Gastroesophageal Reflux Disease (GERD) (Heartburn)

What is Gastroesophageal Reflux Disease (GERD) (Heartburn)?

Gastroesophageal reflux disease (GERD) is a condition where stomach contents flow backward into the esophagus, or even into parts like the mouth, throat, or lungs, leading to inflammation of the esophagus. This disease is very common and often dealt with by gastroenterologists and general physicians. Essentially, GERD is long-term symptoms or internal damage caused by the abnormal backflow of stomach contents into the esophagus.

There are two types of GERD based on symptoms. One where symptoms are present, but there are no visible erosions upon examination, and the other where there are both symptoms and visible esophagus erosion. It’s more common in men, but the non-erosive type is more prevalent in women. In Western countries, 10% to 20% of the population experiences GERD, and a severe form of the disease is seen in around 6% of people. However, in Asian countries, prevalence is lower at approximately 5%.

Risk factors for GERD include being over 50, having a body mass index (BMI) over 30, smoking, anxiety, depression, lack of physical activity. Some medications that affect the esophageal sphincter, such as nitrates, calcium channel blockers, and anticholinergics, can also lead to GERD. GERD can cause complications such as inflammation of the esophagus, upper digestive tract bleeding, anemia, ulcers, difficulty in swallowing, stomach cancer, and the Barrett esophagus disease. It can even result in complications outside the digestive system, such as tooth erosion, laryngitis, cough, asthma, sinusitis, and a lung condition known as idiopathic pulmonary fibrosis.

The most recognizable symptoms of GERD are heartburn and acid reflux. Diagnosis is usually based on these symptoms and the patient’s response to a specific medication called proton pump inhibitors (PPIs). Most people diagnosed with GERD will have typical symptoms like heartburn and reflux. If there are more alarming symptoms or long-term medication isn’t working, further diagnostic tests like an endoscopy and reflux monitoring will be necessary. The international Lyon Consensus recommends confirming GERD diagnosis in symptomatic patients through these tests before starting them on an invasive or long-term treatment.

Patients who experience chest pain need to be checked for heart-related problems before determining if it’s due to GERD. For patients with mild-to-moderate GERD symptoms, treatment typically involves lifestyle changes, PPI therapy, and treatment of any resulting complications from esophageal reflux. Patients who don’t respond to these initial strategies might need more invasive procedures, such as laparoscopic fundoplication or magnetic sphincter augmentation.

What Causes Gastroesophageal Reflux Disease (GERD) (Heartburn)?

The esophagus, which is the tube that connects your mouth to your stomach, has several structures that work to prevent stomach acid from backing up into it. This includes a valve-like mechanism between the esophagus and stomach, composed of the lower esophageal sphincter, diaphragm, a portion of the esophagus within the abdomen, the angle of His, and the phrenoesophageal membrane.

The lower esophageal sphincter is a band of muscle measuring 3 to 5 cm long that has a high resting tension to keep the stomach contents from flowing back into the esophagus. The diaphragm is another muscle that supports the lower esophageal sphincter by providing outside reinforcement.

The part of the esophagus in the abdomen collapses when not carrying food, which also aids the lower esophageal sphincter. The angle of His, an acute angle between the esophagus and the top of the stomach, amplifies the function of the lower esophageal sphincter. The phrenoesophageal membrane, a stretchy, fibrous band of tissue, extends from the diaphragm and wraps around the esophagus.

Other physiological safeguards against stomach acid reflux include esophageal movement, saliva production, and the natural protection of the esophagus lining.

The movement of the esophagus works to return any backed-up acid to the stomach. Saliva, which contains bicarbonate and is slightly basic, acts as a lubricant. Evolved submucosal glands in the esophagus secret additional bicarbonate and mucin to protect the lower esophagus lining from acidic stomach contents.

The reflux of stomach acid into the esophagus in healthy individuals is often minimal, and any refluxed contents are eliminated through esophageal movement. In patients with GERD, acid reflux is more prevalent as these individuals cannot effectively clear refluxed contents or produce defense mechanisms.

Possible causes of GERD include weakening or relaxation of the lower esophageal sphincter, hiatal hernia, increased pressure in the abdomen due to obesity or pregnancy, poor esophageal movement, and reduced saliva production. The natural defense mechanisms of the esophagus lining might also be weakened.

