Gastroesophageal Reflux Disease (GERD)

Gastroesophageal reflux disease, or GERD, develops when abnormal relaxation of the muscle at the bottom of the esophagus allows the stomach contents to flow back into the esophagus (reflux). The presence of acid in the esophagus causes irritation, inflammation, and erosion of the esophageal lining. GERD is sometimes called acid reflux disease.

The digestive process begins with chewing and the mechanical breaking down of food into particles. Then chemical digestion begins with the salivary glands secreting digestive enzymes into the saliva. Hydrogen carbonate, also in the saliva, controls the pH (percentage hydrogen) of the stomach contents, keeping the mixture slightly alkaline to help the digestive enzymes work effectively. Protein digestion follows, with the introduction of hydrochloric acid and pepsin into the mix. Meanwhile, cells in the stomach lining secrete a thick layer of mucus to protect the stomach lining from being damaged by stomach acid. In people with GERD, however, the cells in the esophageal lining (mucosa) do not secrete mucus, and stomach acid that passes back into the esophagus irritates cells lining the esophagus, eventually causing inflammation and, in some people, erosion of esophageal mucosa. GERD symptoms are felt as a burning sensation and pain behind the breastbone, usually described as heartburn. GERD is typically diagnosed when these symptoms are experienced at least twice a week, indicating that stomach acid is coming into contact with the esophagus on a regular basis.

Acid reflux or heartburn is extremely common, affecting more than half of all adults and 25% of pregnant women, although not everyone who has heartburn has GERD, and not everyone who has GERD has heartburn. Between 18% and 28% of Americans are diagnosed with GERD and treated clinically. The precise number of people with GERD is difficult to determine, because many people never see a doctor and self-treat symptoms with over-the-counter medications.

People of any race or age may develop GERD, including infants and children. The disease is most common among people over age 50, pregnant women, and people who are overweight or obese. The condition is often overlooked in infants and children and is likely to be underdiagnosed in this group.

GERD is caused by a weakened LES that opens inappropriately and allows stomach acid to come in contact with cells lining the esophagus. The most common cause for LES weakening is hiatal hernia, which is the protrusion of part of the stomach through a small opening in the muscular membrane that lies between the chest cavity and the abdomen (diaphragm). Hiatal hernias occur commonly in adults over age 50 and usually do not cause health problems or require treatment. However, the diaphragm normally supports the LES and this support is weakened when hiatal hernia occurs, causing the LES to close less tightly. Some clinicians believe that hiatal hernia complicates GERD rather than causes it. Other causes of a weakened LES are obesity, smoking, excess alcohol consumption, pregnancy, and certain acid-producing foods and medications (e.g., blood pressure and heart medications, muscle relaxants, and anxiety medications). Lying down soon after a meal, eating large meals shortly before bedtime, and poor posture may also contribute to development of GERD.

Consuming foods that require more acid in the stomach during digestion also increases the likelihood of developing GERD. Foods that have been suggested to trigger GERD include:

The most common symptom of GERD is heartburn. Heartburn is a sharp pain in the center of the chest that can spread to the neck and last for up to two hours. The pain can be substantial enough to be confused with angina or a heart attack. If there is any question about whether the pain is caused by a heart attack, the individual should seek medical attention immediately. Heartburn pain does not get worse with physical activity, but often worsens when bending forward or lying down. Heartburn is extremely common. Almost everyone experiences it at some time, usually after eating an unusually large or spicy meal.

Some individuals with GERD may regurgitate or involuntarily bring up stomach contents into the mouth. This causes a bitter taste and may erode tooth enamel if it occurs frequently. Other less typical symptoms are wheezing, a persistent dry cough, shortness of breath, and increased incidence of asthma. GERD may also cause hoarseness, which is usually noticed in the morning on rising. These symptoms are caused partly by irritation or congestion in the esophagus, and also when stomach contents approach or enter the airways.

Some people have difficulty swallowing or feel as if the food they have eaten is stuck behind their breastbone. This symptom may be caused by a narrowing of the esophagus where it enters the stomach, which develops as a result of erosion and scarring of esophageal tissue.

The most common symptoms of GERD in infants and children are repeated nonprojectile vomiting (spitting up), persistent coughing, and wheezing.

GERD is often diagnosed tentatively when a patient reports having heartburn twice or more a week on a regular basis. The physician will typically suggest lifestyle changes, and if there is no improvement will order more extensive tests. Antacid medications may be prescribed, and if these relieve symptoms, it may be considered confirmation of acid reflux or GERD.

A barium esophagram, also called a barium swallow, may be done to visualize the esophagus and LES and evaluate structural aspects. It involves x-raying the esophagus, LES, stomach, and beginning of the small intestine. No other imaging exams such as ultrasound, magnetic resonance, or computed tomagraphy are used to diagnose GERD.

An upper endoscopy may be performed in a doctor's office or outpatient clinic under light sedation. The diagnostic procedure (esophagoscopy) allows the physician to see the lining of the esophagus and stomach on a monitor. The procedure involves passing a flexible, lighted fiber-optic instrument called an endoscope down through the mouth and throat. A tiny camera at the end of the endoscope allows the doctor to see any inflammation or damage in the esophageal lining. The doctor may also remove small tissue samples (biopsy) from the esophageal lining that will later be stained and examined microscopically for abnormal cells.

