Overview

Gastroesophageal reflux disease (GERD)is the abnormal backflow of stomach acid up into the esophagus, the long, muscular tube that connects the back of the mouth to the stomach. The muscle at the border of the esophagus and stomach, called a sphincter, works as a barrier that is normally closed to prevent the contents of the stomach from washing up into the esophagus. It should open only when you swallow.

Acid reflux occurs when this sphincter, or “gate,” opens at the wrong time or is too weak, allowing stomach contents to leak back (or reflux) into the esophagus.

Gastroesophageal refers to the stomach and esophagus. Reflux means to flow back or return. Therefore, gastroesophageal reflux is the return of the stomach’s contents back up into the esophagus.

In normal digestion, the lower esophageal sphincter (LES) opens to allow food to pass into the stomach and closes to prevent food and acidic stomach juices from flowing back into the esophagus. Gastroesophageal reflux occurs when the LES is weak or relaxes inappropriately, allowing the stomach’s contents to flow up into the esophagus.

The severity of GERD depends on LES dysfunction as well as the type and amount of fluid brought up from the stomach and the neutralizing effect of saliva.

Some doctors believe a hiatal hernia may weaken the LES and increase the risk for gastroesophageal reflux. Hiatal hernia occurs when the upper part of the stomach moves up into the chest through a small opening in the diaphragm (diaphragmatic hiatus). The diaphragm is the muscle separating the abdomen from the chest. Recent studies show that the opening in the diaphragm helps support the lower end of the esophagus. Many people with a hiatal hernia will not have problems with heartburn or reflux. But having a hiatal hernia may allow stomach contents to reflux more easily into the esophagus. Coughing, vomiting, straining, or sudden physical exertion can cause increased pressure in the abdomen resulting in hiatal hernia. Obesity and pregnancy also contribute to this condition. Many otherwise healthy people age 50 and over have a small hiatal hernia. Although considered a condition of middle age, hiatal hernias affect people of all ages.

Hiatal hernias usually do not require treatment. However, treatment may be necessary if the hernia is in danger of becoming strangulated (twisted in a way that cuts off blood supply) or is complicated by severe GERD or esophagitis (inflammation of the esophagus). The doctor may perform surgery to reduce the size of the hernia or to prevent strangulation.

How Common Is Heartburn and GERD?

More than 60 million American adults experience heartburn at least once a month, and more than 15 million adults suffer daily from heartburn. Many pregnant women experience daily heartburn. Recent studies show that GERD in infants and children is more common than previously recognized and may produce recurrent vomiting, coughing, and other respiratory problems.

What Is the Treatment for GERD?

Doctors recommend lifestyle and dietary changes for most people needing treatment for GERD. Treatment aims at decreasing the amount of reflux or reducing damage to the lining of the esophagus from refluxed materials. Avoiding foods and beverages that can weaken the LES is often recommended. These foods include chocolate, peppermint, fatty foods, coffee, and alcoholic beverages. Foods and beverages that can irritate a damaged esophageal lining, such as citrus fruits and juices, tomato products, and pepper, should also be avoided if they cause symptoms.

Decreasing the size of portions at mealtime may also help control symptoms. Eating meals at least 2 to 3 hours before bedtime may lessen reflux by allowing the acid in the stomach to decrease and the stomach to empty partially. In addition, being overweight often worsens symptoms. Many overweight people find relief when they lose weight. Cigarette smoking weakens the LES. Stopping smoking is important to reduce GERD symptoms.

Elevating the head of the bed on 6-inch blocks or sleeping on a specially designed wedge reduces heartburn by allowing gravity to minimize reflux of stomach contents into the esophagus. Do not use pillows to prop yourself up; that only increases pressure on the stomach. Along with lifestyle and diet changes, your doctor may recommend over-the-counter or prescription treatments.

Antacids can help neutralize acid in the esophagus and stomach and stop heartburn. Many people find that nonprescription antacids provide temporary or partial relief. An antacid combined with a foaming agent helps some people. These compounds are believed to form a foam barrier on top of the stomach that prevents acid reflux from occurring. Long-term use of antacids, however, can result in side effects, including diarrhea, altered calcium metabolism (a change in the way the body breaks down and uses calcium), and buildup of magnesium in the body. Too much magnesium can be serious for patients with kidney disease. If antacids are needed for more than 2 weeks, a doctor should be consulted.

For chronic reflux and heartburn, the doctor may recommend medications to reduce acid in the stomach. These medicines include H2 blockers, which inhibit acid secretion in the stomach. H2 blockers include: cimetidine(Tagamet), famotidine (Pepcid), nizatidine (Axid), and ranitidine (Zantac).

