Gastro-esophageal Reflux Disease

Non-technical - US target audience

Definition

Gastro-esophageal reflux disease (GERD) is a condition in which stomach acids and other stomach contents back flow up into the esophagus, the tube leading from the mouth to the stomach, causing a burning sensation in the middle of the chest known as heartburn.

Demographics

Estimates of the number of people in the United States with GERD may be significantly under-reported because some people who experience heartburn self-treat through over-the-counter medications and are never officially diagnosed with GERD unless a more serious condition occurs. The American College of Gastroenterology estimates that about 60 million Americans experience heartburn at least once a month; of these, 15 million experience the condition daily. Other estimates suggest that 7% of the population has heartburn daily, and of these individuals, 20–40% have GERD, while heartburn in the remaining individuals arises fromother causes.

GERD occurs in all races and at all ages but is most common in people over age 40 years. Men and women are equally affected, although white men are ten times more likely to develop Barrett’s esophagus (a precursor of esophageal cancer) than women.

Description

The mechanism behind GERD is a weakness in the lower esophageal sphincter (LES), causing stomach acids to back into the esophagus. The LES is a muscle located at the bottom of the esophagus that acts as a door keeper to the stomach. Normally, when food is eaten, it passes through the esophagus into the stomach, and the LES closes to keep the highly acidic stomach contents from washing back into the esophagus. Although a malfunctioning LES can be present from birth and can cause infants and children to complain of stomachaches and have frequent bouts of vomiting, GERD is most often seen in adults.

The esophagus risks being damaged every time stomach acids wash into it. Constant irritation by stomach acids can cause esophagitis, a condition in which the esophagus becomes red and irritated. Because the lining of the esophagus is thinner and less acid-resistant than the stomach or the intestines, untreated GERD over many years can cause ulcers to develop in the esophagus. These can bleed and can, in turn, result in anemia. Scar tissue can also build up. The body may try to protect the esophagus by developing a thick lining made up of cells like those in the stomach and intestine. This is known as Barrett’s esophagus and is a pre-cancerous condition that can lead to cancer of the esophagus.

Some people have trouble eating because there is a feeling that something is in their throats or that their food keeps getting stuck when they eat. This may be a serious condition called dysphagia, which develops from long-term GERD. It is a narrowing of the esophagus, caused by a thickening of the lining in response to acids from the stomach. When swallowing hurts, the condition is called odynophagia.

This type of GERD often is referred to as silent reflux because no other symptoms are reported.

Everyone experiences heartburn occasionally, especially after overeating or eating fatty foods. Continued heartburn, though, can disrupt sleep. Moreover, if stomach acids keep bathing the esophagus, chronic inflammation of the lower esophagus can occur. In addition, if stomach material from the esophagus finds its way into the windpipe (trachea), it can enter the lungs, leading to asthma and pneumonia. For elderly individuals who are bedridden, aspiration of stomach contents can cause choking, infection, and even suffocation and death.

Causes and symptoms

Causes

Often, a structural abnormality called a hiatal herniais the cause of constant reflux and GERD. In a hiatal hernia, a part of the stomach protrudes through a hole in the diaphragm (a sheet of muscle that separates the abdominal cavity from the chest cavity). This condition is more common in older individuals.

Impaired motility in the stomach also can be a factor in GERD. In this case, the stomach nerves or muscles do not allow the stomach and the esophagus to contract normally, thereby allowing acid to build up in the esophagus.

Scleroderma, a disease that causes muscular tissue to thicken, can affect digestive muscles and keep the LES open.

Lifestyle factors affect the development of GERD.

Being overweight or pregnant increases abdominal pressure, and can cause the LES to remain open, thus allowing the stomach contents to squeeze into the esophagus.

Wearing tight clothing around the abdomen, eating large meals, and lying down after eating can keep the LES open.

Some foods may act as triggers for GERD, including chocolate, peppermint, high fat foods, citrus foods, tomato products, and onions.