Occasionally 24-hour esophageal pH monitoring will be performed to confirm GERD or identify the cause of symptoms. The pH scale measures acidity and can determine how much acid is entering the esophagus from the stomach. In this outpatient procedure, a small probe attached to flexible tubing is inserted through one nostril and down into the esophagus. It is connected to a monitor worn on the patient's belt or over the shoulder. Rather than leaving the tube in the patient's nose, a disposable capsule can be placed in the esophagus to transmit information wirelessly to the monitor. The monitor will show how much stomach acid backs up into the esophagus. Monitoring is usually continuous for 24 to 48 hours.

GERD is categorized according to the degree of damage to the esophagus:

Lifestyle changes are the easiest and least expensive approach to treating GERD in its earliest stages. Recommended lifestyle changes include:

When lifestyle changes are not enough to relieve symptoms within a few weeks, over-the-counter acid-suppressing medications may be recommended. Antacids, such as Alka-Seltzer, Maalox, Rolaids, or Tums, reduce the acidity of liquid already in the stomach. Many antacids contain aluminum and magnesium, and should not be taken regularly for long periods because these minerals may disrupt the chemical balance in the body. Antacids may also interact with some medications, so it is important to discuss any over-the-counter medications used for heartburn relief.

Acid-suppressive pharmaceutical drugs known as H2 blockers help reduce the production of acid in the stomach. H2 blockers available without a prescription include cimetidine (Tagamet), ranitidine (Zantac), and nizatidine (Axid). Some of these are also available in higher strengths with a doctor's prescription. H2 blockers are most effective when taken about an hour before meals. They do not affect acid already in the stomach.

Proton pump inhibitors use a different chemical mechanism to block the stomach's acid production. They are reported to be more effective than H2 blockers and are used when H2 blockers fail. Some are available in over-the-counter strength, whereas others require a prescription. Common proton pump inhibitors are omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), and esomeprazole (Nexium); and the combination drugs omeprazole/sodium bicarbonate (Zegerid), and pantoprazole (Protonix).

Although most individuals diagnosed with GERD can be treated effectively with acid-reducing medications, erosive esophageal reflux can be a more serious condition requiring surgery. Surgery is the solution when all other treatments have failed and symptoms remain. The most common surgery to correct GERD is called fundoplication, which is performed as a laparoscopic procedure rather than as open surgery. In laparoscopic surgeries, a small incision is made in the abdomen and an instrument called an endoscope is inserted. The endoscope is a flexible, lighted fiberoptic instrument with a tiny camera attached that sends images of the surgical site to a monitor. The images guide the surgeon as other inserted instruments are used to wrap the top of the stomach (the fundus) around the bottom of the esophagus, forming a cuff. The cuff provides additional support for the LES and is effective in about 92% of cases, at least initially. Long-term success rates are variable. Laparoscopic fundoplication usually requires a hospital stay of one to three days and full recovery takes about two to three weeks.

Although acid-reducing medications are used to treat GERD effectively, diet is also important because foods affect the amount of acid produced. Hydrocholoric acid is produced to digest protein, so high-protein foods require the stomach to produce more acid. A high-carbohydrate diet has been suggested to alleviate acid reflux. Foods and beverages that have been reported to trigger symptoms should be avoided or consumed in moderation. A low carbohydrate diet that is high in nutrients but low in fats and sugars has been shown to help reduce reflux symptoms, especially if it includes a high intake of vegetables such as broccoli, green beans, asparagus, and dark leafy greens (e.g., kale, collards, spinach, and chard).

GERD is a chronic disease and often progressive. About 80% of people with GERD will get relief from lifestyle changes and medications, although relapses are common. H2 blockers treat only about half of people with grade 1 or grade 2 GERD effectively, whereas proton pump inhibitors are effective in reducing symptoms and healing the esophageal lining in nearly all patients who take them. When H2 blockers are not effective, treatment with proton pump inhibitors may provide relief. Among the 20% of individuals for whom no medications are effective, 92% are reported to improve with fundoplication surgery.

The most serious complication of GERD is Barrett's esophagus, a disease in which normal cells lining the esophagus are replaced with abnormal cells. About 30% of people with Barrett's esophagus eventually develop esophageal cancer.

Other long-term complications of GERD include narrowing or scarring of the base of the esophagus, a condition called peptic stricture. Narrowing of the lower esophagus can cause difficulty swallowing and sensations of blockage in the chest. In addition, people with GERD are sometimes more prone to ear infections, laryngitis, and progressively worse asthma.

Proton pump inhibitors are known to interact with common drugs such as the antiplatelet drug warfarin (Coumadin), benzodiazepine anti-anxiety drugs such as diazepam (Valium), and disulfiram (Antabuse), used to treat alcohol abuse. Some concerns have been raised about delayed-release capsules having an effect on bone density, and in the United Kingdom bone scans are carried out on long-term users. Ongoing studies continue to investigate side effects and drug interactions associated with GERD treatments.

Prevention of GERD is dependent upon lifestyle choices, including maintaining normal weight, not smoking, minimizing alcohol consumption, and following a low-fat, low-sugar diet that is high in essential nutrients. This means minimizing protein intake and consuming more vegetables such as broccoli, green beans, asparagus, and dark leafy greens (e.g., kale, collards, spinach, and chard).

See also Digestive diseases ; Dyspepsia ; Heartburn ; Magnesium ; Ulcers .