What If Heartburn or GERD Symptoms Persist?

Endoscopy is an important procedure for individuals with chronic GERD. By placing a small lighted tube with a tiny video camera on the end (endoscope) into the esophagus, the doctor may see inflammation or irritation of the tissue lining the esophagus (esophagitis). If the findings of the endoscopy are abnormal or questionable, biopsy(removing a small sample of tissue) from the lining of the esophagus may be helpful. An upper GI series may be performed during the early phase of testing. This test is a special X-ray that shows the esophagus, stomach, and duodenum (the upper part of the small intestine). While an upper GI series provides limited information about possible reflux, it is used to help rule out other diagnoses, such as peptic ulcers.

Esophageal manometric and impedance studies — pressure measurements of the esophagus — occasionally help identify low pressure in the LES or abnormalities in esophageal muscle contraction. For patients in whom diagnosis is difficult, doctors may measure the acid levels inside the esophagus through pH testing. Testing pH monitors the acidity level of the esophagus and symptoms during meals, activity, and sleep. Newer techniques of long-term pH monitoring are improving diagnostic capability in this area.

People with severe, chronic esophageal reflux or with symptoms not relieved by the treatments described above may need more complete diagnostic evaluation. Doctors use a variety of tests and procedures to examine a patient with chronic heartburn.

Does GERD Require Surgery?

A small number of people with GERD may need surgery because of severe reflux and poor response to medical treatment. However, surgery should not be considered until all other measures have been tried. Fundoplication is a surgical procedure that increases pressure in the lower esophagus. Endoscopic procedures that involve making the LES function better or using electrodes to promote scarring of the LES are newer options in treatment.

What Are the Complications of Long-Term GERD?

Sometimes GERD results in serious complications. Esophagitis can occur as a result of too much stomach acid in the esophagus. Esophagitis may cause esophageal bleeding or ulcers. In addition, a narrowing or stricture of the esophagus may occur from chronic scarring. Some people develop a condition known as Barrett’s esophagus. This condition can increase the risk of esophageal cancer.

What Other Factors Contribute to GERD?

Dietary and lifestyle choices may contribute to GERD. Certain foods and beverages, including chocolate, peppermint, fried or fatty foods, coffee, or alcoholicbeverages, may trigger reflux and heartburn. Studies show that cigarette smoking relaxes the LES. Obesity and pregnancy can also play a role in GERD symptoms.

Symptoms of Gastroesophageal Reflux Disease

Heartburn

The most common symptom people with GERD suffer is heartburn. Heartburn is pain or discomfort, sometimes described as burning, which rises from the stomach up into the chest. The discomfort often occurs after meals but can happen any time during the day, even waking you at night. Almost everyone experiences heartburn at some time, but frequent or persistent heartburn more than twice a week over several months is the hallmark of GERD.

Approximately 10 to 20 percent of the U.S. population has some symptoms of GERD every day.

Other Symptoms

In addition to heartburn, other symptoms of GERD include:

• a sour or bitter liquid coming into the mouth (also known as “regurgitation”)
• difficulty swallowing or painful swallowing, especially with dry bread or poorly chewed food
• chest pain, which may be confused with the pain of a heart attack
• hoarseness, sore throat, feeling of fullness in the throat, choking at night and altered voice
• lung problems, which might include wheezing, frequent pneumonia, damaged airways or chronic asthma

Symptoms of Infants with Gastroesophageal Reflux Disease

Infants with GERD may fail to gain weight, may develop more slowly, may have recurrent respiratory problems, or may just be irritable.

Causes of Gastroesophageal Reflux Disease

Altered or Abnormal Esophageal Mechanisms

To understand the causes of GERD, it helps to understand the normal protective mechanisms involved in preventing acid from refluxing into the esophagus. The lower esophageal sphincter, the muscle at the border of the esophagus and stomach that works as a gate and prevents reflux, may open frequently or have a low pressure. Either can lead to reflux.

A healthy esophagus should also be able to “clear” the acid through regular contractions, called “peristalsis,” and by neutralizing the acid with saliva. Additionally, the stomach must empty properly. If any of these mechanisms becomes altered or abnormal, acid can wash up into the esophagus and cause heartburn or other symptoms.

External Factors

Anything that increases the pressure on the stomach can contribute to GERD by overcoming the lower esophageal sphincter. However, certain other factors can also trigger GERD. For example, smoking causes the lower esophageal sphincter to relax, allowing stomach contents to wash back up into the esophagus and trigger GERD symptoms. Drinking alcohol and taking certain medications can also trigger symptoms.

