At one time or another everyone has an episode of heartburn, that uncomfortable burning sensation in the chest, usually after a meal. When this temporary condition becomes aggravating on a regular basis, more than twice a week, Gastroesophageal Reflux Disease (GERD) is diagnosed. GERD, or acid reflux, is when the valve separating the esophagus and stomach does not close. Acid backs up into the esophagus when this gate does not close and seal off the esophagus from the stomach.
The esophagus is the pipeline leading from the mouth to the stomach. In GERD, the lower esophageal sphincter (LES) opens or closes spontaneously and sporadically. The usual symptoms are heartburn, mostly after meals. Meals trigger the stomach to produce digestive fluids or acid that backs up into the esophagus. As meals are a critical part of maintaining body mass, supporting mood and initiating cell growth, frequent and painful reflux can disrupt one’s lifestyle and health. Infrequent acid reflux symptoms do not equal an increased risk of death, however, indicating a benign nature or even a protective nature for the majority of sufferers.
Transient relaxation of the sphincter and frequent episodes of reflux may however, lead to esophagitis or an inflamed lining of the esophagus. The esophagus may become narrow or bleed. The esophagus is easily injured and other consequences include asthma and vocal problems. Precancerous and cancerous conditions may develop. GERD complications may result in surgery or hospitalizations with esophageal adenocarcinoma, esophagitis, Barrett’s esophagus, esophageal ulcer, and esophageal stricture.
Seven million people in the US suffer from GERD; 60 percent of the population at some time during the year, and 20 to 30 percent weekly. The number of hospitalizations for GERD with a obesity diagnosis has risen by 112 percent while all other hospitalizations increased by only 13 percent.
The age group 18–34 years old is seeing increases of GERD at a rate of 273 percent. The US spent $622 million in 2005 for treatment. The American College of Emergency Physicians states that up to 60 percent of patients with chest pain visits to the emergency room are not related to the heart, but rather to gastrointestinal disturbances. Worldwide symptomology is increasing, in developed countries especially.
The British spelling of esophagus is “oesophagus” so GERD is called GORD in many European countries. GERD is a disease and heartburn is its most common symptom. GERD is a chronic condition and clinically diagnosed with a cluster of symptoms and signs. Significant health-care utilization and diminished quality of life is seen, although little attention is shown to the affliction. The cause or pathogenesis of GERD is yet unknown and no cure is agreed upon. However, lifestyle modifications and medications are effective for almost everyone.
Cause of Gerd
The majority of reflux episodes do not feature highly concentrated acid events. Researchers now believe that acid is not causing as much damage to the esophagus as was previously thought. When scientists dosed animal subject’s esophagus with stomach acid it took weeks to develop esophagitis. For GERD to be caused by the chemical acid, injury would have been seen immediately as acid has acute corrosion. Therefore, GERD is an inflammation to the esophageal mucosa. Inflammatory cells infiltrate and cause epithelial thickening more like that of the stomach or intestine, in order to protect itself from further injury by acid.
Esophageal muscles may also have a lack of tone which causes performance problems in motility. The digestive system can’t clear acids and other gastric contents and they back up into the esophagus. Abnormal muscular movements may delay esophageal motility especially when lying down. Potential drug treatments would aim to increase motility.
Alteration of a microbiome is often seen in GERD patients and not healthy subjects, but researchers are not sure if bacteria is triggering GERD or responding to it. These microbiome communities outnumber other cells in the human body by 10 to 1, yet their effect on physiology is not well understood. While healthy people have a high concentration of Streptococcus, GERD patients have microbiomes dominated by Gram-negative bacteria. New therapies with antibiotics, probiotic bacteria or prebiotics may restore balance.
Finding a genetic cause for GERD and related complications can improve detection, treatment, and quality of life. Twelve genes for mutation analysis have been identified as priority candidates. Three major genes, MSR1, ASCC1, and CTHRC1 account for 11% for GERD associated conditions. This is considered a moderate to high load of genetic susceptibility. In addition, two genes, CDK6 and CDK4 showed expression for the growth of esophageal cancer cells. Targeted therapies to chemically inhibit or block the effect of oncogenes may be developed in the future.
