Gastroesophageal reflux disease (GERD)
Basics
Gastroesophageal reflux disease (GERD) is a chronic condition in which there is a backflow (reflux) of stomach acid into the food pipe (esophagus).
GERD is a condition in which acid from the stomach repeatedly escapes upward into the esophagus, exposing the sensitive lining of the esophagus to stomach acid. The most common symptoms of GERD are heartburn (a burning sensation in the throat and chest) and regurgitation (a sensation of acid or stomach material “coming back up”).
Almost everyone occasionally experiences a reflux of acid from their stomach into their esophagus. In most people, reflux symptoms (such as heartburn) are mild and do not last long. However, for millions of people the symptoms are chronic (recurring).
GERD can cause frequent heartburn. People who suffer from GERD usually have heartburn two or more times a week, and the heartburn lasts for more than a couple of hours.
GERD is a bothersome condition. It is usually not serious; however, it can sometimes lead to more serious conditions. The repeated backflow of acid from the stomach can irritate, inflame, and eventually erode the internal lining of the esophagus. This condition is referred to as esophagitis. A serious complication of GERD, called Barrett's esophagus, may later develop in a small percentage of cases. Barrett's esophagus can increase the risk of cancer of the esophagus. Esophageal bleeding and difficulty swallowing can occur as a result of chronic GERD.
Causes
GERD can be caused by the malfunction of the lower esophageal sphincter (LES) and other problems Figure 01.
The LES is responsible for closing and opening the lower end of the esophagus and is essential for keeping food and acid in the stomach. The LES can be weakened by certain foods and drugs or by injury. When the LES is weak, it does not close completely after food enters the stomach or it doesn't stay closed. This allows acid to back up from the stomach into the esophagus Figure 01.
The diaphragm, a flat muscle that separates the lungs from the abdomen, also helps to keep contents in the stomach. When there are problems with the diaphragm, such as a hiatal hernia, GERD symptoms can occur.
Other problems that can cause GERD include defects or injuries in the lining of the esophagus, problems with peristalsis (the wave-like muscle contractions of the esophagus that move food down into the stomach), or overly acidic stomach contents.
Figure 01. The anatomy of GERD
Although researchers do not know why, about 50% of asthma patients also have GERD.
Some scientists think that the coughing and sneezing that happens with asthma changes the pressure in the chest, which may allow abnormal acid backflow from the stomach into the esophagus. In addition, certain asthmatic drugs that open up the airways may also relax the LES, allowing reflux.
Treatment for certain types of bacterial infection can trigger GERD.
Approximately 20% to 30% of patients treated for Helicobacter pylori (or H. pylori), a type of bacterial infection associated with peptic ulcers, may develop GERD. Researchers believe that H. pylori protects against GERD by lowering stomach acid. Ridding the body of H. pylori removes this protection.
Crohn's disease and other medical conditions can contribute to GERD.
Crohn's disease causes inflammation in the small intestine. It usually occurs in the lower part of the small intestine, but it can affect any part of the digestive tract, from the mouth to the anus. Crohn's disease can cause inflammation of the esophagus and may contribute to the development of GERD.
Other conditions that are associated with GERD include diabetes, scleroderma (a disease that causes the hardening of the skin), peptic ulcers (sores or inflamed areas that form in the lining of the esophagus, stomach, or small intestine), and certain forms of cancer. Pregnancy can also cause GERD.
Heredity may influence the severity of GERD.
Your genes may make you more vulnerable to Barrett's esophagus, a precancerous condition caused by severe GERD.
Symptoms
The most common symptoms of GERD are heartburn and regurgitation Table 01. These symptoms are most likely to occur 1 to 3 hours after eating.
Symptoms are most likely to occur when you bend over or lie down (especially on your back) after a heavy meal. Many people with GERD have symptoms at night that awaken them from sleep.
Symptoms of GERD in most people are mild and do not last more than a couple of hours. In some people, GERD causes severe, disruptive, and possibly life-threatening symptoms and complications Table 01.