Pregnancy

Pregnant women are particularly vulnerable to acid reflux. The symptoms typically get worse in the third trimester when the enlarged uterus pushes up on the stomach.Hormones during pregnancy also cause the digestive system to work more slowly and make the lower esophageal sphincter relax more often. Symptoms typically disappear after childbirth. Acid reflux is also more common in patients who have a hiatal hernia, which means the stomach’s normal position has shifted upward so that part of it is in the chest.

Risks of Gastroesophageal Reflux Disease

GERD isn’t always a benign disease, although most people will never develop serious complications. Untreated, chronic GERD can lead to esophageal damage. This damage can include inflammation, ulcers, bleeding and scarring of the esophageal tissues. Advanced or serious conditions caused by GERD include the following:

• Erosive esophagitis: This is severe inflammation of the lining of the esophagus.
• Esophageal ulcers: These are crater-like sores in the lining of the esophagus, which can bleed and may sometimes cause anemia (low red blood cell counts).
• Esophageal strictures: This is the narrowing of the esophagus caused by scar tissue, which can lead to difficulty swallowing and episodes of food being caught in the esophagus.
• Barrett’s esophagus: This is a condition in which the normal lining of the esophagus is replaced by abnormal cells. Approximately 10 to 15 percent of those with GERD develop Barrett’s esophagus. It is most commonly found in Caucasian men over age 50. Patients with Barrett’s also have a slightly increase d risk of esophageal cancer, so they should have an endoscopy every few years to check for signs of cancer.
• Reflux laryngitis: Inflammation of the voice box may occur when stomach acid spills into the trachea and irritates the vocal cords. This may lead to sore throat, chronic throat clearing or a hoarse voice. The relationship between reflux and laryngitis is not completely clear, so other causes of laryngitis such as allergies, smoking or postnasal drip should always be investigated .
• Respiratory complications: T These complications occur when stomach contents wash back up the esophagus and spill into the trachea and down into the lungs, or when stomach contents traveling into the esophagus cause a reflex of the bronchi(the small airways in the lungs) that may lead to wheezing, cough, worsening of asthma or infections like pneumonia.
• Dental erosions: Severe GERD can lead to an increased risk of tooth decay due to stomach acids wearing away the tooth enamel.
• Increased risk of cancer of the esophagus: People with severe and long-standing GERD have an increased risk of esophageal cancer, even when they don’t develop Barrett’s esophagus.

Conditions Sometimes Confused with Gastroesophageal Reflux Disease

Some diseases and conditions can present with similar symptoms to GERD. These include esophageal spasms, esophageal cancer, peptic ulcer disease, gastritis, asthma and coronary artery disease.

Adult Asthma

There is an association between asthma and GERD, especially in those with wheezing that gets worse at night, when lying down or after meals, and in people with respiratory symptoms such as frequent coughing or hoarseness or recurrent pneumonia. According to the American Academy of Allergy, Asthma & Immunology, as many as 70 percent of people with asthma also have GERD.

Heart Disease

One of the most concerning symptoms and conditions that might be confused with GERD is chest pain due to heart disease. The question arises: Is it heartburn or heart attack? There are some differences.

The classic description of cardiac chest pain is crushing, heavy or dull pain below the sternum (chest bone) that may extend up to the neck, shoulders or arms, and shortness of breath. The pain is usually relieved with nitroglycerin.

The chest pain with GERD is typically burning and may extend upward. Pain due to GERD usually occurs after meals and is often relieved by antacids. However, the pain can be so similar to that of chest pain that it is often difficult or impossible to distinguish between the two without sophisticated testing.

NOTE: The symptoms of chest pain that accompany a heart attack are notoriously inconsistent with the classic description, especially in women, who often develop atypical pain, such as abdominal or back pain. As opposed to heart disease, pain from GERD should not go to the back, shoulders or arms. However, the absence of these symptoms does NOT eliminate heart problems as the cause. If pain lasts for more than few minutes, do not try to diagnose yourself; seek immediate medical attention.

Diagnosis

Many people with gastroesophageal reflux disease (GERD) go undiagnosed for years because they don’t consider their symptoms serious or they are able to treat the symptoms with common over-the-counter medications. Although rarely life threatening, frequent heartburn and other GERD-related symptoms can cause significant limitations in daily life and may lead to more significant complications, such as erosive esophagitis and Barrett’s esophagus. Early diagnosis is important, not only for symptom relief, but to prevent long-term complications.

Diagnosing GERD is usually based on symptoms. Often your health care professional will begin by providing you with a sample questionnaire such as:

For the following questions describe your symptoms as never, rarely, once or twice a week, frequently, more than once a day.

