Gastroesophageal reflux disease (GERD) is believed to affect approximately twenty million Americans, and is a known risk factor for esophageal cancer.1
A digestive disorder, it is caused by the return of acidic stomach juices, or food and fluids, backing up into the esophagus (the tube from the mouth to the stomach). GERD is a condition in which the lower esophageal sphincter (a muscular valve) opens for no apparent reason, or does not close properly, and stomach contents flow backward into the esophagus.
Also known as peptic esophagitis, reflux esophagitis, and chronic heartburn, GERD is a common condition that can occur even without having eaten. When acid reflux occurs, food or fluid can be tasted in the back of the mouth. The reflux action can irritate the esophagus, causing a burning sensation in the chest or throat (heartburn or acid indigestion) as well as other symptoms.
Occasional gastroesophageal reflux (GER) – also known as acid reflux or acid regurgitation – is common, and is not necessarily an indication of GERD. Persistent reflux, however, occurring more than twice a week is considered to be GERD. The disease requires medical attention as it can lead to more serious health problems.
Frequent heartburn or acid indigestion – a burning pain in the lower part of the mid-chest, behind the breastbone, and mid-abdomen – is the predominant GERD symptom in adults. The burning sensation sometimes spreads to the throat, accompanied by a sour taste in the mouth; is worsened by bending, eating, lying down, and/or stooping; is more frequent or worse at night; and is relieved by antacids.
Most children with GERD, and some adults, experience the disease without heartburn; they may have asthmatic symptoms, a dry cough, and/or trouble swallowing.
Other symptoms of GERD include,
- Chest pain, especially while lying down
- Hoarseness and/or voice changes
- Nausea and/or vomiting
- Regurgitation of food or sour liquid
- Sore throat
- Vomiting blood
Causes and Risk Factors for GERD
The cause of GERD is not clear. Even though the esophagus still functions, people with GERD have lower esophageal sphincters that tend to relax. Hiatal hernias – a condition whereby part of the stomach protrudes into the lower chest – may contribute to GERD.
Some conditions that interfere with digestion can also increase the risk of GERD:
- Connective tissue disorders such as scleroderma (an autoimmune disease that affects the skin, blood vessels, and connective tissue)
- Delayed stomach emptying (or gastroparesis, a disorder in which the stomach takes too long to empty its contents)
- Hiatal hernia
- Peptic ulcers
- Zollinger-Ellison syndrome (pancreatic tumor activity leads to excess stomach acid)
Foods commonly believed to worsen reflux symptoms:
- Caffeinated drinks
- Carbonated beverages
- Citrus fruits
- Fatty foods
- Fried foods
- Peppermint and mint flavorings
- Spicy foods
- Tomato-based foods such as chili, pizza, salsa, and spaghetti sauce
Other factors that worsen reflux symptoms:
- Certain medications including calcium channel blockers for high blood pressure, sedatives, and tranquilizers
- Cigarette smoking
- Large meals
- Lying down soon after eating
Who Gets GERD?
People of all ages, occupations, races, and social status can have GERD. It does not occur more often among family members. Research indicates that though it is often overlooked, GERD is common in infants and children, and can show up as coughing, heartburn, laryngitis, nausea, repeated regurgitation, or respiratory problems such as asthma, pneumonia, or wheezing.
Complications from GERD
Left untreated, chronic GERD can lead to serious and life-threatening health problems. The constant backwash of stomach acid reflux irritates the esophageal lining; this can result in inflammation (esophagitis), which can be damaging to the esophageal lining, and cause bleeding or ulcers. Scars from tissue damage can lead to a narrowing of the esophagus, making swallowing difficult.
Other complications from GERD include large hiatal hernias, severe pulmonary problems such as bronchitis and/or pneumonia, and GERD that cannot be controlled with medication.
Some GERD sufferers develop Barrett’s esophagus, a condition in which esophageal lining cells become abnormally colored and shaped. Over time, this condition can result in an increased risk of esophageal cancer, and eventual death.
GERD Testing and Diagnosis
When GERD symptoms fail to improve with lifestyle changes and/or medication, testing may help to pinpoint the exact problem.
Barium swallow radiograph uses X-rays, preceded by a barium solution drink, helps detect abnormalities such as ulcers, hiatal hernias, and other structural or anatomical problems of the esophagus.
The Bernstein test measures the quantity and acidity of stomach contents, reproducing heartburn symptoms in conjunction with other tests to measure esophageal function.
Continuous esophageal pH monitoring involves the insertion of a small tube into the esophagus where it will remain for twenty-four to forty-eight hours to measure, via a small computer, when and how much acid backs into the esophagus throughout the day. In combination with a food diary, the relationship between symptoms and reflux activity can determine what – if any – foods act as reflux triggers. This type of monitoring can also help determine whether respiratory symptoms are set off by reflux.
Esophageal manometry measures the pressure in the lower part of the esophagus. Abnormal sphincter pressure may indicate esophageal problems.
Stool guaiac tests for blood in the feces. An abnormal result can be an indication of esophagitis.
Upper endoscopy is performed under light sedation. The throat is sprayed to numb it, and then a thin, flexible plastic tube with a light and camera on its end (an endoscope) is inserted. The device enables abnormalities, ulceration, and/or inflammation of the esophagus to be viewed. A biopsy to remove sample esophageal tissue may be performed at the same time. The tissue is examined microscopically to detect damage caused by acid reflux, and – if infection or abnormal growths are not found – to rule out other problems.
