through the digestive tract.

BackContinue The Stomach At the end of the esophagus, a muscular ring called a sphincter (pronounced: sfink-ter) allows food to enter the stomach and then squeezes shut to keep food or fluid from flowing back up into the esophagus. The stomach muscles churn and mix the food with acids and enzymes, breaking it into much smaller, more digestible pieces. An acidic environment is needed for the digestion that takes place in the stomach. Glands in the stomach lining produce about 3 quarts of these digestive juices each day.

Most substances in the food we eat need further digestion and must travel into the intestine before being absorbed. When it's empty, an adult's stomach has a volume of one fifth of a cup, but it can expand to hold more than 8 cups of food after a large meal.

By the time food is ready to leave the stomach, it has been processed into a thick liquid called chyme (pronounced: kime). A walnut-sized muscular tube at the outlet of the stomach called the pylorus (pronounced: py-lore-us) keeps chyme in the stomach until it reaches the right consistency to pass into the small intestine. Chyme is then squirted down into the small intestine, where digestion of food continues so the body can absorb the nutrients into the bloodstream. The Small Intestine The small intestine is made up of three parts:

1.

the duodenum (pronounced: due-uh-dee-num), the C-shaped first part

2.

the jejunum (pronounced: jih-ju-num), the coiled midsection

3.

the ileum (pronounced: ih-lee-um), the final section that leads into the large intestine

The inner wall of the small intestine is covered with millions of microscopic, finger-like projections called villi (pronounced: vih-lie). The villi are the vehicles through which nutrients can be absorbed into the body.

Food Is the Body's Fuel Source What's the first step in digesting food? Believe it or not, the digestive process starts even before you put food in your mouth. It begins when you smell something irresistible or when you see a favorite food you know will taste good. Just by smelling that homemade apple pie or thinking about how delicious that ice cream sundae is going to taste, you begin to salivate — and the digestive process kicks in, preparing for that first scrumptious bite.

If it's been a while since your last meal or if you even think about something tasty, you feel hungry. You eat until you're satisfied and then go about your business. But for the next 20 hours or so, your digestive system is doing its job as the food you ate travels through your body.

Food is the body's fuel source. The nutrients in food give the body's cells the energy and other substances they need to operate. But before food can do any of these things, it has to be digested into small pieces the body can absorb and use.

Almost all animals have a tube-type digestive system in which food enters the mouth, passes through a long tube, and exits as feces (poop) through the anus. The smooth muscle in the walls of the tube-shaped digestive organs rhythmically and efficiently moves the food through the system, where it is broken down into tiny absorbable nutrients.

During the process of absorption, nutrients that come from the food (including carbohydrates, proteins, fats, vitamins, and minerals) pass through channels in the intestinal wall and into the bloodstream. The blood works to distribute these nutrients to the rest of the body. The waste parts of food that the body can't use are passed out of the body as feces.

Continue

What Is the Digestive System and What Does It Do? Every morsel of food we eat has to be broken down into nutrients that can be absorbed by the body, which is why it takes hours to fully digest food. In humans, protein must be broken down into amino acids, starches into simple sugars, and fats into fatty acids and glycerol. The water in our food and drink is also absorbed into the bloodstream to provide the body with the fluid it needs.

The digestive system is made up of the alimentary canal and the other abdominal organs that play a part in digestion, such as the liver and pancreas. The alimentary canal (also called the digestive tract) is the long tube of organs — including the esophagus, the stomach, and the intestines — that runs from the mouth to the anus. An adult's digestive tract is about 30 feet long. Digestion Begins in the Mouth

The process of digestion starts well before food reaches the stomach. When we see, smell, taste, or even imagine a tasty snack, our salivary glands, which are located under the tongue and near the lower jaw, begin producing saliva. This flow of saliva is set in motion by a brain reflex that's triggered when we sense food or even think about eating. In response to this sensory stimulation, the brain sends impulses through the nerves that control the salivary glands, telling them to prepare for a meal.

As the teeth tear and chop the food, saliva moistens it for easy swallowing. A digestive enzyme called amylase (pronounced: ah-meh-lace), which is found in saliva, starts to break down some of the carbohydrates (starches and sugars) in the food even before it leaves the mouth.

Swallowing, which is accomplished by muscle movements in the tongue and mouth, moves the food into the throat, or pharynx. The pharynx (pronounced: fair-inks), a passageway for food and air, is about 5 inches long. A flexible flap of tissue called the epiglottis (pronounced: ep-ih-glah-tus) reflexively closes over the windpipe when we swallow to prevent choking.