1. Have you experienced heartburn?
2. Does heartburn interfere with normal activities or sleep?
3. Does your heartburn cause severe pain that makes you unable to perform normal activities or sleep?
4. Have you experienced difficult or painful swallowing?
5. Have you experienced persistent coughing?
6. Have you experienced hoarseness or scratchy throat?
7. Have you had trouble breathing or wheezing?
8. Have you had chest pain?
9. How often do you take an antacid or over-the-counter medication for your symptoms?

Next, your health care professional conducts a physical exam, evaluating your mouth, teeth and throat for signs of redness, swelling or dental erosions. A lung exam may also be performed to listen for wheezing or other abnormal breath sounds, and a heart and abdominal exam may be given to check for masses, tenderness, abnormal sounds or heartbeats or abnormal collections of fluids, and to evaluate the size of your liver.

Many times, your health care professional gets enough information from your history (your symptoms) and your physical examination to make either a firm or probable diagnosis of GERD without any other tests. Usually when this is the case, medications can be started immediately. If your symptoms get much better with these medications, then it is very likely that your symptoms are due to GERD.

Those with more persistent or severe symptoms, or other concerning features like bleeding or weight loss, may require other diagnostic tests, including:

Laboratory tests. While there is no lab test or blood marker specifically for GERD, some people require laboratory tests to rule out other causes for their symptoms, such as blood tests for anemia, liver function, kidney function or cardiac enzymes (used to check if there has been any damage to the heart).

Endoscopy. In this test, you receive a mild sedative, and a lighted flexible tube, called an endoscope, is passed through your mouth into your esophagus and down into your stomach. This allows your health care practitioner to visually check for inflammation and ulcers of the esophagus and stomach and for other abnormalities such as bleeding, narrowing of the esophagus and scarring. Most people with heartburn have a normal endoscopy, but it is important to perform the test in some people to look for more extensive damage to the esophagus. Endoscopy also allows your doctor to take biopsies (small samples of the lining of the esophagus). Endoscopic biopsies are the only reliable way to diagnose Barrett’s esophagus, a complication of GERD.

pH monitoring. During this test, a catheter (a very thin tube) is passed through the nose and into the bottom of the esophagus to measure acid reflux over 24 hours as you go through your normal activities. The catheter is attached to a small device that measures the amount of acid that reaches the esophagus. Wireless systems of measuring gastroesophageal reflux are also available. Instead of wearing a catheter for 24 hours, a small device about the size of a gel cap is attached to the esophagus, and pH measurements are transmitted via radio waves to a pager-sized receiver on your belt. This system, called the Bravo esophageal pH test, allows prolonged (48 hour) monitoring. The capsule detaches within 7 to 10 days and passes on its own in the stool. Even though this system eliminates the discomfort of wearing the tubes in the nose, the procedure requires an endoscopy to place the device, and some people may notice the capsule and complain of chest pain, problems swallowing or painful swallowing.

Esophageal impedance testing. To measure the movement of the contents in your esophagus, your health care professional may order esophageal impedance testing, which involves placing a catheter through your nose and into your esophagus. If your doctor orders this test, it is usually combined with the pH monitoring test so that only one catheter is in your esophagus. This test is different from the pH monitoring test because it does not rely on the acidity of the stomach contents. This test can determine if stomach contents reflux into the esophagus even if they are not acid, making it useful for figuring out if there are nonacidic substances, like bile or ingested food and liquids, backing up into the esophagus.

Esophageal manometry. During this test, a special tube is passed into the esophagus to measure both the muscle function during swallowing and the function of the lower esophageal sphincter. This test is not adequate for diagnosing reflux but is sometimes recommended if you’re having trouble swallowing. It is usually reserved for patients who have an unclear diagnosis after other testing or for whom surgery is being considered.

Upper gastrointestinal x-ray series. During this test, you drink a liquid contrast solution. As you swallow the liquid, x-rays are taken. This test doesn’t diagnose GERD, but it can diagnose a hiatal hernia, narrowing of the esophagus or tumors obstructing the esophagus.

Treatment

Gastroesophageal reflux disease (GERD), although common, is often unrecognized and thus is left untreated, self-treated or treated incorrectly. This is unfortunate because GERD usually responds well to appropriate management.