Smoking can stimulate acid production in the stomach and also can relax the LES.

Consuming alcoholic, caffeinated, and carbonated drinks also can contribute to GERD.

Some medications have been linked to the development of GERD. They include high blood pressure medications such as calcium channel blockers, nitrate heart medications, asthma drugs such as theophylline, antidepressants, sedatives such as diazepam (Valium), and corticosteroid drugs.

Nitrates in foods also may trigger GERD.

Non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, and naproxen can irritate the stomach and lead to GERD.

Symptoms

Although heartburn is the characteristic symptom of GERD, people with this condition also may experience other symptoms. Regurgitation of stomach acid into the mouth (sometimes called water brash) is often present.

Some individuals report abdominal pain, difficulty in swallowing, nausea, morning hoarseness, sore throat, coughing, wheezing, or a need to repeatedly clear the throat.

Others experience vomiting or frequent burping o rhiccups. A few note weight loss or snoring. Some people do not experience noticeable symptoms. This is for milder forms of common GERD symptoms, but they experienced more instances of difficulty swallowing, vomiting, anemia, and weight loss.

The study also found that abdominal pain and heartburn seemed to decrease with age and that GERD in the elderly most often was related to nonsteroidal anti-inflammatory drug (NSAID) use.

Having heartburn several times a week or waking up with heartburn at night is a good indicators that an appointment should be made for evaluation by a physician. If symptoms disturb sleep or interfere with work or leisure activities, a doctor should be consulted.

Losing weight, breathing difficulties, vomiting blood, or has producing black, tarry stool, indicate that a doctor should be seen immediately.

In addition, if an individual has been treated by a family physician for GERD for more than two years, a consultation with a gastro-enterologist (a doctor specializing in diseases of the digestive system) usually is recommended.

Diagnosis

Examination

Because GERD is common, it often will be diagnosed after the doctor takes a thorough medical history, listens carefully for GERD symptoms, and does a physical examination. If the patient responds positively to treatment, no further tests are ordered. However, if the patient has serious symptoms such as intense pain, vomiting blood, or rapid weight loss, the doctor will investigate these through a series of tests. In addition, if the patient has been complaining of heartburn for a long time or has been treated for GERD for more than two years, other tests will likely be ordered to gauge the extent of damage done to the esophagus.

Procedures

The most common procedures are the upper gastro-intestinal (GI) series and the upper GI endoscopy.The upper GI series examines the esophagus, stomach, and the duodenum (the first section of the small intestine). The patient drinks a cup of barium (barium swallow), a metallic, chalky liquid that coats the digestive track and makes it show up on x rays. Xrays or images are then taken as the barium flows down the esophagus, into the stomach, and into the duodenum. The patient may be asked to turn to the side so that the technician can gently massage the stomach tomove the barium into the duodenum. Images are sent to a videomonitor where the doctors and technicians observe the behavior of the upper digestive tract and snap still images from themonitor. The upper GI series can reveal anatomical changes in the esophagus, such as a hiatal hernia or esophageal narrowing. It also can assess damage to the esophagus, detect stomach ulcers or ulcers in the duodenum, and determine whether an intestinal blockage is present.

The upper GI endoscopy, also called the esophago-gastroduodenoscopy (EGD), offers a more complete picture of what is happening in the upper digestive tract. It is the test of choice for many gastroenterologists.

Before the endoscopy, the patient receives a mild sedative, and then the doctor inserts a small, flexible tube down the patient’s throat. At the end of the tube is a light, a tiny camera, and a small instrument used to take tissue samples (biopsies). The camera broadcasts live images from the esophagus and stomach to a video monitor. Using these tools, the doctor can capture still images for further diagnosis and can examine suspicious areas more closely with the camera or by taking tissue samples. The EGD allows the doctor to determine the extent of damage to the esophagus and to rule out serious complications such as Barrett’s esophagus. Mild GERD may show no damage to the esophagus at all.

