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Gastroesophageal Reflux Disease

Definition
Gastroesophageal reflux disease, or GERD, is a chronic condition in which
the backward flow (reflux) of stomach acid into the esophagus leads to
heartburn, chest pain, and possible long-term health complications. The
underlying cause is weakness in the sphincter (ring-shaped muscle) at the
lower end of the esophagus where the esophagus joins the stomach.

Description
GERD could be described as a more serious or chronic form of
gastroesophageal reflux (GER), a condition that occurs when the lower
esophageal sphincter (LES) opens by itself for varying periods of time or
does not close properly. When the LES is open, the contents of the
stomach move upward into the esophagus. The acid in the digestive
juices irritates the tissues that line the esophagus, causing a burning
sensation behind the breastbone or at the back of the throat. If the
stomach contents are regurgitated (brought back up without trying) as far
as the mouth, the person will experience a sour or unpleasant taste in the
mouth.
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Most people have occasional episodes of heartburn (also called acid

indigestion) because of emotional stress, something they ate, or eating
too large a meal. The time to be concerned about GERD is when
heartburn occurs more than twice a week, is severe enough to wake the
person from sleep, or is not helped by over-the-counter antacids.

GERD is not just a problem for adults; it can affect children as well. One
major difference between children and adults with GERD, however, is that
children are more likely to develop GERD without heartburn. Instead,
their symptoms are more likely to include a dry cough, bad breath,
trouble swallowing, or wheezing. In babies, symptoms of GERD may
include spitting up food repeatedly, failure to gain weight, burping, and
refusing food.

Demographics
Heartburn is a very common digestive problem in the general population.
Among adults, GERD is most common in people over forty. It appears to
affect all races and ethnic groups equally. Uncomplicated

GERD is equally common in men and women. Men, however, are three
times more likely than women to develop a chronic inflammation of the
esophagus, and ten times more likely to develop Barrett esophagus, a
precancerous change in the cells of the tissues at the lower end of the
esophagus.

Some people are at increased risk of developing GERD:

• Pregnant women.
• Obese people.
• Smokers.
• People with a hiatal hernia.
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A hiatal hernia is a condition in which the upper part of the stomach

pushes upward through a weak spot in the diaphragm. The hernia
weakens the ability of the lower esophageal sphincter to keep stomach
acid from flowing into the esophagus.
• People who eat large amounts of foods known to increase the amount of
acid in the stomach. These include citrus fruits, chocolate, tea, coffee,
alcohol, fatty and fried foods, garlic and onions, mint flavorings, spicy
foods, and tomato-based foods like spaghetti sauce, chilli, and pizza.
• People who take certain types of prescription medications, most
commonly tranquilizers, sleeping medicines, and medications for high
blood pressure.

Causes and Symptoms

The basic cause of GERD is the inability of the LES to keep the contents of
the stomach from moving backward into the lower end of the esophagus.
The weakness of the lower esophageal sphincter may result from a
structural disorder like hiatal hernia (a stomach abnormality); conditions
that put pressure on the contents of the stomach, like pregnancy or
obesity; a digestive tract that is still developing; or a disorder of the
stomach that prevents it from emptying at a normal rate of speed.
Recurrent heartburn is the most common symptom of GERD, although
most children and some adults with GERD do not have it. Other
symptoms include:
• Belching or burping
• Regurgitating undigested food after meals
• Nausea and vomiting; vomiting blood
• Hoarseness, particularly in the morning
• Sore throat
• Coughing or wheezing
• Difficulty swallowing
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Diagnosis
There is no single laboratory test that a doctor can use to diagnose GERD.
In most cases the patient’s history and description of symptoms are
enough to suggest the diagnosis and begin treatment with medications
and lifestyle changes.

If the patient’s symptoms are severe or are not helped by initial

treatments, the doctor may refer the patient to a gastroenterologist, a
doctor who specializes in disorders of the digestive tract.

