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GERD, or gastroesophageal reflux disease, occurs when gastric juice from the stomach backs up into the bottom of the esophagus and causes irritation, inflammation or erosion of the cells lining the esophagus. GERD is sometimes called acid reflux disease.
The esophagus carries food from the mouth to the stomach. A ring of strong muscle called the lower esophageal sphincter (LES) is located at the spot where the esophagus enters the stomach. The LES relaxes and opens when a person swallows, allowing food to enter the stomach. The LES stays closed in healthy people the rest of the time, preventing the contents of the stomach from backing up into the esophagus. In people with GERD, the LES is weak and opens at inappropriate times, allowing a backwash of stomach contents into the bottom part of the esophagus.
The stomach makes hydrochloric acid that is needed to digest food and help kill bacteria and other foreign organisms that are accidentally consumed with food. The cells lining the stomach secrete a thick layer of mucus that protects them from damage by stomach acid. The cells lining the esophagus do not secrete mucus, so when the LES opens and the acid mixture from the stomach come into contact with them, they become first irritated, then later inflamed, and finally eroded. The individual often feels this damage as heartburn. Heartburn is a pain or burning behind the breastbone. GERD is diagnosed when the stomach acid comes in contact with the esophagus twice or more in a week on a regular basis.
Acid reflux or heartburn is extremely common. About 7% of Americans, or more than 15 million people, have heartburn every day. About 60 million Americans have heartburn at least once a month, although not everyone who has heartburn has GERD, and not everyone who has GERD has heartburn. The exact number of people with GERD is difficult to determine, as many people self-treat symptoms with over-the-counter medications.
People of any race or age can develop GERD, including infants and children, but the disease is most common among people over age 50, pregnant women, and people who are overweight or obese. The condition is often overlooked in infants and children and is likely to be underdiagnosed in this group.
GERD is caused by stomach acid coming in contact with cells of the esophagus. The most common cause for this is weakening of the LES. Hiatal hernia is thought to increase the likelihood of developing GERD. The diaphragm is a sheet of muscle that divides the chest cavity from the abdominal cavity. With a hiatal hernia, a tear develops in the diaphragm and a portion of the stomach protrudes through the hole and up into the chest cavity. Hiatal hernias are very common, especially in people over age 50, and usually do not cause health problems or need treatment. However, the diaphragm gives support to the LES. When it is torn, this support is weakened, and the LES closes less tightly. The relationship between hiatal hernia and GERD is somewhat controversial. Many people with a hiatal hernia do not have heartburn, and some people who do not have a hiatal hernia do have heartburn.
Certain lifestyle choices increase the likelihood of developing GERD. These include:
- alcohol consumption
- poor posture
- eating large meals shortly before bedtime
Certain foods also increase the likelihood of developing GERD. These foods include:
- greasy or fried foods
- citrus fruits or juices (e.g. orange, grapefruit)
- caffeinated beverages (e.g. coffee, colas)
- garlic and onions
- tomato-based foods (e.g. spaghetti sauce, chili)
- foods flavored with mint
- garlic and onions
- spicy foods
- wine, beer, and distilled spirits
GERD also has less typical symptoms. Some people regurgitate or involuntarily bring up the contents of the stomach into the mouth. This causes a bitter taste, and if it occurs often enough can erode tooth enamel.
Other less typical symptoms are wheezing, shortness of breath, increased incidence of asthma, and a persistent dry cough. GERD can also cause the person’s voice to sound hoarse. Hoarseness is usually worse in the morning. These symptoms are caused by contents of the stomach approaching or enter the airways.
Some people have difficulty swallowing or feel as if the food they have eaten is stuck behind their breastbone. This symptom can also be caused by a narrowing of the esophagus where it enters the stomach.
The most common symptoms of GERD in infants and children are repeated non-projectile vomiting (spitting up), persistent coughing, and wheezing.
Often GERD is tentatively diagnosed on the basis of the patient reporting heartburn twice or more a week on a regular basis. Normally the physician will suggest lifestyle changes (see treatment below), and if there is no improvement will order more extensive tests.
An upper GI series, sometimes called a barium swallow, includes x rays of the esophagus, stomach, and upper part of the intestine. Often the patient drinks a solution of barium to improve contrast on the x rays. These x rays help rule out abnormalities such as a narrowing of the esophagus (esophageal stricture) and ulcers.
An upper endoscopy is a diagnostic procedure that allows the physician to see the lining of the esophagus and stomach. It is performed in a doctor’s office or an outpatient clinic under light sedation. A tube called an endoscope is inserted down the throat. At the end of the endoscope is a tiny camera that allows the doctor to see if there is damage to the cells lining the esophagus. During this procedure, the doctor may use also remove small tissue samples (a biopsy) from the esophagus in order to look for abnormal cells under the microscope.
