What is Gastroesophageal Reflux Disease?
Gastroesophageal reflux disease, also known as GERD, is a long-lasting stomach disorder that leads to stomach contents flowing back into the food pipe. It’s a common digestive problem in the United States, affecting 20% of people. Not only does this cause significant financial impact due to healthcare costs, but it also negatively impacts a person’s quality of life.
The cause of GERD can be down to a variety of factors – it could be an internal issue, related to the body’s structure, or a combination of both. This can result in the lower part of the food pipe being exposed to acidic stomach contents. Most times, GERD manifests as heartburn and feelings of food re-entering the mouth. But other times, it might present as chest pain, tooth decay, a persistent cough, voice box inflammation, or even asthma.
GERD can be split into three subtypes based on how it appears under an endoscope (camera that lets a doctor examine your food pipe) and what the tissue analysis reveals: non-erosive reflux disease (NERD), erosive esophagitis (EE), and Barrett’s esophagus (BE). NERD is the most common form, seen in 60-70% of GERD patients, followed by EE and BE, seen in 30% and 6-12% of patients, respectively.
For many years, the main ways to manage GERD have been changes to lifestyle and medications called proton pump inhibitors (PPIs). However, GERD that doesn’t respond to these treatments is becoming more common, requiring a more personalized treatment approach.
What Causes Gastroesophageal Reflux Disease?
We still don’t know exactly what causes gastroesophageal reflux disease (GERD), which is when stomach acid frequently flows back into the tube connecting your mouth and stomach (the esophagus). However, several risk factors have been identified over the years.
Some potential causes of GERD include certain abnormalities in the movement of the esophagus, which may result in poor acid clearance, or when the lower esophageal sphincter (LES) (the muscular ring where the esophagus and stomach meet) does not function properly.
Anatomical factors like the presence of a hiatal hernia (when part of the stomach pushes up through the diaphragm) or increased pressure inside the abdomen, often seen in obesity, can increase the risk of developing GERD.
In fact, a past review of various studies have shown a clear link between obesity and an increased risk of developing GERD symptoms, esophagitis (inflammation of the esophagus), and esophageal cancer (cancer of the esophagus). Another study of more than 6000 patients with GERD found that those with a higher body mass index (BMI) were more likely to have erosive reflux disease, which is a severe form of GERD that can damage the esophagus.
In addition to obesity, several other risk factors have been linked to the development of GERD symptoms. These include being 50 years of age or older, low socioeconomic status, tobacco use, heavy alcohol consumption, connective tissue disorders, and pregnancy. Certain behaviors, like lying down after meals (postprandial supination), and certain types of medications, such as some antidepressants, anticholinergic drugs (used to treat various conditions such as allergies and motion sickness), and nonsteroidal anti-inflammatory drugs (NSAIDs, which are commonly used to relieve pain and reduce inflammation), have also been associated with GERD.
Risk Factors and Frequency for Gastroesophageal Reflux Disease
GERD, or gastroesophageal reflux disease, is a commonly occurring digestive disorder that affects around 20% of adults in western cultures. Studies have suggested that the true percentage could be higher, since many people can now treat their symptoms with over-the-counter acid reducing medications. Interestingly, while GERD is somewhat more common in men than women, women who have GERD symptoms are often found to have a condition called NERD (non-erosive reflux disease), while men typically have a different type of damage known as erosive esophagitis. On the downside, men who experience GERD symptoms for a long time have a greater likelihood (23%) of developing a condition called Barrett’s esophagus in comparison to women (14%).
- GERD is a prevalent digestive disorder, affecting around 20% of adults in the western world.
- The actual number of cases may be higher due to the availability of over-the-counter acid reducing medications.
- GERD is slightly more common in men.
- Women with GERD symptoms are more likely to have NERD (non-erosive reflux disease).
- Men with GERD are more likely to have erosive esophagitis.
- Long-term GERD symptoms can lead to Barrett’s esophagus, with a higher likelihood in men (23%) than women (14%).