Consequences of GERD
Only a minority of patients develop complications of GERD. These complications include:
- Esophageal erosions – breaks in the lining of the esophagus. Those of an older age, those being of male gender, those with divorced/widowed status and those who have heavy tea consumption habits are also at higher risk.
- Esophageal stricture – scarring and narrowing of the esophagus. A stiff, thin or thick deviation in normal anatomy is seen with circular or linear patterns.
- Esophageal ulcer – a hole, sore, lesion or break in the lining of the esophagus.
- Epithelium Changes – normal esophageal lining or epithelium may be replaced with abnormal cells.
- Barrett’s esophagus – when inflammation and gastric acid causes the normal lining of the esophagus to change. These cell changes are precancerous and may lead to cancer.
- Cancer – survival rates for esophageal adenocarcinoma is 70 percent to 80 percent for early-stage patients. Advanced stage 3 or 4 patients have only a 5 percent to 20 percent survival rate. Most times the cancer has already spread, limiting survival chances. Experts say that esophageal cancer is increasing more rapidly than any other type of cancer. Patients with mild or moderate symptoms of GERD are more likely to be diagnosed with cancer. Those with severe symptoms are more likely to be aggressively treated and screened for precancerous conditions. Those with mild symptoms are unaware of that changes in the cell lining that may be precancerous. These cell changes become Barrett’s esophagus and may transform into cancer. Researchers believe that even patients without severe symptoms should be screened for Barrett’s esophagus to identify it before it becomes cancerous.
- Asthma – some patients with asthma might benefit from treatment of GERD and vice versa. Microaspiration causes gastric droplets to enter the airways and may cause asthma and Chronic Pulmonary Disease (COPD).
- Disordered Sleep – pain when lying down and altered nerve function in upper GI tract may lead to disordered sleep which creates a vicious cycle leading to symptoms of insomnia. 40-50% of people with GERD report significant impairment in sleep, including arousal from sleep, increased wakefulness and overall poor sleep quality. Insomnia is a known factor for depression and weight gain. Measuring sleep in GERD patients may help in long-term treatment and quality of life.
- Sleep Apnea – people with sleep apnea also have gastrointestinal conditions. Obstructive sleep apnea is a condition where the airway collapses during sleep and blocks airflow. Patients are forced to awake violently in order to get enough air. 84% of sleep apneas patients had some type of pathological gastrointestinal disorder, including hiatus hernia, erosive esophagitis, histological esophagitis, erosive gastritis, duodenal ulcer, and biliary reflux. About 12 million Americans have sleep apnea, and researchers believe that they should also be referred for gastrointestinal evaluation and treatment.
- Obesity – a direct relationship is shown between body mass index and the likelihood of experiencing GERD-related symptoms. Being overweight or obese increases the chance of having heartburn, acid reflux, GERD and related complications. Having these symptoms may also cause a rise in body mass, due to sleep disorders altering the hunger/satiation cycles.
- Pregnancy – heartburn is a common complaint for pregnant women, usually during the first trimester and worsening during the second and third trimesters. Elevated hormones like progesterone, and abdominal pressure from the developing fetus is thought to cause GERD symptoms.
- Children – diagnosis of GERD in children is not as clear as it is in adults. Symptom analysis finds different results and diagnosis should be based on clinical judgment, testing and follow-up studies. The most likely indicator for GERD in infants and children is chronic cough.
- Vocal cords – atypical damage to the throat and vocal cords may result from GERD symptoms. Usually those patients with more severe GERD symptoms develop laryngitis and vocal cord problems.
- Teeth – any type of systemic inflammation can make its way to the mouth and mucous membranes. The inflammation and acidic erosion in the gastrointestinal system sometimes erodes the tooth enamel, wearing them down. Odontoblast cells can be affected by GERD and cause tooth decay.
- Nose and Sinus – chronic rhinosinusitis (CRS) can develop due to GERD. Nose- and sinus-related problems can reduce the quality of life due to deviations in the respiratory process.
- Heartburn Season – for many people regardless of heritage, overindulging at holidays and festivities becomes problematic. Often fatty foods are present and people tend to eat more during holidays.
