Marks (2009) said that there are actually certain conditions vulnerable to having GERD. He said that one example is the situation of pregnant women who, apparently, have elevated hormone levels which may cause a reflux, not to mention the growing fetus that increases pressure in the abdomen. Pathophysiology According to Fisichella (2008), there are several “physiological and anatomical factors” that prevent the reflux of gastric juice from the stomach into the esophagus. Some of these reportedly include:

• The lower esophageal sphincter (LES) should be the average length while there should be a standard number of set relaxations in the absence of swallowing. • The gastroesophageal junction should always be positioned in the abdomen so that the diaphragmatic crura can help LES and in turn function as an extrinsic sphincter. However, having a hiatal hernia will definitely disturb the synergistic action and might cause even more reflux. • Esophageal clearance must be able to counteract the acid secreted through the LES.

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(On the other hand, mechanical clearance can be achieved with esophageal peristalsis while chemical clearance with saliva. ) • The stomach must be emptied properly, without the use of artificial processes. Meanwhile, Fisichella (2008) said that abnormal GERD is caused by the abnormalities of one or more of the following body defense mechanisms: • A functional (frequent transient LES relaxation) or mechanical (hypotensive LES) problem of the LES is the most common cause of GERD.

• Specific foods, medications, or hormones which can decrease the pressure of the LES. • Obesity – a condition wherein a person’s extra body fat accumulates to the point when a person’s health may be compromised. Symptoms and Effects According to Fisichella (2008), GERD can cause typical (esophageal) symptoms or atypical (extraesophageal) symptoms. But she did say that diagnosis of GERD based on the typical symptoms is accurate in only 70 percent of patients. • Typical symptoms include the following:

o Heartburn – the most common typical symptom of GERD – is a feeling of burning or discomfort behind the breastbone that usually happens after one eats, lies down, or bends over o Regurgitation – a natural arrival of gastric and/or esophageal contents into the pharynx. It supposedly can arouse respiratory problems if the gastric contents spill into the tracheobronchial tree (the structure from the trachea, bronchi, and bronchioles that forms the path to supply air to the lungs)

o Dysphagia – it usually occurs in about one third of patients because of an involuntary problem, patients with it supposedly experience a feeling like food is stuck behind the breastbone • Atypical symptoms include the following: o Coughing and/or wheezing – respiratory symptoms resulting from the target of gastric contents to reach the tracheobronchial tree or the vagal reflex arc (which controls the pulse), effectively the tightening of the airway o Hoarseness – results from pain of the vocal cords caused by the gastric refluxate and is usually experienced by patients during the morning

o Reflux – the most common cause of chest pain that is not caused by the heart but actually accounts for approximately 50 percent of GERD cases Frequency Fisichella (2008) said that in the United States, of the population with heartburn, 20 to 40 percent have GERD. And since many try to control the effects of some diseases by trying different types of medication, some of these cases still remain unrecorded. She did say, however, that both men and women, regardless of age, are equally susceptible to GERD.

But its presence, she said, increases in people older than 40 years. Proton Pump Inhibitors (PPI) PPIs are a group of drugs that is meant for well-defined and long-term reduction of gastric acid production. Today, they are the most effective inhibitors of acid secretion available, allowing them to be among the most widely-selling drugs in the world. According to Marks (2008), PPIs reduce the production of acid by jamming the enzyme in the wall of the stomach that produces acid.

In turn, the reduction of acid prevents ulcers and allows any ulcers that exist in the esophagus, stomach, and duodenum to heal. PPIs approved in the United States Among the available and approved PPI in the US are omeprazole (Prilosec),lansoprazole (Prevacid), rabeprazole (Aciphex), pantoprazole (Protonix), esomeprazole (Nexium), and Zegarid, a rapid release form of omeprazole. (Marks, 2008) Hayden (2006) said that these medications are available as “time-release capsules” that are usually taken orally once a day – some of which are given intravenously (IV) in the hospital.