Another test, esophageal manometry, measures pressure within the esophagus and how well the LES functions. A thin tube is inserted through the nose and down the throat. Coupled with the 24-hour pH probe study, esophageal manometry becomes the best determinant of GERD because it monitors how often the patient has reflux into the esophagus during a full day. One episode of acid reflux is considered having a pH of less than 4.0 for at least 15–30 seconds. This test can determine if there is a correlation between episodes of acid reflux and other symptoms, such as chronic cough, wheezing, or sleep apnea.

To do a pH probe study, a small computer is attached to the outside end of the thin tube in the patient’s nose, and the computer is worn around the waist or over the shoulder. The patient goes home, carries on a normal routine, then comes back to have the probe removed and the results analyzed.

A more comfortable form of the 24-hour pH probe study is the Bravo pH probe that is placed in the esophagus during endoscopy. This tiny probe transmits data to a miniature recorder the size of a paper clip that is worn around the waist. Eventually, the probe makes its way through the digestive system and is passed in the patient’s stool in a week to ten days.

Sometimes, chest x-rays are ordered to check for pneumonia or lung damage due to aspiration of stomach contents.

Treatment

The preferred treatments for GERD are lifestyle changes and drugs.

Lifestyle changes

Either prescribed alone or in combination with drug therapy, lifestyle changes can ease many GERD symptoms. Food choices, the timing of meals, and the size of meals are key lifestyle factors. Individuals should avoid foods that trigger GERD and eat smaller, more frequent meals. Doing so helps to control the amount of acid in the stomach. Individuals also should stop eating three hours before lying down. Lying down after eating can cause stomach contents to backflow into the esophagus. In addition, elevating the head of the bed about six inches may help keep acid within the stomach. Losing weight and avoiding slumping will reduce pressure on the stomach.

Diet and lifestyle modifications:

  • Eat smaller but more frequent meals
  • Avoid common triggers (including tomato sauces, fried or spicy foods, alcohol, and caffeinated beverages)
  • Lose excess weight
  • Sleep with the head elevated
  • Avoid eating before bed

Drugs

Drugs often are prescribed along with lifestyle changes, even in the early stages of the disease.

Commonly, the first medications prescribed are over-the-counter antacidsand/or histamine-2 receptor blockers (H2 blockers).

Antacids, such as Gaviscon, Tums, Maalox, Mylanta, and Rolaids help neutralize acid already in the stomach or esophagus but do nothing to heal inflammation. Some have a foaming agent that helps prevent acid from backflowing into the esophagus. Unless otherwise instructed by a doctor, antacids can be used every day for three weeks. If taken longer, they can produce diarrhea,interfere with calcium absorption in the body, and increase levels of magnesium, which can damage the kidneys. Antacids are not recommended for individuals taking drugs to correct hypothyroidism.

Common H2 blockers are nizatidine (Axid), ranitidine (Zantac), famotidine (Pecid), and cimetidine (Tagamet). At half the strength of their prescription counterparts, these over-the-counter medications block acid production, but they have no effect on acid already present in the stomach. These drugs should be taken thirty minutes to one hour before meals. H2 blockers do not work as quickly as antacids, but they produce longer relief and are effective in reducing acid reflux at night. These drugs can heal mild esophageal damage but are not strong enough to heal serious injury. Standard dosage for 6–12 weeks has been found to relieve symptoms in half of GERD patients using H2 blockers.

If symptoms do not improve, proton-pump inhibitors (PPIs) may be given. PPIs can be bought without a prescription and, like H2 blockers, are also available in stronger strengths with a prescription. PPIs include esomeprazole (Nexium), omeprazole (Prilosec, Losec), lansoprazole (Prevacid, Zoton), and rabeprazole (Aciphex, Pariet). These drugs block the production of an enzyme that aids in acid formation. PPIs can reduce stomach acid by more than 95%. They are used to treat GERD and can heal some gastric and duodenal ulcers and prevent upper GI tract bleeding. PPIs are contraindicated for people with liver disease and may make the intestinal tract more susceptible to bacterial infections.