Anyone can get GERD even infants and children. Adults over the age of 40 are most likely to develop symptoms. 50 percent of cases are between the ages of 45-64. People in the age range of 18–34 are seeing the biggest increases in incidence. 30% of all hospitalizations occur among the elderly. Every social class, ethnic group and age is represented in GERD diagnoses, with slightly more cases seen among women. In the US, the Western region had the lowest incidence while the South had the highest incidence. The Midwest region is seeing the largest increase in incidence.
Obesity is a major factor in developing GERD, with a direct link between body mass and heartburn. People with normal weight do not experience heartburn like obese people do. Pregnancy also precipitates heartburn events and GERD. Smoking cigarettes is likely to trigger GERD symptoms as well.
Symptom-reflux association analysis (SAA) parameters can help diagnose GERD results with an agreement of these 3 SAA parameters:
- Symptom index (SI) – the percentage of reflux related symptom episodes.
- Symptom sensitivity index (SSI) – the percentage of symptom related reflux episodes.
- Symptom association probability (SAP) – a new type of statistical analysis using a contingency table consisting of four possible combinations of reflux and symptoms.
Common GERD Symptoms
The major factor in identifying symptoms is meals. Meals stimulate the gastric fluids to multiply in order to break down and digest stomach contents. When a person seeks medical treatment, the physician may ask about what was eaten and when. In other cases, a physician may ask if the problem presented when standing upright or lying down. An evaluation of current medication may be conducted as some medications can trigger heartburn. The top 4 typical symptoms for GERD are:
- chest pain – nonspecific, in the mid-chest, and in the mid-abdomen.
- heartburn – a rising, burning sensation behind the breastbone.
- regurgitation – acid or sour contents in the mouth.
- dysphagia – pain or trouble swallowing.
Atypical but common symptoms include:
- anemia – the amount of red blood cells which oxidize cells is reduced.
- vomiting – forced and unintended disgorgement of stomach contents.
- weight loss – an alarming symptom where body mass is reduced in a short amount of time.
- asthma – labored breathing which may induce panic.
- hoarseness/laryngitis- acid can cause inflammation of the back of the throat.
- chronic cough – an irritated airway causing removal of mucous.
- wheezing- an erratic breathing condition sometimes producing a distinct sound like whistling.
- blood in the stool – digestive problems and epithelial erosion may find its way into the excretory system.
- hematemesis – vomiting or coughing up blood.
- nausea – a dizzy, sick feeling preceding vomiting.
- early satiation – feeling not hungry or barely eating and feeling full.
- bloating – feeling full and gaseous as if the stomach and abdomen are big.
- belching – burping or ejecting stomach gases from the mouth.
People with non-erosive disease (NERD) differ from patients with erosive esophagitis. Non-erosive esophagitis patients have better sphincter muscle tone, better motility of esophagus contents, less acidic exposure and better nighttime experiences. Cardiac or pulmonary disease also produces symptoms similar to GERD.
People often visit a hospital with chest pains that turn out to be not related to a heart condition. A gastroenterologist is consulted who is familiar with GERD and its treatment. A series of tests are conducted depending on severity of symptoms and the patient’s discomfort:
- Endoscopy – a thin, flexible tube inspects the lining of the upper gastrointestinal tract. This procedure identifies GERD and is the only way to diagnose Barrett’s esophagus. Other deviations including tumors and cancer may be detected in this way as well.
- Biopsy – a small sample of tissue may be obtained for further analysis.
- Conventional pH monitoring – measures acidity.
- MII-pH monitoring – a device that can detect non-acid reflux without depending on the acidity of the contents that refluxes into the esophagus.
- Esophageal impedance – uses a probe that is placed into the esophagus with a catheter to differentiate between acidic reflux and non-acidic reflux that would not be detected by a pH probe.
- Narrow band imaging – evaluates mucosal surfaces and improves the endoscopic diagnosis of GERD by differentiating between normal mucosa and inflamed mucosa.
- Scintigraphic imaging – uses internal radionuclides to create two-dimensional images. Evaluation of the gastrointestinal system is complicated and imaging techniques may aid in evaluation. Scintography may be more effective than traditional barium X-ray technology.