Moreover, certain people are more prone to developing GERD. These risk factors include being male, white, over the age of 50, a tobacco user, and a drinker of alcohol. Other risk factors include slow stomach emptying, liver disease associated with metabolic dysfunction, lower thoracic pressure, and psychosocial stress.

Risk Factors and Frequency for Gastroesophageal Reflux Disease (GERD) (Heartburn)

GERD, or acid reflux disease, shows different rates among different parts of the world. In Western countries, about 10-20% of people have GERD and 6% of them have severe forms of the disease. In Asian countries, around 5% of people have GERD. Both men and women are equally likely to have GERD, but men are more likely to have certain serious forms of the disease. Depending on the study, either men or women might have a higher rate of reflux esophagitis, or inflammation caused by GERD. Reflux esophagitis is most common in people age 60 to 70.

• GERD is also being diagnosed more and more in children, with 12-50% of children aged 0 to 18 diagnosed between 2000 and 2005.
• Premature babies also often have GERD.

Certain factors can increase your risk of having GERD, such as genetic differences, environmental factors, and lifestyle choices. Pregnant women often experience GERD, especially in the later stages of pregnancy. Overweight and obese people also have a higher risk of GERD, as do people with a liver disease called nonalcoholic fatty liver disease. Certain medications can also cause GERD symptoms.

Signs and Symptoms of Gastroesophageal Reflux Disease (GERD) (Heartburn)

GERD, or Gastroesophageal Reflux Disease, is characterized by heartburn and acid regurgitation. Heartburn is a burning sensation experienced mainly behind the breastbone within an hour of eating. This discomfort often starts in the upper area of the stomach and spreads towards the neck. Physical activities or lying down can trigger this sensation. Acid regurgitation is the feeling of a sour burning fluid moving up into the throat or mouth. This can be triggered by activities that increase pressure in the abdomen, such as bending forward.

Swallowing difficulties or dysphagia are reported by 30% of GERD patients who have reflux esophagitis. This condition can be associated with a narrowing of the esophagus due to scar tissue, weak muscle contractions (peristalsis), or inflammation of the mucosal lining. Other symptoms can include the sensation of a lump in the throat (globus) or increased salivation due to acidity in the esophagus (water brash).

Without heartburn and acid regurgitation, the less common symptoms such as hoarseness, globus, nausea, abdominal pain, and indigestion (dyspepsia) are unlikely to be associated with GERD. However, it’s important to note that some patients with severe esophagitis or Barrett’s esophagus, a complication of GERD, may not display any symptoms at all.

Atypical symptoms of GERD are also encountered, these include:

• Chest pain: Pain originating from the esophagus due to acid reflux may mimic heart pain.
• Chronic cough: GERD can lead to persistent coughing, believed to be caused by the acid stimulating nerves in the lower esophagus.
• Asthma: There is a noted association between asthma and GERD, although it is not clear whether one condition causes the other. Asthma medications might further promote acid reflux.
• Extraesophageal symptoms: GERD can also cause problems outside the esophagus such as dental erosion, change in voice, sore throat, and sudden tightening of the voice box.

Testing for Gastroesophageal Reflux Disease (GERD) (Heartburn)

Diagnosing gastroesophageal reflux disease or GERD can be a bit tricky. It is typically based on your symptoms, how you respond to a specific type of medicine called a proton pump inhibitor (PPI), and some diagnostic tests. If you have common symptoms like heartburn or acid reflux, a trial of PPI medication might help to confirm GERD. But if your symptoms are unusual, like chest pain, or you have serious symptoms, it’s recommended to run some tests instead of relying just on medication to diagnose GERD.

In wider scenarios, patients without alarm symptoms like difficulty swallowing, painful swallowing, significant weight loss, bleeding in the digestive tract, or loss of appetite may be started on PPI drugs for eight weeks. If their symptoms improve, it’s an indication that they may have GERD. If their symptoms don’t improve, or if they have atypical or alarming symptoms, other diagnostic tests like upper-endoscopy and ambulatory reflux monitoring might be required. People with chest pain should also be checked for heart issues before being evaluated for GERD. Similarly, people with difficulty swallowing may need an endoscopic examination to check for other serious problems like strictures, ulcers, or cancer in the esophagus.