From the throat, food travels down a muscular tube in the chest called the esophagus (pronounced: ih-sah-fuh-gus). Waves of muscle contractions called peristalsis (pronounced: per-uh-stall-sus) force food down through the esophagus to the stomach. A person normally isn't aware of the movements of the esophagus, stomach, and intestine that take place as food passes through the digestive tract.

BackContinue The Stomach At the end of the esophagus, a muscular ring called a sphincter (pronounced: sfink-ter) allows food to enter the stomach and then squeezes shut to keep food or fluid from flowing back up into the esophagus. The stomach muscles churn and mix the food with acids and enzymes, breaking it into much smaller, more digestible pieces. An acidic environment is needed for the digestion that takes place in the stomach. Glands in the stomach lining produce about 3 quarts of these digestive juices each day.

Most substances in the food we eat need further digestion and must travel into the intestine before being absorbed. When it's empty, an adult's stomach has a volume of one fifth of a cup, but it can expand to hold more than 8 cups of food after a large meal.

By the time food is ready to leave the stomach, it has been processed into a thick liquid called chyme (pronounced: kime). A walnut-sized muscular tube at the outlet of the stomach called the pylorus

(pronounced: py-lore-us) keeps chyme in the stomach until it reaches the right consistency to pass into the small intestine. Chyme is then squirted down into the small intestine, where digestion of food continues so the body can absorb the nutrients into the bloodstream. The Small Intestine The small intestine is made up of three parts:

1.

the duodenum (pronounced: due-uh-dee-num), the C-shaped first part

2.

the jejunum (pronounced: jih-ju-num), the coiled midsection

3.

the ileum (pronounced: ih-lee-um), the final section that leads into the large intestine

The inner wall of the small intestine is covered with millions of microscopic, finger-like projections called villi (pronounced: vih-lie). The villi are the vehicles through which nutrients can be absorbed into the body.

BackContinue The Liver The liver (located under the ribcage in the right upper part of the abdomen), the gallbladder (hidden just below the liver), and the pancreas (beneath the stomach) are not part of the alimentary canal, but these organs are still important for healthy digestion.

The pancreas produces enzymes that help digest proteins, fats, and carbohydrates. It also makes a substance that neutralizes stomach acid. The liver produces bile, which helps the body absorb fat. Bile is stored in the gallbladder until it is needed. These enzymes and bile travel through special channels (called ducts) directly into the small intestine, where they help to break down food.

The liver also plays a major role in the handling and processing of nutrients. These nutrients are carried to the liver in the blood from the small intestine. The Large Intestine From the small intestine, food that has not been digested (and some water) travels to the large intestine through a valve that prevents food from returning to the small intestine. By the time food reaches the large intestine, the work of absorbing nutrients is nearly finished. The large intestine's main function is to remove water from the undigested matter and form solid waste that can be excreted. The large intestine is made up of three parts:

1.

The cecum (pronounced: see-kum) is a pouch at the beginning of the large intestine that joins the small intestine to the large intestine. This transition area allows food to travel from the small intestine to the large intestine. The appendix, a small, hollow, finger-like pouch, hangs off the cecum. Doctors believe the appendix is left over from a previous time in human evolution. It no longer appears to be useful to the digestive process.

2.

The colon extends from the cecum up the right side of the abdomen, across the upper abdomen, and then down the left side of the abdomen, finally connecting to the rectum. The colon has three parts: the ascending colon and transverse colon, which absorb water and salts, and the descending colon, which holds the resulting waste. Bacteria in the colon help to digest the remaining food products.

3.

The rectum is where feces are stored until they leave the digestive system through the anus as a bowel movement.

Things That Can Go Wrong With the Digestive System Nearly everyone has a digestive problem at one time or another. Some conditions, such as indigestion or mild diarrhea, are common; they result in mild discomfort and get better on their own or are easy to treat. Others, such as inflammatory bowel disease (IBD), can be long lasting or troublesome. A doctor who specializes in the digestive system and who can be helpful when dealing with these conditions is called a GI specialist or gastroenterologist. Conditions Affecting the Esophagus Conditions affecting the esophagus may be congenital (meaning people are born with them) or noncongenital (meaning people can develop them after birth).

Some examples include:

1.