Signs and Symptoms of Gastroesophageal Reflux Disease
GERD, or gastroesophageal reflux disease, usually shows up as heartburn and acid reflux. However, there are many other symptoms that might indicate someone has GERD. These include:
- Difficulty swallowing – or “dysphagia”
- Pain when swallowing – or “odynophagia”
- Burping
- Stomach pain
- Nausea
- Heartburn, which is a burning sensation behind the breastbone that can also be felt in the neck and usually happens after eating or when lying down
- Regurgitation, which means stomach acid or food comes back up into the mouth or throat
- Atypical or lesser-known symptoms such as chest pain, chronic cough, asthma, inflamed voice box (laryngitis), dental erosions, change in voice quality, hoarseness, and feeling like something is stuck in the throat (globus sensation)
Testing for Gastroesophageal Reflux Disease
Diagnosing gastroesophageal reflux disease (GERD), a common condition where stomach acid comes up into the esophagus causing heartburn, can be tricky because there isn’t a single, definitive test for it. The diagnosis is often made based on your reported symptoms or a combination of responses to specific medications, examination of the upper digestive tract, and tests that can monitor if and when stomach acid is coming back up the esophagus.
One common way doctors try to diagnose GERD is with a proton pump inhibitor (PPI) trial. PPIs are a type of medicine that reduces the amount of stomach acid produced. If you see your doctor with typical GERD symptoms like heartburn and regurgitation (where food or liquid in the stomach leaks up towards the mouth) and a PPI helps your symptoms, your doctor will likely diagnose you with GERD. However, some experts question the accuracy of this method.
If you come in with typical GERD symptoms plus certain “alarm” symptoms — including difficulty swallowing, pain when swallowing, anemia (a lack of red blood cells), unexplained weight loss or vomiting blood — your doctor might suggest a procedure called an esophagogastroduodenoscopy (EGD). This procedure uses a long, flexible tube with a light and camera at one end to look at the inside of your esophagus, stomach and the first part of your small intestine. The EGD can help your doctor rule out other conditions and complications related to GERD.
Contrary to common practice, the current guidelines from the American College of Gastroenterology (ACG) do not recommend taking tissue samples from the lower part of the esophagus to diagnose GERD. In addition, they recommend that if a patient with heartburn-like symptoms is at high risk for coronary artery disease (a condition where the arteries supplying blood to the heart become narrow), they should be evaluated for that condition first.
Some doctors might use imaging tests like barium radiographs to look for signs of GERD. While these tests can detect some complications of GERD, they don’t usually help in diagnosing the condition.
A procedure called ambulatory esophageal reflux monitoring may be recommended if your GERD symptoms continue despite taking medication, or if you have symptoms not typically associated with GERD. This measures how often and for how long stomach acid enters the esophagus, and whether this acid reflux matches your symptoms. This monitoring can be done by attaching a tiny pH sensor to the wall of your esophagus (which measures the level of acidity), or by temporarily placing a thin, flexible tube (catheter) through the nose and into the esophagus. Currently, this test is the only way to definitively identify the presence of stomach acid in the esophagus, how often it’s happening, and if this flow of acid matches with your symptoms.
Before any type of GERD-related surgery, medical guidelines strongly recommend performing this preoperative ambulatory pH monitoring test if there’s no visual evidence of damaging acid reflux in the esophagus.
Treatment Options for Gastroesophageal Reflux Disease
The main aim in managing GERD, more commonly known as acid reflux, is to help to ease symptoms and stop complications like esophagitis (inflammation of the food pipe), BE (Barrett’s Esophagus, a serious complication of GERD), and esophageal cancer. There are several approaches to treatment, including changing lifestyle habits, medicines like antacids and others to reduce stomach acid, surgical procedures, and therapies that involve working through the inside of the body (endoluminal therapies).