Another diagnostic test, esophageal manometry, doesn’t help much in diagnosing GERD on its own, but it is often done before an anti-reflux surgery to rule out muscular disorders like achalasia or severe impairment of muscle mobility.

Ambulatory esophageal reflux monitoring is another test that measures the amount and frequency of acid reflux in your esophagus. It’s usually done when patients don’t respond well to PPI medications. This test can rule out GERD, but it’s typically done after stopping PPI therapy. In some cases, patients continue to have GERD symptoms despite being on PPIs, and their endoscopy test results may be normal because the PPIs have healed the inflammation caused by the acid reflux. Ambulatory reflux monitoring is also recommended in cases of refractory (resistant to treatment) GERD and in patients with extraesophageal symptoms suggesting GERD.

An upper endoscopy (also known as esophagogastroduodenoscopy) is recommended if you have typical GERD symptoms along with alarm or atypical symptoms. This procedure is often done in particular groups at high risk, such as those who are overweight, 50 years or above, or have had chronic acid reflux for more than 5 years. It’s also generally done in patients at risk of complications like Barrett’s esophagus, difficulty swallowing, gastrointestinal bleeding, esophageal stricture, esophageal cancer, peptic ulcer disease, and significant weight loss. According to current guidelines, patients suspected of having GERD but also at risk for heart disease should be evaluated for heart problems first. However, patients suspected of having GERD-induced noncardiac chest pain should undergo a diagnostic assessment (including endoscopy) before beginning PPI therapy.

When it comes to imaging studies, GERD is generally not diagnosed through methods like barium radiographs. Such studies are not very valuable in diagnosing GERD, although they can detect some complications like moderate to severe inflammation, esophageal strictures, a hiatal hernia, or tumors.

Treatment Options for Gastroesophageal Reflux Disease (GERD) (Heartburn)

For people with mild to moderate symptoms of GERD (Gastroesophageal reflux disease), lifestyle changes coupled with medication therapy such as proton pump inhibitors (PPIs), are usually the initial approach. Those patients with more severe GERD or patients who don’t respond to initial treatments may require long-term medication or more invasive procedures, like certain forms of surgery.

Lifestyle changes play a crucial role in managing GERD. Patients should be advised to lose any excess weight, as obesity significantly increases the risk of GERD. It’s also helpful to avoid eating at least 3 hours before bedtime and to elevate the head while sleeping to decrease reflux episodes. Other helpful changes include avoiding trigger foods like chocolate, caffeine, alcohol, and spicy foods, and abstaining from tobacco products.

Medication typically involves a PPI taken for eight weeks before the first meal of the day. If the patient only partially responds to this, the dose can be increased. Other medications such as antacids, histamine receptor antagonists, or movement-enhancing drugs may also be used but are not recommended for patients who don’t respond to PPIs. Patients who still have symptoms despite these treatments should be evaluated for other potential causes of their symptoms, such as food allergies, slow stomach emptying, irritable bowel syndrome, a muscular disorder of the esophagus, and mental health disorders.

For patients with more severe esophagitis, ongoing use of PPI therapy or surgery may be necessary. Patients suffering from medically resistant GERD, chronic inflammation of the esophagus, negative reactions to medication, or hernias, or those who wish to discontinue long-term medical treatment, might require surgical intervention. Laparoscopic fundoplication and bariatric surgery are common surgical options, with gastric bypass surgery being predominant in cases of obesity. However, patients should be assessed thoroughly with pH monitoring and manometry prior to surgery.

Some studies suggest that surgical treatment may be more effective or on par with medical treatment for GERD. However, some postoperative risks exist, including bloating, difficulty swallowing, and inability to belch. Studies also indicate that weight loss surgery can improve GERD symptoms. Gastric bypass surgery appears to be the most effective bariatric procedure in reducing GERD symptoms.

In today’s world of ever-advancing medical techniques, various endoscopic therapies have been developed to treat GERD. Still, most have been discontinued due to a lack of long-term effectiveness. Two notable exceptions include magnetic sphincter augmentation and transoral incision-less fundoplication, which data indicate can lead to decreased need for PPIs and improved quality of life.

What else can Gastroesophageal Reflux Disease (GERD) (Heartburn) be?