Table 1. Symptoms of GERD
| A burning sensation in the throat and chest (heartburn) |
| A feeling of acid or stomach contents backing up into the esophagus (regurgitation) |
| Chest pain that feels like angina (heart pain): tightness, pressure, heaviness |
| Asthma (bronchospasm) |
| Trouble swallowing (dysphagia) |
| Chronic (recurring) nausea and vomiting |
| Blood in the stool (bowel movement) or in the vomit |
| Hoarseness (laryngitis) |
| Chronic cough |
| The sense that there is a lump in your throat or that you have to clear your throat all of the time |
| Frequent belching |
| Sleep apnea, which is the repeated but temporary interruption of breathing during sleep. Sleep apnea can lead to restless sleep, morning headaches, and afternoon drowsiness |
| Iron deficiency in the blood (anemia) caused by chronic blood loss from ulcers in the esophagus |
| A sour or bitter taste in the mouth |
Risk Factors
Your lifestyle and diet may increase your risk of GERD.
There are many things that can irritate your esophagus or cause increased acid reflux, which can worsen your GERD symptoms.
Medications can trigger symptoms of GERD.
A number of drugs can cause the LES to relax or function improperly or can irritate the esophagus, causing GERD symptoms. Examples of these drugs include:
To help prevent GERD symptoms caused by medications, it may help to drink at least 4 to 6 ounces of liquids when taking medicines and to take pills one at a time.
Other medical conditions, such as hiatal hernia or traumatic injury, can make GERD worse.
A muscular wall called the diaphragm separates the chest and lungs from the stomach and abdominal organs. When a portion of the stomach pushes through a weakened area of the diaphragm, the resulting condition (called a hiatal hernia) can irritate the esophagus. Trauma to the chest can damage the delicate muscles controlling LES tone. Either of these conditions can lead to symptoms of GERD.
Diagnosis
Gastroesophageal reflux disease (GERD) is a chronic condition in which there is a backflow (reflux) of stomach acid into the food pipe (esophagus).
GERD is a condition in which acid from the stomach repeatedly escapes upward into the esophagus, exposing the sensitive lining of the esophagus to stomach acid. The most common symptoms of GERD are heartburn (a burning sensation in the throat and chest) and regurgitation (a sensation of acid or stomach material “coming back up”).
Almost everyone occasionally experiences a reflux of acid from their stomach into their esophagus. In most people, reflux symptoms (such as heartburn) are mild and do not last long. However, for millions of people the symptoms are chronic (recurring).
GERD can cause frequent heartburn. People who suffer from GERD usually have heartburn two or more times a week, and the heartburn lasts for more than a couple of hours.
GERD is a bothersome condition. It is usually not serious; however, it can sometimes lead to more serious conditions. The repeated backflow of acid from the stomach can irritate, inflame, and eventually erode the internal lining of the esophagus. This condition is referred to as esophagitis. A serious complication of GERD, called Barrett's esophagus, may later develop in a small percentage of cases. Barrett's esophagus can increase the risk of cancer of the esophagus. Esophageal bleeding and difficulty swallowing can occur as a result of chronic GERD.
GERD can be caused by the malfunction of the lower esophageal sphincter (LES) and other problems Figure 01.
The LES is responsible for closing and opening the lower end of the esophagus and is essential for keeping food and acid in the stomach. The LES can be weakened by certain foods and drugs or by injury. When the LES is weak, it does not close completely after food enters the stomach or it doesn't stay closed. This allows acid to back up from the stomach into the esophagus Figure 01.
The diaphragm, a flat muscle that separates the lungs from the abdomen, also helps to keep contents in the stomach. When there are problems with the diaphragm, such as a hiatal hernia, GERD symptoms can occur.
Other problems that can cause GERD include defects or injuries in the lining of the esophagus, problems with peristalsis (the wave-like muscle contractions of the esophagus that move food down into the stomach), or overly acidic stomach contents.Figure 01. The anatomy of GERD
Although researchers do not know why, about 50% of asthma patients also have GERD.
Some scientists think that the coughing and sneezing that happens with asthma changes the pressure in the chest, which may allow abnormal acid backflow from the stomach into the esophagus. In addition, certain asthmatic drugs that open up the airways may also relax the LES, allowing reflux.
Treatment for certain types of bacterial infection can trigger GERD.
Approximately 20% to 30% of patients treated for Helicobacter pylori (or H. pylori), a type of bacterial infection associated with peptic ulcers, may develop GERD. Researchers believe that H. pylori protects against GERD by lowering stomach acid. Ridding the body of H. pylori removes this protection.
Crohn's disease and other medical conditions can contribute to GERD.
Crohn's disease causes inflammation in the small intestine. It usually occurs in the lower part of the small intestine, but it can affect any part of the digestive tract, from the mouth to the anus. Crohn's disease can cause inflammation of the esophagus and may contribute to the development of GERD.