- Manometry – examines the physical structure and pressure in the esophagus. Peristalsis or the flow of food down the pipeline is measured with a probe inserted through the nose, down the throat, down the esophagus, and into the stomach.
Treatment for GERD consists of suppressing acid, however new theories implicate inflammation as the cause for GERD, with anti-inflammation medications and lifestyle changes recommended. Nutritional choices become important including avoiding certain foods and beverages. Home treatments like antacids for heartburn may not work as the esophagus suffers repeated damage from acidic events, and medical treatment and long-term management becomes necessary.
Pain management becomes an issue for GERD sufferers and they often want to know if there is anything else they can do to relieve pain. Patients may be only eating small, bland meals, avoiding alcohol and taking their medications but still be suffering from pain. When lifestyle changes and medications don’t work in severe cases, surgery is an option. Surgery won’t cure the acidic or inflammatory conditions or the underlying problem, but surgery can mechanically fix the esophagus to some extent.
GERD may be an immune-mediated injury, where cytokines attract inflammatory cells to the esophagus and start an inflammatory process which causes the injury in the first place. Medications would consist of anti-inflammatory agents, nonsteroidal anti-inflammatory drugs (NSAIDs). Aspirin, ibuprofen, and naproxen are common over the counter medications which reduce pain and inflammation. COX-2 inhibitors are often prescribed for long-term conditions because they may be safer for the stomach.
Proton pump inhibitors (PPI) are generally safe medicines which can serve to achieve and maintain remission. Patients must continue to take the drug as a high rate of relapse is seen upon stopping treatment. Proton pump inhibitors may take hours or days to reach their full effect. Active healing of the esophagus may take a considerable time after acid suppression is realized. While most people do continue take their medications, long-term outcomes may be reduced due to a lack of compliance with medication.
- Esomeprazole – 92 percent of people who take esomeprazole remained in remission. Esomeprazole, brand name Prilosec and Nexium, suppresses acid secretion by inhibiting the functioning of ATPase enzyme in gastric parietal cells. Physicians may use this drug to both diagnosis GERD and prescribe initial treatment. During an endoscopy the physician may administer the drug to see if acid suppression is successful.
- Rabeprazole – brand name Pariet, also works to reduce the production of stomach acid. Sometimes it is used with antibiotics to eliminate harmful bacteria and treat ulcers.
- Lansoprazole – brand name Prevacid, works to prevent the stomach from secreting gastric acid. This medication can be taken naso-gastrically for those who cannot swallow pills.
- Dexlansoprazole – brand names Kapidex, Dexilant, has a dual release technology. One dose is released about an hour after ingestion in the proximal duodenum and the second release about four hours later in the small intestine.
The downside of chronic and long-term use of PPIs may cause one to be asymptomatic even when the esophagus and gastrointestinal system is still being damaged. Other complications associated with PPIs:
- vitamin B12, iron and calcium malabsorption – alteration of the gastric pH may produce defects in absorption of nutrients.
- fractures in postmenopausal women – increased rates of hip fractures, possibly related to altered calcium absorption.
- bacterial infections in many patients – acid suppressors alter gastrointestinal and respiratory bacteria, increasing the likelihood of an infection.
- pneumonia – hospitalized patients who use PPIs have a 30% greater incidence of pneumonia. Acid suppressive medications exposed patients to acquiring pneumonia while admitted to the hospital. Suppressing acid is thought to modify respiratory bacteria. Acquiring pneumonia while in the hospital may lead to an extended stay in the hospital and increases the risk of death.
- body weight – 71% of patients may gain an average of 3.5 kg. or 8 lbs. Patients who take PPIs are encouraged to lead a balanced lifestyle including exercise to prevent weight gain.
Alternative Methods of Treatment
The Linx system
Proton Pump inhibitors are commonly used but often do not prevent reflux. The Linx system is an alternative treatment after trying medication, but before trying surgery. A small, flexible band of titanium beads similar to a bracelet is placed laparoscopically around the lower esophagus. A magnetic core holds the beads in place and together they act to support the natural sphincter action of the esophagus.
