Gastroesophageal Reflux (GERD)
What Is GERD?
Gastroesophageal reflux disease (GERD), the most common cause of heartburn (which actually has nothing to do with the heart), is the regurgitation of the contents of the stomach and duodenum (the first portion of the small intestine) into the esophagus, the muscular tube through which food travels from the mouth to the stomach. Because the esophagus lacks the protective lining of the stomach, it is easily irritated by digestive juices; the irritation causes a “burning” sensation in the chest.
The lower esophageal sphincter (LES), a circular band of muscle located at the junction of the esophagus and stomach, is usually clenched but opens when a person swallows to permit food or liquid to enter the stomach. Reflux occurs when, for a variety of possible reasons, the LES allows stomach contents to pass upward into the esophagus.
Usually reflux produces no symptoms other than occasional heartburn—but when symptoms occur often or worsen, it is considered GERD
Who Gets GERD?
GERD is extremely common and can affect anyone at any age: Heartburn affects about 7 to 10% of U.S. adults every day and up to 44% at least once a month. Symptoms of reflux are more common in individuals who are obese, smoke cigarettes, or drink alcohol.
- Heartburn (a burning sensation in the chest behind the breastbone). In rare cases, pain may radiate to the neck and arms, mimicking heart attack symptoms (see below).
- Difficulty swallowing liquids or foods.
- Regurgitation of food, usually tasting sour or bitter, when lying down or bending forward.
- Pain upon swallowing.
- Hoarseness or wheezing from regurgitation into the throat and lungs.
- Chest pain, thought to be due to an esophageal spasm set off by acid irritating the esophagus.
Note: Heartburn and heart attack have overlapping symptoms. But a heart attack is more likely to be accompanied by pain that radiates up to the jaw or out to the arm, is accompanied by sweating, nausea, dizziness, or shortness of breath, and is felt on physical exertion. If you suspect chest pain is caused by a heart attack, or if you are not sure of the cause, call 911 for emergency help.
- Weakness or inappropriate opening of the LES.
- Hormonal changes and increased abdominal pressure during pregnancy.
- Overeating and obesity. Extra weight causes extra pressure on the stomach and diaphragm and can result in reflux.
- Excessive consumption of alcohol.
- Fatty, spicy, or acidic foods and drinks; chocolate; and mints (such as spearmint and peppermint).
- Excessive consumption of caffeinated beverages, which weaken the LES pressure and also stimulates acid secretion. For uncertain reasons, decaffeinated coffee also stimulates acid secretion and can increase the severity of reflux.
- Certain medications are associated with GERD, including asthma medications, calcium channel blockers, antihistamines, non-steroidal anti-inflammatory drugs, bisphosphonate drugs, sedatives, and tricyclic antidepressants.
- Recent research has also suggested a possible link between GERD and sensitivity to gluten, a protein found in wheat, barley and rye. Individuals with celiac disease or who have an intolerance to gluten may experience GERD symptoms.
What If You Do Nothing?
Mild occasional heartburn will usually resolve itself in a matter of hours and is no cause for concern. But if you have heartburn frequently, you should see your doctor, since persistent acid reflux can lead to inflammation (esophagitis) and scarring of the esophagus, making it difficult to swallow. Chronic GERD can also lead to a precancerous condition called Barrett’s esophagus. You will probably need to adopt some lifestyle and dietary changes in combination with medications to reduce or eliminate the problem.
A patient history usually indicates the diagnosis. Frequent episodes of a burning sensation in the chest or of sour or bitter liquid or food coming back to the mouth are hallmarks of gastroesophageal reflux. Your doctor may also order one or more of the following tests to diagnose GERD:
Barium x-ray. X-rays are taken after the patient swallows barium, which clearly outlines the esophagus and stomach and can demonstrate reflux and show the extent of damage in the esophagus.