Life changes, like losing weight if needed and not eating within three hours of going to bed, are usually the first steps in treating GERD. It’s also helpful to have good sleep habits, since a good night’s sleep can reduce the number of times stomach acid backs up into the esophagus. Raising the head of your bed can also help with GERD symptoms and pH balance in the stomach. The value of avoiding certain foods such as chocolate, caffeine, and spicy foods, citrus, and fizzy drinks is debated among experts.
If lifestyle changes aren’t enough, medication can help. These can include over-the-counter medicines such as some types of antacids and H2 blockers (which reduce the amount of acid your stomach makes), as well as prescription drugs known as proton pump inhibitors (PPIs). These reduce the production of stomach acid even further. Of all these options, PPIs have been found to be the most effective for both types of GERD (where the esophagus is damaged by acid and where it isn’t). Another option is prokinetic agents, which help the stomach empty faster, but their use in treating GERD is limited due to a lack of evidence and potential side effects on the nervous and cardiovascular systems.
GERD can also be treated with surgery, especially when medications aren’t effective, side effects from medications are intolerable, the person wants to avoid long-term medication, or the person has a large hiatal hernia. The types of surgery include Nissen fundoplication (a way to reinforce the lower esophagus to keep acid from backing up), partial fundoplication, and weight loss surgery in obese patients. Weight loss surgery has been found to be increasingly effective due to a growing prevalence of obesity in the US. However, all types of surgery carry a risk of complications, and it’s not yet clear whether surgery is better than medication for treating GERD.
There are also newer, minimally invasive procedures for GERD, including implanting a ring of magnetic beads (magnetic sphincter augmentation or MSA) to reinforce the lower esophagus, and a procedure called transoral incision-less fundoplication (TIF) which recreates the barrier between the stomach and esophagus using small incisions. Studies have shown that these techniques can reduce the need for medication and improve quality of life.
What else can Gastroesophageal Reflux Disease be?
The list of medical conditions that you see here are different possibilities that doctors might consider when diagnosing certain digestive or heart problems. This includes:
- Coronary artery disease
- Achalasia
- Eosinophilic esophagitis (EoE)
- Non-ulcer dyspepsia
- Rumination syndrome
- Esophageal diverticula
- Gastroparesis
- Esophageal and stomach tumors
- Peptic ulcer disease (PUD)
Possible Complications When Diagnosed with Gastroesophageal Reflux Disease
Erosive Esophagitis, or EE, is a condition where there are sores or ulcers on the lining of the esophagus. Sometimes, people with EE may not show any symptoms, or they may display worsening symptoms of GERD (Gastroesophageal Reflux Disease), a condition where stomach acid frequently flows back into the tube connecting your mouth and stomach. The severity of EE is determined using an endoscopic grade based on the Los Angeles esophagitis classification system. This system uses grading from A to D based on factors such as length, location, and severity of the sores in the esophagus.
- Erosive Esophagitis (EE)
In some cases, long-term acidic irritation to the bottom part of the esophagus can result in scarring. This scarring could cause the esophagus’s lower region to become constricted, leading to a problem called a peptic stricture. Symptoms could include difficulty swallowing or food getting stuck in the esophagus. The American College of Gastroenterology suggests treatment that includes esophageal dilation, a procedure to widen the esophagus, which is combined with continuous PPI therapy (Proton Pump Inhibitor), a medication used to reduce stomach acid production, to prevent repeated need for dilation.
- Esophageal Strictures
A condition called Barrett’s Esophagus can occur due to long-term exposure of the bottom of the esophagus to stomach acid. This results in a pathological change of the distal esophageal lining, the part of the esophagus that is normally lined by stratified squamous epithelium, into metaplastic columnar epithelium. This condition is seen more frequently in Caucasian males over 50 years, overweight individuals, and those with a history of smoking. It can also increase the risk of developing esophageal adenocarcinoma, a type of cancer. Current recommendations suggest performing continuous surveillance endoscopy in patients diagnosed with Barrett’s Esophagus.
- Barrett Esophagus