Other conditions that are associated with GERD include diabetes, scleroderma (a disease that causes the hardening of the skin), peptic ulcers (sores or inflamed areas that form in the lining of the esophagus, stomach, or small intestine), and certain forms of cancer. Pregnancy can also cause GERD.
Heredity may influence the severity of GERD.
Your genes may make you more vulnerable to Barrett's esophagus, a precancerous condition caused by severe GERD.
The most common symptoms of GERD are heartburn and regurgitation Table 01. These symptoms are most likely to occur 1 to 3 hours after eating.
Symptoms are most likely to occur when you bend over or lie down (especially on your back) after a heavy meal. Many people with GERD have symptoms at night that awaken them from sleep.
Symptoms of GERD in most people are mild and do not last more than a couple of hours. In some people, GERD causes severe, disruptive, and possibly life-threatening symptoms and complications Table 01.
Table 1. Symptoms of GERD
| A burning sensation in the throat and chest (heartburn) |
| A feeling of acid or stomach contents backing up into the esophagus (regurgitation) |
| Chest pain that feels like angina (heart pain): tightness, pressure, heaviness |
| Asthma (bronchospasm) |
| Trouble swallowing (dysphagia) |
| Chronic (recurring) nausea and vomiting |
| Blood in the stool (bowel movement) or in the vomit |
| Hoarseness (laryngitis) |
| Chronic cough |
| The sense that there is a lump in your throat or that you have to clear your throat all of the time |
| Frequent belching |
| Sleep apnea, which is the repeated but temporary interruption of breathing during sleep. Sleep apnea can lead to restless sleep, morning headaches, and afternoon drowsiness |
| Iron deficiency in the blood (anemia) caused by chronic blood loss from ulcers in the esophagus |
| A sour or bitter taste in the mouth |
Your lifestyle and diet may increase your risk of GERD.
There are many things that can irritate your esophagus or cause increased acid reflux, which can worsen your GERD symptoms.
Medications can trigger symptoms of GERD.
A number of drugs can cause the LES to relax or function improperly or can irritate the esophagus, causing GERD symptoms. Examples of these drugs include:
To help prevent GERD symptoms caused by medications, it may help to drink at least 4 to 6 ounces of liquids when taking medicines and to take pills one at a time.
Other medical conditions, such as hiatal hernia or traumatic injury, can make GERD worse.
A muscular wall called the diaphragm separates the chest and lungs from the stomach and abdominal organs. When a portion of the stomach pushes through a weakened area of the diaphragm, the resulting condition (called a hiatal hernia) can irritate the esophagus. Trauma to the chest can damage the delicate muscles controlling LES tone. Either of these conditions can lead to symptoms of GERD.
The way that your clinician will diagnose you depends on your symptoms and how you respond to treatment.
If both heartburn and acid regurgitation are present and antacids seem to help, GERD can be diagnosed by your symptoms alone. If you have chest pain, antacids do not help you, or you have unusual symptoms such as bleeding or difficulty swallowing, your clinician may need to run tests to determine the cause of your symptoms.
Testing can help rule out other conditions that share the symptoms of GERD. These include infections and chemical esophagitis (irritation of the esophagus after exposure to certain chemicals or medications). The radiation that you might receive if you have cancer in the neck, chest, or head often causes injury and inflammation in the esophagus (esophagitis). Crohn's disease of the esophagus, angina, tumors, and ulcers are some other conditions that may feel like GERD. Your clinician may need to run tests to rule out these conditions before you are diagnosed with GERD.
There are several different kinds of tests that are used to check for GERD Table 02.
Testing to diagnose GERD is not always necessary. For symptoms that can be serious or that are hard to relieve, your clinician may need to perform certain tests Table 02.