Ambulatory acid (pH tests). These tests can detect reflux and determine the severity of the condition. In the standard test, a thin tube with an acid-sensitive probe attached is inserted into the esophagus through the nose; the other end of the tube extending from the nose is attached to a recorder the patient wears around the waist or over the shoulder on a strap as he or she goes through normal everyday activities. The recorder measures the amount of acid reflux and the physician analyzes the information. A newer version of the test entails inserting a capsule that can be wirelessly monitored, so that a catheter doesn’t have to stay in place.
- Endoscopy. After sedating the patient, the doctor examines the esophagus and stomach, using a lighted tube inserted through the nose, to look for evidence of esophagitis. A camera on the tube can take pictures for further analysis and it is also possible to remove tissue samples for analysis.
GERD therapies range from lifestyle changes that can be done at home to surgery to correct the lower esophageal sphincter structure.
- Lifestyle Measures. The treatment of GERD starts with lifestyle measures, which may eliminate symptoms in some people with mild reflux. Eat smaller meals—large meals can increase pressure in the stomach and promote reflux—and avoid certain foods and beverages that trigger heartburn. These include acidic foods (tomato-based products and citrus fruits, for example), peppermint, chocolate, coffee, teas, carbonated beverage, and alcohol. Elevating the head at night by six inches can also relieve GERD symptoms.
- Antacids. For occasional heartburn, you can take an over-the-counter antacid on an as-needed basis. Antacids, which contain aluminum oxide, magnesium carbonate, or sodium bicarbonate, rapidly neutralize stomach acid and are typically taken after meals when you experience heartburn. These medications provide fast relief, but their effect is short lived.
- H2-blockers. Over-the-counter H2-blockers, such as cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR), and ranitidine (Zantac 75), have a longer effect on gastric acid than antacids. They usually need to be taken twice a day. A combination antacid/H2-blocker, Pepcid Complete, also appears to be more effective at relieving symptoms than H2-blockers or antacids alone.
- Proton pump inhibitors. Proton-pump inhibitors (PPIs) are the most potent suppressors of gastric acid and can give the esophagus a chance to heal. Two of them—omeprazole (Prilosec OTC) and lanzoprazole (Prevacid 24 HR)—are available over-the-counter. Frequent and long-term need for these drugs suggests severe reflux, so check with a doctor if you need more than occasional relief.
- Prescription medications. To treat symptoms that do not respond to self-care methods, your doctor may recommend a prescription-strength H-2 blocker or PPI. Your doctor may also prescribe a promotility agent, such as metoclopramide or bethanecol, which speeds the passage of food from the stomach to the small intestine.
- Surgery. In severe cases of GERD, surgery to strengthen the LES may be necessary. Some of the newer surgical treatments are endoscopic procedures to reduce gastroesophageal reflux, including transesophageal radiofrequency, endoscopic suturing, endoscopic gastroplasty, endoscopic injection and implantation. There is also the Linx Reflux Management System, a minimally invasive procedure in which a magnetic band is implanted to help support the lower esophageal sphincter and prevent reflux.
- Avoid overeating; instead, eat more frequent, smaller meals.
- Avoid fatty or acidic foods that trigger heartburn.
- Try not to eat within two or three hours of going to bed, and avoid napping after a meal. Also, don’t exercise immediately after eating.
- Avoid tight pants, girdles, and belts.
- Lose weight if you are overweight.
- Avoid excessive consumption of alcohol.
- Don’t smoke.
- Decrease your consumption of coffee and caffeinated beverages.
When To Call Your Doctor
Call a doctor if symptoms of heartburn persist or worsen, recur frequently despite self-treatment, or if GERD episodes wake you up at night. (If you experience severe chest pain at any time, call for an ambulance. This may signal a heart attack or other problems requiring immediate medical attention.)
Reviewed by Jenifer K. Lehrer, M.D., Department of Gastroenterology, Aria-Torresdale Hospital, Aria Health System, Philadelphia, PA. Review provided by VeriMed Healthcare Network.