Tracheoesophageal fistula (pronounced: tray-kee-oh-ih-saf-uh-jee-ul fish-chuh-luh) and

esophageal atresia (pronounced: ih-saf-uh-jee-ul uh-tree-zhuh) are both examples of congenital conditions. Tracheoesophageal fistula is where there is a connection between the esophagus and the trachea (windpipe) where there shouldn't be one. In babies with esophageal atresia, the esophagus comes to a dead end instead of connecting to the stomach. Both conditions are usually detected soon after a baby is born — sometimes even beforehand. They require surgery to repair.

2.

Esophagitis (pronounced: ih-saf-uh-jeye-tus) or inflammation of the esophagus, is an

example of a noncongenital condition. Esophagitis is usually caused by gastroesophageal reflux disease (GERD), a condition in which the esophageal sphincter (the tube of muscle that connects the esophagus with the stomach) allows the acidic contents of the stomach to move backward up into the

esophagus. GERD can sometimes be corrected through lifestyle changes, such as adjusting the types of things a person eats. Sometimes, though, it requires treatment with medication. Occasionally, esophagitis can be caused by infection or certain medications. Conditions Affecting the Stomach and Intestines Almost everyone has experienced diarrhea or constipation at some point in their lives. With diarrhea, muscle contractions move the contents of the intestines along too quickly and there isn't enough time for water to be absorbed before the feces are pushed out of the body. Constipation is the opposite: The contents of the large intestines do not move along fast enough and waste materials stay in the large intestine so long that too much water is removed and the feces become hard.

Other common stomach and intestinal disorders include:

1.

Celiac disease is a digestive disorder caused by the abnormal response of the immune

system to a protein called gluten, which is found in certain foods. People with celiac disease have difficulty digesting the nutrients from their food because eating things with gluten damages the lining of the intestines over time. Some of the symptoms are diarrhea, abdominal pain, and bloating. The disease can be managed by following a gluten-free diet.

2.

Irritable bowel syndrome (IBS) is a common intestinal disorder that affects the colon.

When the muscles in the colon don't work smoothly, a person can feel the abdominal cramps, bloating, constipation, and diarrhea that may be signs of IBS. There's no cure for IBS, but it can be managed by making some dietary and lifestyle changes. Occasionally, medications may be used as well.

3.

Gastritis and peptic ulcers. Under normal conditions, the stomach and duodenum are

extremely resistant to irritation by the strong acids produced in the stomach. Sometimes, though, a bacterium called Helicobacter pylori or the chronic use of certain medications weakens the protective mucous coating of the stomach and duodenum, allowing acid to get through to the sensitive lining beneath. This can irritate and inflame the lining of the stomach (a condition known as gastritis) or cause peptic ulcers, which are sores or holes that form in the lining of the stomach or the duodenum and cause pain or bleeding. Medications are usually successful in treating these conditions.

4.

Inflammatory bowel disease (IBD) is chronic inflammation of the intestines that affects

older kids, teens, and adults. There are two major types: ulcerative colitis, which usually affects just the rectum and the large intestine, and Crohn's disease, which can affect the whole gastrointestinal tract from the mouth to the anus as well as other parts of the body. They are treated with

medications, but in some cases, surgery may be necessary to remove inflamed or damaged areas of the intestine. Disorders of the Pancreas, Liver, and Gallbladder Conditions affecting the pancreas, liver, and gallbladder often affect the ability of these organs to produce enzymes and other substances that aid in digestion.

These include:

1.

Cystic fibrosis is a chronic, inherited illness where the production of abnormally thick mucus

blocks the ducts or passageways in the pancreas and prevents its digestive juices from entering the intestines, making it difficult for a person to properly digest proteins and fats. This causes important nutrients to pass out of the body unused. To help manage their digestive problems, people with cystic fibrosis can take digestive enzymes and nutritional supplements.

2.

Hepatitis is a viral infection in which the liver becomes inflamed and can lose its ability to

function. Some forms of viral hepatitis are highly contagious. Mild cases of hepatitis A can be treated at home; however, serious cases involving liver damage may require hospitalization.

3.

The gallbladder can develop gallstones and become inflamed — a condition called

cholecystitis (pronounced: ko-lee-sis-teye-tus). Although gallbladder conditions are uncommon in teens, they can occur when a teen has sickle cell anemia or is being treated with certain long-term medications.

The kinds and amounts of food a person eats and how the digestive system processes that food play key roles in maintaining good health. Eating a healthy diet is the best way to prevent common digestive problems.

Reviewed by: Steven Dowshen, MD Date reviewed: April 2007