Table 2. Testing That May Be Done to Diagnose or Rule Out GERD
| Name of test | What it is | How it's done |
|---|---|---|
| Barium swallow | A type of x-ray used to identify severe inflammation or structural abnormalities of the esophagus. | The patient drinks a barium-containing solution. The barium will show up on x-ray, allowing the clinician to spot problem areas in the esophagus. |
| Endoscopy | A procedure in which a scope is inserted through the mouth into the esophagus, stomach, and possibly part of the bowel. Endoscopy is more accurate than a barium swallow in diagnosing GERD, but it is also more expensive and more difficult. | A local anesthetic is sprayed into the throat and an endoscope (a thin, flexible plastic tube) is then inserted into the mouth and down the esophagus. A tiny camera in the endoscope shows the surface of the esophagus. Visible damage confirms a diagnosis of GERD. The absence of visible damage, however, does not rule out GERD. Occasionally a small section of tissue is removed for testing during an endoscopy (this is called a biopsy). |
| pH monitoring | A probe measures the amount of acid backing up in the esophagus and the pattern of its occurrence throughout a 24-hour period. This test is useful for determining if respiratory symptoms, such as coughing or wheezing, are related to reflux in patients with unexplained asthma. | A small tube is placed down through the nose and into the esophagus, where it stays for 24 hours while the patient goes about his or her normal day. Because pH monitoring measures only acidic content, it cannot determine if other damaging digestive agents (such as bile or pancreatic enzymes) are backing up into the esophagus. |
| Esophageal manometry | This test helps detect problems with movement of the esophagus and functioning of the lower esophageal sphincter by measuring pressures in the esophagus. | Special tubing is passed through the nose or mouth and into the esophagus. Pressure readings are taken. |
Prevention and Screening
Treatment
Blood in your stool or vomit can be serious and requires medical attention.
Go to the emergency room if:
Notify your doctor if you are having difficulty swallowing food or if you have lost weight without trying.
Unusual pain when swallowing food or having difficulty getting food to go down into your stomach are symptoms that require medical attention. A clinician should always evaluate significant, unexplained weight loss.
There are a number of simple lifestyle changes you can adopt to avoid or reduce symptoms of GERD Figure 02.
Taking these simple steps can alleviate some symptoms of GERD:
Figure 02. How to elevate the head of your bed
If lifestyle changes do not work for you, your clinician may recommend certain medications. It is best for you to talk to your clinician about possible medications to treat GERd.
Surgery may be a reasonable treatment option in patients with severe and long-lasting GERD that does not respond to medication or lifestyle changes.
Surgery may completely stop regurgitation. Compared with long-term drug treatment, which does not cure patients and has unknown long-term side effects, surgery is considered the superior therapy for patients with chronic, severe GERD.
Heartburn is a frequent complaint in pregnant women.
More than 50% of pregnant women first experience heartburn in their first trimester, while others will not have heartburn until their second or third trimesters. If you had trouble with GERD symptoms in your first pregnancy, GERD will likely happen again in your next pregnancy. Your clinician will recommend that you make the same lifestyle changes as other patients. Eat multiple small meals instead of three large ones, do not lie down until 2-3 hours after meals, and raise the head of your bed at night. If you wish to take medication for your GERD, speak with your clinician first.
Infants and children can develop GERD.
In infants, reflux symptoms usually resolve by 18 months of age. For children with severe symptoms (apnea, choking, persistent vomiting), surgery may be necessary. Children with Down syndrome, mental retardation, cerebral palsy, or a repaired tracheoesophageal fistula (an abnormality of the esophagus that is present at birth) are at higher risk for developing GERD.
Symptoms experienced by the elderly may be deceptively mild.
There are several factors that make the elderly at risk for GERD and its complications:
The majority of patients with GERD respond well to lifestyle changes and drug therapy.
It is important to continue to take your medication as prescribed and adhere to recommended lifestyle changes. When treatment is stopped, symptoms of GERD often return quickly.
GERD may cause esophageal complications.
Some conditions that may result due to chronic acid reflux into the esophagus include:
Approximately 10% of patients with GERD will eventually develop Barrett's esophagus, a precancerous condition.
In Barrett's esophagus, cellular changes occur that can increase the risk of cancer in the inner lining of the esophagus. The condition is caused by chronic, severe exposure to acid and bile reflux. Patients who develop GERD at an early age and whose symptoms last longer than average are at a higher risk for developing Barrett's esophagus.
Although cancer due to Barrett's esophagus is one of the most rapidly increasing types of cancer in North America, it is rare in comparison to other forms of cancer. Patients with Barrett's esophagus must be monitored periodically with endoscopy and biopsy in order to detect cancer early.
The kind of follow-up treatment you receive will depend on your specific needs.
If you have frequent symptoms that are serious, you will require more rigorous follow-up. If you have Barrett's esophagus you need frequent endoscopy and tissue biopsies to check for abnormal cell growth and precancerous cells.