Some researchers insist that all GERD patients be screened for Barrett’s esophagus. Treatment of Barrett’s esophagus aims to reduce the amount of abnormal lining in the esophagus. Ablation therapy is a safe and effective method to remove unwanted tissue in order that new healthy tissue may grow. Different types of ablation may be used including radiofrequency ablation, multipolar electrocoagulation, argon plasma coagulation, and cryotherapy. Ablation can also be used in conjunction with medication and surgery.
Surgery For GERD
Some patients do not respond to medication, are reluctant to take long-term medication, suffer medication side effects and/or may prefer to have anti-reflux surgery. 85 percent of patients who elect surgery achieve long-term remission of GERD. Some types of surgery include:
- Laparoscopic Nissen Fundoplication – major surgery to mechanically fix the anatomical problem by wrapping part of the stomach around the lower end of the esophagus to help keep acid from getting back up into the esophagus.
- Laparoscopy – Laparoscopic anti-reflux surgery (LARS) is a minimally invasive surgery that accomplishes the goals of major surgery. This procedure requires 1 to 5 port holes for the insertion of medical instruments, but has the same internal incisions and scarring seen in major surgery.
- TIF procedure – Transoral Incisionless Fundoplication is a minutely invasive surgery that accomplishes the goals of major surgery without an external or internal incision. The procedure is accomplished trans-orally or through the mouth. The procedure recreates the anti-reflux barrier between the esophagus and stomach by using part of the stomach to create a valve.
Strategies during Pregnancy
Pregnant women often develop heartburn and GERD related symptoms usually during the first trimester and worsening during the second and third trimesters. Physicians recommend that pregnant women try to solve the problem first through lifestyle and dietary changes. Dietary recommendations are the same as for non-pregnant people. These tips however apply just to pregnant women:
- Tight fitting clothes serve to further restrict the abdomen and put pressure on the lower esophageal sphincter.
- Consult your doctor before taking any medication including antacids to relieve heartburn symptoms. Antacids should be used cautiously during pregnancy. Antacids containing aluminum or calcium are considered safe. Antacids containing magnesium-or sodium bicarbonate should be avoided.
- Zantac was found to be effective in reducing the symptoms of heartburn and acid regurgitation with no adverse effects on the fetus.
- The proton pump inhibitor Lansoprazole, brand name Prevacid is reported safe for pregnant women, however should be reserved for more severe cases. Newer PPIs have limited data about safety during pregnancy.
Nutrition: Foods to Avoid
GERD sufferers may have a restricted diet or bland diet which becomes unsatisfying and difficult to maintain. Some foods may irritate while others may not. Individuals are encouraged to experiment and discover for themselves which foods trigger symptoms. The situation may be fluid in that some foods may become more acceptable at a later time. Fasting for a day or two to clear all food and then introducing foods one at a time may help to identify triggers. A food diary is also a good idea to track GERD events. Consultation with a nutritionist is recommended to identify culprits and ensure a well-balanced and satisfying diet. Some foods and beverages thought to trigger GERD symptoms:
- fatty foods
- greasy food
- spicy food
- tomato sauces
- carbonated drinks
- citrus fruits
Sleep is an important physiological process but GERD sufferers may face problems with sleeping:
- Don’t lie down after eating because it’s easier for acid to back up into the esophagus while lying down.
- Wait at least 3 hours after eating before going to bed because when you go to bed with a full stomach, acid is more readily available to back up into the esophagus.
- Large meals may produce heartburn in some people.
- Raise the head off of the bed 4 to 6 inches with a pillow. Sleeping with the head and shoulders elevated may reduce acid build-up.
As GERD may be an immune system deficiency maintaining a healthy immune system through exercise is important. Exercise also works to maintain a low body mass which may reduce GERD symptoms. As many obese people have GERD, weight loss is encouraged. PPI’s may increase the risk of weight gain so patients are best served by maintaining a healthy weight through exercise.
Esophageal mucosa may benefit from the protective effects of ecabet sodium (ES). Prevention of reflux esophagitis may be realized with the administration of ES. This mucoprotective agent inhibits the epithelial thickening of the lower and middle esophagus. ES may have uses as a prophylactic to prevent GERD, or to speed healing.