A gastroenterologist may order one or more of the following tests:

• Barium swallow. In a barium swallow, the patient is given a chalky
liquid containing barium, a chemical that coats the inside of the digestive
tract and outlines its shape on an x ray. A barium swallow can help to
detect hiatal hernias, abnormal narrowing of the esophagus, or a growth
in the esophagus.
• Endoscopy. Endoscopy is a technique that allows a gastroenterologist to
look directly into the esophagus and stomach by inserting a long flexible
tube (endoscope) attached to a light source and video camera down the
patient’s throat. Endoscopy allows the doctor to take tissue samples to
check for a Barrett esophagus or cancer of the esophagus as well as to
look at the structure of the esophagus and LES.
• Acid probe test. This test measures the acidity of the patient’s stomach
contents over a 24-hour period and the length of time that the lower
esophagus is exposed to stomach acid. A probe is inserted through the
patient’s nose via a long, flexible catheter to a point just above the LES.
The other end of the catheter is attached to a small computer that the
patient wears around the waist during the test. The computer measures
the length of time and frequency of acid reflux into the lower esophagus.
• Tests to measure the speed of stomach emptying. These tests are
usually performed only when the doctor thinks that delayed emptying of
the stomach is a factor in the patient’s GERD.
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Treatment
Most patients with GERD can be successfully treated by a combination of
medications and lifestyle changes. There are several types of medications
that doctors may prescribe for GERD.
• Over-the-counter antacids, such as Alka-Seltzer, Maalox, Mylanta,
Rolaids, and Riopan. Antacids can be purchased in any pharmacy in either
tablet or liquid form and work well to control mild cases of GERD. They
should be taken after each meal and at bedtime.
• Foaming agents. Gaviscon is the best-known of this type of medication.
They work by coating the stomach contents with foam, which prevents
reflux.
• H2 blockers. These are drugs like Tagamet, Zantac, and Pepcid; they
work by decreasing the production of stomach acid. They are available in
both over-the-counter and prescription strength.

• Proton pump inhibitors (PPIs). These drugs also work by decreasing

stomach acid and are generally more effective than the H2 blockers. Most
are available by prescription. PPIs include drugs like Prilosec, Protonix,
Prevacid, and Nexium.
• Prokinetics. These are drugs that work by speeding up the rate of
stomach emptying. Reglan and Urecholine are examples of drugs in this
group.

People who are not helped by medications may need surgery to treat
GERD. The operation that is usually done is called fundoplication. In this
procedure, the surgeon wraps the upper part of the stomach around the
lower end of the esophagus to strengthen the LES, prevent acid reflux,
and repair a hiatal hernia. The operation is safe and can be done in
infants as well as adults.

Prognosis
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Most people diagnosed with GERD do very well with medications and
lifestyle changes. Of those who require surgical treatment, 92 percent
have no more symptoms of GERD.

Complications from GERD, such as narrowing of the esophagus or Barrett

esophagus, develop in about 20 percent of patients. These patients
should be treated with surgery as soon as their complication is diagnosed.

Prevention
Lifestyle changes are the most effective form of prevention for GERD.
The NIH recommends:
• Not smoking. Smoking increases the production of stomach acid.
• Keeping one’s weight within the recommended guidelines for one’s age,
sex, and height.
• Avoiding foods and beverages that trigger acid indigestion.
• Eating small frequent meals rather than three large ones.
• Avoiding lying down for three hours after eating.
• Raising the head of the bed by 6–8 inches (15–20 centimetres).
This should be done by using wooden blocks or foam wedges; just using
extra pillows will not be effective.
• Wear clothing with loose waistlines. Tight belts or waistbands put
pressure on the abdomen.

When to See the Doctor about Heartburn

Occasional episodes of heartburn do not necessarily mean that someone
has GERD. To tell whether a visit to the doctor for further evaluation
might be a good idea, the American College of Gastroenterology (ACG)
suggests the following checklist:
• Does the person have one or more of the following: pain behind the
breastbone moving upward from the stomach; burning sensation in the
back of the throat; or a sour taste in the mouth?
• Do these symptoms usually appear after a meal?
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• Does the person experience heartburn two or more times per week?
• Do antacids provide only temporary relief from the symptoms?
• Is the person still having heartburn in spite of taking prescription
medication for it?
• Does the person wake up at night because of heartburn?
• Does the person have trouble swallowing food?
• Does the person notice blood in the stools? Are they regurgitating
blood?
• Is the person losing weight without trying to?
If the person can answer yes to two or more of these questions, he or she
should see a doctor to be tested for GERD.