GERD Prevention and Treatment
Recommended lifestyle adjustments:
- Avoid alcohol
- Avoid bending and/or stooping for long periods of time, especially after eating
- Avoid dietary fat, caffeine, chocolate, garlic, onion, and peppermint (they may cause lower esophageal pressure)
- Lose weight (if needed)
- Sleep with the head of the bed elevated (extra pillows are not sufficient; use wood blocks under the bedposts to raise the head of the bed six to eight inches)
- Stop smoking
- Take medications with plenty of water
- Wait three to four hours after eating before lying down
Home remedies for temporary relief:
- Apples with the skins on; or
- Graham crackers; or
- Soda crackers; or
- Starchy foods containing complex carbohydrates such as potatoes, breads, and pastas
- One glass of warm water with one half a teaspoon of baking soda (sodium bicarbonate); or
- One glass of water with cream of tartar and baking soda (one half teaspoon each, completely dissolved); or
- One cup of water with one tablespoon of apple cider at the first sign of acid reflux; or
- One cup of water with two to three undiluted tablespoons of apple cider vinegar for an acute attack
Note that long-term use of these gassy drinks may aggravate GERD symptoms as they can increase pressure and cause more acid reflux.
Medications to alleviate symptoms include,
Antacids, such as Alka-2, Alka-Seltzer, Gelusil, Maalox, Mylanta, Rolaids, Riopan, Titralac, and Tums – after meals and at bedtime – are usually the first medications recommended to relieve heartburn and other mild GERD symptoms. Antacids can have side effects such as diarrhea and/or constipation. Liquid antacids coat the esophagus and help reduce stomach acid, but an antacid can’t heal an inflamed, damaged esophagus.
Foaming agents, such as Gaviscon or Zantac, work by covering the stomach contents with foam to prevent reflux.
H2-receptor blockers such as cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR), and ranitidine (Zantac 75), lessen acid production. Available in both prescription and over-the-counter strengths, they provide short-term relief for fifty percent of those with GERD symptoms, and provide longer-lasting effects than antacids.
H2-receptor blockers take approximately thirty minutes to work, so are best taken prior to a meal that may cause heartburn. If taken at bedtime, they’re effective at minimizing reflux at night. Infrequently, they cause side effects such as bowel changes, dizziness or drowsiness, and dry mouth.
Proton pump inhibitors such as esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec, Zegerid), pantoprozole (Protonix), and rabeprazole (Aciphex) block acid production and allow time for healing. Proton pump inhibitors are more effective than H2-receptor blockers, have few side effects, and can relieve symptoms and heal damaged esophageal tissue for nearly anyone with GERD.
Prokinetics (also known as promotility agents) such as bethanechol (Urecholine) and metoclopramide (Reglan) help to tighten the lower esophageal sphincter, and assist the stomach in emptying more quickly. Metoclopramide also improves muscle action in the digestive tract. Frequently, prokinetics produce side effects such as anxiety, depression, fatigue, problems with physical movement, and sleepiness. Safer versions are in development.
Anti-reflux surgery and other procedures
While medication is generally effective, surgery is a viable option for those who cannot afford or tolerate it, or when drugs and lifestyle changes are ineffective in managing persistent GERD symptoms.
Surgery may also be recommend for those who develop certain complications such as,
- A large hiatal hernia
- Severe pulmonary problems such as bronchitis or pneumonia
- Severe esophagitis, especially with bleeding
- Recurrent narrowing of the esophagus
Nissen fundoplication is the standard surgical treatment for GERD. During surgery, the upper part of the stomach is wrapped around the lower esophageal sphincter to tighten it, prevent acid reflux, and repair hiatal hernias. Nissen fundoplication may be performed as either a standard, open operation, or using a laparoscope (more popular as it’s less invasive). Either way, the operation itself is the same, and is performed under general anesthesia.
With laparoscopic surgery, the surgeon makes three or four small incisions in the abdomen, and inserts a flexible tube with a tiny camera to look at the abdomen and pelvis. The laparoscopic procedure has the same results as the open fundoplication, but patients can leave the hospital sooner.
Most people who undergo Nissen fundoplication are relieved of GERD symptoms for a minimum of two years. Complications – though normally mild, disappear within a year – include bloating, diarrhea, and difficulty swallowing.
Less invasive procedures to correct reflux
There are several newer procedures available to GERD patients that aren’t as invasive as surgery. They generally take less time to perform, require no incisions, and enable patients to return home hours after the procedure has been done.
Various anti-reflux techniques – recommended for GERD patients with Barrett’s esophagus or hiatal hernia – are performed endoscopically. A long, flexible tube is inserted through the mouth, down into the esophagus. These include the Bard EndoCinch system, the NDO Plicator, and the Stretta system.
The EndoCinch and the NDO Plicator systems involve putting stitches in the lower esophageal sphincter to create pleats that help strengthen the muscle.2 The Stretta system uses electrodes to create tiny burns on the lower esophageal sphincter.3 When the burns heal, the scar tissue helps toughen the muscle. The long-term effects of these three procedures are unknown.4
GERD Can Be Treated…with Great Success
Left untreated, gastroesophageal reflux can lead to esophageal bleeding and ulcers, and a narrowing of the esophagus. While GERD can be debilitating and even life threatening in some cases, most people improve with simple behavioral modification and prescription medications.
For those whose symptoms are resistant to drugs and lifestyle changes, the success rate for the minimally invasive surgery is ninety to ninety-five percent for patients with typical GERD symptoms.5