New methods to diagnose GERD offer improved sensitivity, specificity, and are not expensive or invasive. Exhaled breath condensate analysis and electronic nose technology are new methods undergoing trials.
- Exhaled breath condensate analysis (EBC) can determine airway inflammation. Sampling of pH, nitrogen oxides (NOx), and leukotriene B4 (LTB4) markers can discover inflammatory airway diseases and GERD biomarkers.
- Electronic nose technology can diagnose multi-microbial problems and is used to sense medical, animal and plant diseases. The instrument measures electrical resistance changes to fingerprint volatile compounds.
Differentiation between a GERD event and coughing is made easier with a sound device to precisely measure the timing and sounds. A reflux event has a different sound than coughing. Coughing, especially in infants and children, is the most recognizable symptom of GERD. A custom-built validated recording device and microphone was used and integrated with software and an audiovisual display. The data is also being used to identify how a cough interacts with or results from a reflux event.
Barrett’s esophagus – cells change, harden or thicken in reaction to erosive acid. This condition is thought to be pre-cancerous. Patients may have Barrett’s esophagus, but may not be aware of it, if their symptoms are not severe. Researchers recommend that all GERD sufferers be screened for Barrett’s as treatment is available, and because it may be a precursor for cancer.
Obesity – people who are overweight or obese commonly have GERD, much more so than in the normal weight population. Hospitalization for GERD symptoms has seen a three fold increase in obese patients.
Peptic ulcer disease – a hole in the lining of the stomach or duodenum can form from imbalanced digestive fluids, bacteria, and aspirin-type drugs.
Hiatal hernia – part of the stomach may distend through the diaphragm and into the chest. Symptoms of GERD are present as the hernia interferes with the esophageal sphincter.
Functional dyspepsia – is a common upper GI condition with abdominal pain pressure or discomfort in the upper abdomen. Upset stomach can develop from a medical problem or food issue.
GERD is a clinical diagnosis for chronic events relating to esophagus malfunctioning. Specifically, the valve at the end of the esophagus leading to the stomach does not close properly. Digestive fluids and acids back up into the esophagus and cause gastrointestinal distress. These fluids are meant to be sealed into the stomach to digest food and nutrients. When the acid is allowed back into the esophagus where it does not belong, people experience discomfort.
The main symptoms are nonspecific chest pain in the mid-chest, and in the mid-abdomen. Sometimes this symptom is mistaken for a heart related event, and people commonly visit the emergency room at the hospital when they experience this kind of pain. Heartburn is another main symptom causing a rising, burning sensation behind the breastbone. Regurgitation of stomach contents into the mouth or having an acid or sour taste in the mouth is the third main symptom. Dysphagia is having pain or trouble swallowing and is the fourth and final main symptom of GERD.
Other symptoms may be present and these symptoms, combined with an individual’s medical history and diagnostic tests may lead to a diagnosis of GERD. Once a diagnosis is reached, acid suppressive therapy with the use of PPI’s is the commonly accepted treatment. However, new evidence supports a treatment approach based on providing anti-inflammatory agents to stop inflammation and speed healing. For those with GERD, lifelong medication may be necessary, as relapse is common when stopping medication.
For some however, medication does not work, so surgery is an available option. New kinds of surgery go beyond even “minimally invasive” laparoscopic techniques. Incision-less surgery is possible to mechanically fix the malfunctioning valve at the base of the esophagus.
Most people can achieve remission with lifestyle changes, medication or surgery. For some though, complications can result including cancer. All patients with GERD are advised to get a thorough screening, even if they do not have severe symptoms. Those with mild symptoms may not undergo a complete evaluation and precancerous and cancerous conditions may be present. Finding a cancerous condition at an advanced stage does not give a good outcome.
Basic lifestyle recommendations are the same for GERD patients as for the general population. Exercise serves to keep body mass normal. Nutrition provides raw energy production and supports the immune system. Avoidance of fatty and sugary foods is good advice for everyone, especially GERD patients. Proper sleep plays a critical role in keeping weight down and maintaining a healthy immune system.