When a doctor is trying to diagnose GERD (gastroesophageal reflux disease), they also need to consider many other health conditions that might be causing the symptoms. These include:

• Coronary artery disease (heart conditions related to blocked blood vessels)
• Infectious esophagitis (infection in the esophagus)
• Eosinophilic esophagitis (allergic reaction in the esophagus)
• Peptic ulcer disease (ulcers in the stomach or upper intestines)
• Biliary colic (severe pain in your abdomen due to gallstones)
• Esophageal motor disorders (problems with the muscles and nerves in the esophagus)
• Esophageal stricture (narrowing of the esophagus)
• Esophageal cancer
• Dyspepsia (indigestion)
• Dysphagia (difficulty in swallowing)
• Rumination syndrome (repeatedly bringing up food from stomach into mouth)
• Esophagitis (inflammation in the esophagus) caused by radiation and chemotherapy
• Achalasia (a disorder affecting the ability of the esophagus to move food into the stomach)
• Gastroparesis (a condition where the stomach can’t empty itself of food in a normal way)
• Esophageal or gastric neoplasm (abnormal growth or tumor in the esophagus or stomach)

A careful examination is necessary to distinguish GERD from these other conditions in order to make an accurate diagnosis.

What to expect with Gastroesophageal Reflux Disease (GERD) (Heartburn)

Most people with GERD (gastroesophageal reflux disease) show positive improvement with medication, but it’s common for symptoms to return once the treatment stops – suggesting the necessity of ongoing therapy. There are cases where medication isn’t enough, particularly when there are complications such as a narrowed esophagus, trouble swallowing, lung disease, or Barrett’s esophagus (a condition linked to esophagus cancer). In these instances, a surgical procedure known as fundoplication might be required.

Generally, surgery has an excellent outlook but carries higher risks for patients with other complex health problems alongside esophageal reflux. Of note, about 10% of reflux patients will develop Barrett’s esophagus, a known risk factor for esophageal cancer.

Possible Complications When Diagnosed with Gastroesophageal Reflux Disease (GERD) (Heartburn)

GERD, or gastroesophageal reflux disease, can lead to several complications. The well-known complications include:

• Esophagitis: This condition is characterized by severe reflux and is most common in patients with serious grades of the disease. These patients have lower healing rates even with certain medications, and they can develop Barrett’s esophagus, a condition characterized by changes in the esophageal lining. Doctors generally recommend an endoscopy for these patients 8 to 10 weeks after starting therapy to monitor healing progress.
• Lower esophageal rings (Schatzki): This complication is linked to GERD. The primary method of managing it is through dilatation, followed by medication therapy.
• Barrett’s esophagus: This condition can occur in about 5% to 15% of patients with reflux esophagitis, which is inflammation of the esophagus because of stomach acid backing up into the esophagus. Barrett’s esophagus is more likely in white males over 50 who have severe reflux esophagitis and have been experiencing symptoms for a longer time.
• Peptic stricture: This usually occurs in older patients who have had GERD for an extended time, particularly if they have abnormal esophageal movement and haven’t been treating their reflux symptoms.
• Esophageal adenocarcinoma: Esophageal cancer is more common in men, with a ratio of 8 men for every 1 woman affected.
• Other complications: These can include peptic ulceration, gastric cardia cancer, difficulty swallowing, bleeding in the upper gastrointestinal tract, anemia from prolonged blood loss, laryngitis, cough, sinusitis, bronchial asthma, idiopathic pulmonary fibrosis, and dental erosions.

Preventing Gastroesophageal Reflux Disease (GERD) (Heartburn)

Making some changes to your lifestyle is a key part of managing GERD. If you’re dealing with this kind of digestive disorder, you might find it helpful to make the following adjustments:

If you’re overweight, try to shed some pounds. It’s also a good idea to steer clear of certain foods and beverages such as alcohol, chocolate, citrus juices, peppermint, and coffee. Try not to eat big meals and give yourself at least 3 hours to digest after eating before you lay down.

When you go to sleep, try raising the head of your bed by about 8 inches. This can help prevent stomach acid from flowing back up into your esophagus. Lastly, try to avoid activities that involve bending or stooping, as they can increase pressure on your stomach and potentially worsen your symptoms.