In addition to PPIs, the doctor may prescribe coating agents, such as sucralfate (Carfate), to cover the sores and mucous membranes of the esophagus and stomach. This acts as a protective barrier. Some doctors also a prokinetic agent to tighten the LES and promote faster emptying of the stomach. Metaclopramide (Reglan) is the only prokinetic drug approved for use in the United States. Many doctors are reluctant to use prokinetic drugs because they have serious side effects.

Surgery

If all other treatments fail, surgery is a final option. A surgical procedure called fundoplication creates a one-way valve into the stomach. During surgery, the doctor wraps a part of the stomach around the esophagus and sews it down. This procedure can be done laparoscopically, a less invasive surgical method in which the doctor makes small cuts into the abdomen to insert a camera and the surgical instruments. Laparoscopic surgery produces very little scarring and has a faster recovery rate than traditional open surgery. However, the benefits of fundoplication have been challenged in some studies.

Certain endoscopy treatments can be used to repair the upper digestive tract instead of using surgery. Plication allows the doctor to stitch tears in the esophagus or narrow the LES. The Stretta procedure uses radiofrequency energy to cause the LES sphincter to tighten. The Enteryx procedure lets the doctor inject a bulking material into the LES to narrow it. As of 2010, these procedures were not widely available but were being used at some larger medical centers.

Alternative treatments

Alternative remedies include eating bananas or drinking chamomile or ginger tea. Chamomile should be avoided by people who have ragweed allergies .Some people eat licorice to balance the acid output in the stomach and to increase the mucous coating of the esophagus, but this is contraindicated for people with high blood pressure. Teas made from marsh mallow root, papaya, fennel, and catnip are also suggested treatments for heartburn, as well as eating papayas.

Homeopathic remedies most recommended are Nux vomica, Carbo vegetabilis, and Srsenicum album. Acupuncture and acupressure have also been used to treat heartburn.

Home Remedies

In addition to the lifestyle changes listed above, a common home remedy offering temporary relief is drinking water with sodium bicarbonate (baking soda) in it. However, this remedy can also add uncomfortable gas to the stomach, more sodium to the diet, which can increase blood pressure, and the excessive bicarbonate can produce rebound hyperacidity with worsening symptoms.

Prognosis

In most cases, GERD is easily managed. Between 80% and 90% of individuals improve with drug therapy. However, the length of treatment varies. Some patients may not see improvement for several weeks or months. Some patients can experience relief after two to three months of treatment and are able to modify their lifestyle to minimize symptoms so that medications are reduced or discontinued. Many patients with serious, persistent GERD may need to take medications for the rest of their lives. Even with successful treatment, some patients experience acid breakthrough. This response occurs when symptoms appear even though the patient has faithfully taken medications. Some patients on PPIsmay be symptom free during the day but wake up at night with heartburn. Sometimes, an H2 blocker is given to the patient at night in addition to PPI medications. Some patients on H2 blockers may benefit from a combination pill that contains an antacid and an H2 blocker.

Untreated GERD can lead to the development of Barrett’s esophagus. Barrett’s is a pre-cancerous condition. Many times it can be reversed with proper treatment of GERD.

Prevention

Symptoms of GERD can be prevented by taking drugs as prescribed, avoiding alcohol, not smoking, eating smaller meals, limiting fatty foods, and eliminating trigger foods. Individuals should avoid belts and tight clothing around the waist and try to lose excess weight. Individuals may chew gum or suck on hard candies to increase saliva production, which can sooth the esophagus and wash the acid back to the stomach. People with heartburn should wait two hours after eating before exercising and plan not to eat anything at least three hours before lying down. Finally, elevating the head of the bed at least six inches and sleeping on the left side may reduce night time heartburn.