Occasionally 24-hour pH monitoring is necessary. The pH scale measures the strength of acids. In this test, a tube put down the esophagus measures how much stomach acid back up into the esophagus. Monitoring usually for continues for 24 hours.
GERD is categorized according to the degree of damage to the esophagus.
- Grade I: redness and irritation of the esophagus
- Grade II: some non-adjacent spots of erosion of esophageal cells
- Grade III: increased and continuous patches of erosion
- Grade IV: Barrett’s esophagus, a precancerous condition in which normal cells are replaced by abnormal ones
The goals of treating GERD are to eliminate heartburn and other symptoms, heal damage to the esophagus, and prevent return of symptoms. Treatment proceeds in four stages: lifestyle changes, over-the-counter remedies, prescription drug therapy, and surgery.
Lifestyle changes are the easiest and least expensive approach to treating GERD. They bring relief to many people. Recommended lifestyle changes include:
- Quitting smoking
- If overweight, losing weight •Stopping drinking alcoholic beverages
- Avoiding foods likely to cause heartburn
- Avoiding eating at least 3 hours before going to bed
- Elevating the head of the bed about 4 inches on blocks or using a sloped piece of foam under the mattress to raise the head 6 or more inches.
When lifestyle changes are not enough to relieve symptoms within a few weeks, the next step is to use over-the-counter medications. Antacids, such as Alka-Seltzer, Maalox, Rolaids, or Tums, reduce the acidity of liquid already in the stomach. Many antacids contain aluminum and magnesium. They should not be taken regularly for long periods because these minerals may disrupt the chemical balance in the body.
Drugs known as H2 blockers help reduce the production of acid in the stomach. H2 blockers that are available without a prescription include cimetidine (Tagamet), ranitidine (Zantac), ranitidine (Zantac), and nizatidine (Axid). Some of these are also available in higher strengths with a doctor’s prescription.
H2 blockers are most effective when taken about an hour before meals. They do not affect acid already in the stomach.
Proton pump inhibitors use a different chemical mechanism to block acid production by the stomach. They are more effective than H2 blockers and are used when H2 blockers fail. Some are available in over-the-counter strengths, while others require a prescription. Common proton pump inhibitors include omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aci-phex), esomeprazole (Nexium), and metoclopramide (Reglan)
Surgery is the most drastic treatment for GERD. It is used when all other treatments fail and symptoms remain. The most common surgical operation to correct GERD is called fundoplication. This surgery is done laparoscopically; the entire abdomen does not need to be opened. A small slit is made in the abdomen and a camera guides the surgeon who manipulates small instruments through this slit to wrap the top of the stomach (the fundus) like a cuff around the bottom of the esophagus. This provides additional support for the LES, and is initially successful in stopping GERD about 92% of the time. Long-term success rates are variable. Laparoscopic fundoplication usually requires a hospital stay of 1-3 days and takes about 2-3 weeks for complete recovery.
In 2000, the United States Food and Drug Administraton (FDA) approved two other procedures to treat chronic acid reflux. On involves putting stitches in the LES to create small pleats that make the muscle stronger. The other involves making small cuts in the LES. The scar tissue that forms when the muscle heals makes the LES stronger. There is little data on the long-term success of these procedures. More recently, the FDA has approved an implant that does not require surgery. The implant reinforces and strengthens the LES reinforces. This procedure is too new to have any data concerning long-term success.
Nutritional concerns related to GERD involve lifestyle changes designed to reduce or eliminate heartburn. These dietary changes are likely to have other beneficial health effects as well. Foods to avoid include:
- alcoholic beverages
- coffee, tea, and caffeinated soft drinks
- fatty or fired foods
- acidic foods such as citrus fruit or juice and tomato-based foods
- chocolate or foods with mint flavorings
- highly spiced foods
About 80% of people get relief from GERD through lifestyle changes and medication, although relapses are common. H2-blockers successfully treat 50 to 60% of people with grade I or grade II GERD. Most people not helped by H2 blockers can be healed by 6-8 weeks of treatment with proton pump inhibitor drugs. Of the 20% of people not helped by medication, 92% improve with fundoplication surgery.
The most serious complication of GERD is Barrett’s esophagus. In this disease, normal cells lining the esophagus are replaced with abnormal cells. About 30% of people with Barrett’s esophagus go on to develop cancer of the esophagus. Those at highest risk are white men.
Other long-term complications of GERD include narrowing or scarring of the base of the esophagus, a condition called peptic stricture. This can cause difficulty swallowing. Also, people with GERD may have more ear infections and laryngitis. GERD may worsen asthma.
Prevention of GERD is very similar to the lifestyle changes suggested in the initial stage of treatment— stop smoking, lose weight, reduce or eliminate alcohol consumption, and avoid foods likely to cause heartburn.
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