 Prevention

Facts to Know

Questions to Ask

1. What is GERD?Gastroesophageal reflux disease (GERD) is a condition where stomach acid washes back up into the esophagus, the long muscular tube connecting the back of your throat with your stomach.
2. What are the most common symptoms of GERD?The most common symptoms are heartburn, which is the burning discomfort that rises up from the stomach into the chest, and acid regurgitation, which is the feeling of bitter or sour taste material into the mouth when stomach contents wash back up into the mouth.
3. I had heartburn after I ate Thanksgiving dinner. Do I have GERD?Virtually everyone experiences heartburn at some point, especially after very large fatty meals. GERD is typically diagnosed when heartburn occurs more than twice a week over a period of several weeks or if frequent heartburn disrupts your daily life.
4. I just take antacids and, usually, my symptoms go away. Why should I consider another medication?Antacids are good for occasional symptoms, but recurrent or persistent symptoms could indicate more serious problems. Other medications, such as proton pump inhibitors and H2-blockers, are highly effective, can prevent symptoms from occurring and can heal esophageal inflammation. If you have frequent heartburn, discuss it with your health care professional.
5. What causes GERD?Gastroesophageal reflux disease (GERD) is the abnormal backflow of stomach acid up into the esophagus, the long, muscular tube that connects the back of the mouth to the stomach. The muscle at the border of the esophagus and stomach is called the sphincter. It works as a gate, normally closed to prevent reflux but temporarily opening after you swallow to allow passage of food contents into the stomach. Acid reflux occurs when this sphincter or “gate” opens at the wrong time or is too weak, allowing stomach contents to leak back (or reflux) into the esophagus. Certain foods and medications can cause promote reflux by causing relaxations or low pressure in this sphincter or “gate.”Acid reflux is more common in people with a hiatal hernia, in which the stomach’s normal position has shifted upward so part of it is in the chest .The most common symptom people with GERD suffer is heartburn. If the reflux persists, the lining of the esophagus is damaged and can result in esophageal erosions, ulcers, inflammation or more significant changes, such as a condition called Barrett’s esophagus.
6. Can children have GERD?Yes. Even infants can have GERD.
7. What are the complications of GERD?
   • Erosive esophagitis. This is the chronic inflammation of the lining of the esophagus.
   • Esophageal ulcers. These are small crater-like areas in the lining of the esophagus. They may bleed and can be painful.
   • Esophageal narrowing. Scarring of the esophagus causes this condition. If narrowing occurs, swallowing may become difficult and painful.
   • Barrett’s esophagus. This is a condition where the cells lining the esophagus have become abnormal. It can be a precancerous condition in some people. Although the risk of cancer is low, it requires surveillance by endoscopy every two to three years.
   • Laryngitis. This symptom may be caused by stomach acid causing inflammation of the vocal cords. The relationship between reflux and laryngitis is not completely clear. Other causes, such as allergies, smoking or postnasal drip, should be investigated.
   • Lung problems, such as recurrent pneumonia, wheezing and asthma. Theoretically, these conditions may occur when stomach contents wash back up the esophagus and spill into the trachea and down into the lungs or when stomach contents traveling into the esophagus cause a bronchial reflex.
   • Tooth decay. This condition is caused by stomach acid wearing away the enamel on the teeth.
8. I’ve been told I have a hiatal hernia. What is that?A hiatal hernia develops when part of the stomach protrudes up through the diaphragm (the muscular layer between the abdomen and the chest) and into the chest. Heartburn is a common problem associated with a hiatal hernia. Not all patients with hiatal hernia have GERD, and many GERD patients don’t have a hiatal hernia.
9. Can GERD cause cancer?Chronic GERD can damage the esophagus and lead to a condition called Barrett’s esophagus. Those with Barrett’s esophagus do have a significantly increased risk of cancer of the esophagus. Only endoscopic biopsy can reliably diagnose Barrett’s esophagus. Also, there appears to be an increase in cancer of the esophagus even if Barrett’s esophagus has not developed.
10. Can GERD be cured?No. But with adherence to lifestyle changes and taking medication, the symptoms can usually be easily treated. In some conditions, like pregnancy, GERD will go away on its own after delivery. Surgery does not cure GERD, but the fundoplication wraps part of the stomach around the lower end of the esophagus to prevent acid from refluxing.
11. I have been diagnosed with GERD. What symptoms should I look for?
    • no improvement after two weeks of lifestyle changes and antacids or acid reducers, or if symptoms are worsening
    • choking or difficulty swallowing
    • unexplained weight loss
    • blood in your stool, maroon or tarry-looking stools
    • vomiting blood
    • chest pain
12. Will I have to have any diagnostic tests to determine if I have GERD?Most people can be diagnosed based on their symptoms and the response to treatment. Diagnostic tests are sometimes ordered for those with severe or persistent symptoms or to determine if there is another cause of the symptoms.

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