Key Terms

Calcium channel blocker—A drug that lowers blood pressure by regulating calcium-related electrical activity in the heart.

Dysphagia—Difficulty in swallowing, as if something is stuck in the throat.

Esophagogastroduodenoscopy (EGD)—A test that involves visually examining the lining of the esophagus, stomach, and upper duodenum with a flexible fiber-optic endoscope.

Esophagus—The muscular tube that leads from the back of the throat to the stomach. Coated with mucus and surrounded by muscles, it pushes food to the stomach by contraction.

Fundoplication—A surgical procedure that tightens the lower esophageal sphincter by stretching and wrapping the upper part of the stomach around the sphincter.

Gastroenterologist—A physician who specializes in diseases of the digestive system.

H2 Blockers—Medications used to treat some GERD symptoms, for example, Tagamet, Pepcid, Axid.

Heartburn—A burning sensation in the chest that can sometimes also be felt in the neck, throat, and face. It is the primary symptom of GERD.

Hiatal hernia—A condition in which part of the stomach protrudes above the diaphragm next to the esophagus. 

Laparoscopic surgery—A minimally invasive surgery in which a camera and surgical instruments are inserted through a small incision.

Lower esophageal sphincter (LES)—A muscular ring at the base of the esophagus that keeps stomach contents from entering back into the esophagus.

Odynophagia—Pain felt when swallowing.

pH—A measure of the acidity of a fluid. On a scale of 1–14, a pH of 7 is neutral. Higher pH readings are alkaline and lower pH readings are acidic.

Silent reflux—An acid reflux problem that does not have marked symptoms but can cause chronic, recurrent respiratory symptoms much like asthma.

Sleep apnea—A sleep disorder in which breathing stop briefly then resumes on its own. These pauses can occur many times each night, resulting in poor quality sleep.

Water brash—The flow of saliva and stomach acid back up the esophagus and into the throat or lungs.

Resources

Books

Burns, David L. and Neeral L. Shah.100 Questions & Answers About Gastroesophageal Reflux Disease (GERD). Sudbury, MA: Jones and Bartlett Publishers, 2007

Wendland, Barbara E., and Lisa Marie Ruffolo. Chronic Heartburn: Managing Acid Reflux and GERD Through Understanding, Diet, and Lifestyle. Toronto, Ontario, Canada: Robert Rose, 2006.

Periodicals

Wellbery, Caroline. ‘‘GERD Symptoms Differ with Patient Age.’’American Family Physician(March 15, 2007): 906.

Other

Gastroesophageal Reflux in Children and Adolescents. National Digestive Diseases Information Clearing-house. August 2006. http://digestive.niddk.nih.gov/diseases/pubs/gerinchildren

GERD. MedlinePlus February 4, 2010. http://www.nlm.nih.gov/medlineplus/gerd.html

The Word onGERD. American College of Gastroenterology.  http://www.acg.gi.org/patients/gerd/word.asp

ORGANIZATIONS

American College of Gastroenterology (ACG), P.O. Box 34226, Bethesda, MD, 20827-2260, (301) 263-9000, http://www.acg.gi.org

American Gastroenterological Association (AGA), 4930 Del Ray Avenue, Bethesda, MD, 20814, (310) 654-2055, (301) 654-5920, www.gastro.org

International Foundation for Functional Gastrointestinal Disorders, P. O. Box 170864, MilwaukeeWI, USA, 53217-8076, (414) 964-1799, (USA only) (888) 964-2001, (414) 964-7176,  http://www.iffgd.org

National Digestive Diseases Information Clearing house (NDDIC)., 2 Information Way, Bethesda, MD, 20892-3570, (800) 891-5389; TTY (866) 569-1162 , (703) 738-4929,  http://digestive.niddk.nih.gov