An Educational Resource For Heartburn And Acid Reflux

What is GERD?

Gastroesophageal reflux disease (GERD) is the abnormal reflux of stomach contents, including acid, into the esophagus (the tubular structure that connects the mouth to the stomach). GERD can manifest itself in many different ways. The majority of people with GERD experience a burning sensation in their upper abdomen after eating, commonly known as “heartburn”. However, GERD may also cause hoarseness, difficulty swallowing or asthma. In some people the diagnosis of GERD may be confused with cardiac (heart) pain, which can also result in a burning feeling in the chest.

Approximately 7% of the U.S. population experiences GERD-type symptoms daily and roughly 40% of people have GERD on a monthly basis. Numerous tests can confirm the diagnosis of GERD, however the presence of typical symptoms is usually sufficient to make the diagnosis and begin treatment. It should be mentioned that patients with a history of heart disease or with heart disease risk factors (older age, diabetes, smoking, high blood pressure and/or history of heart disease in family members) might need a formal evaluation to establish that the discomfort is not the result of heart problems.
 

What causes GERD?

The causes of GERD can vary from person to person. Between the end of the esophagus and the stomach is a ring of muscle known as the lower esophageal sphincter. This sphincter normally prevents the backflow of stomach contents into the esophagus. Many patients with GERD have been found to have inappropriate, brief relaxations of this sphincter. These relaxations allow the irritating acid and digestive juices of the stomach to come into contact with the esophageal lining.

Medicines, food and tobacco
Some medicines and foods (e.g. chocolate, peppermint, alcohol) are known to produce relaxations of this sphincter, which can worsen the symptoms of GERD. Tobacco has also been shown to relax the lower esophageal sphincter.

Pressure inside the abdomen
Another cause of GERD is increased pressure inside the abdomen, which may help “push” stomach contents into the esophagus. Pregnancy, obesity and overeating can all increase abdominal pressure and increase the risk for GERD.

Hiatal hernia
Many patients ask about the role of a hiatal hernia in GERD. In normal anatomy, the end of the esophagus and the lower esophageal sphincter are at the same level of the diaphragm, which is the broad muscle that horizontally crosses the abdomen and helps us breathe. There is a hole in the diaphragm through which the esophagus enters the abdominal cavity. Normally the entire stomach is below the diaphragm. If part of the stomach has shifted above the diaphragm, a person is said to have a hiatal hernia. Hiatal hernias are found in approximately 50% of people over the age of 50. Although the majority of people with hiatal hernias do not have GERD, the majority of people with GERD have hiatal hernias.
 

GERD Treatments

The mainstays of the treatment for GERD are lifestyle modifications and, if necessary, medicines to decrease the amount of acid in the stomach.

Nighttime modifications
I advise my patients with GERD to avoid eating late night snacks, and to avoid lying down for at least three hours after eating. I also recommend that they elevate the head of their beds 6 to 8 inches when they sleep.

Eating and drinking modifications
Patients with GERD should avoid excessive carbonated beverages, coffee (including decaffeinated coffee) and alcohol. Chocolate, peppermint and foods that are known to produce discomfort should also be eliminated. Many of my patients ask whether “spicy” foods are bad for reflux. If the food in question provokes discomfort, it should be avoided. In addition, smoking should be stopped and overeating should be avoided. If you are overweight, weight loss may help your GERD.

Antacids and medicines
If these lifestyle modifications fail to relieve your symptoms, occasional over-the-counter antacids may be tried. They act by neutralizing stomach acid. Nonprescription antacids are commonly used – they are taken at least twice a month by more than a quarter of the adult population.

Several over-the-counter medicines now available (e.g. Pepcid, Tagamet, Zantac, Axid) decrease stomach acid by blocking the cells that produce stomach acid. These same types of medicines are available in stronger prescription dosages. If your reflux symptoms are not responding to over-the-counter medicines or you are requiring increasing doses to alleviate your discomfort, you should see your doctor about the stronger medicines available and the possible need for further tests. Pregnant patients with GERD must also be careful to check with their doctors about what medicines are safe for the baby.

Surgical procedures
It is generally agreed upon that shorter courses of medications taken on an as-needed basis are better than lifelong medical treatment to control GERD. However, in up to 80% of people with moderate to severe GERD, a recurrence of symptoms and esophagitis occurs when medical treatment is stopped. Esophagitis, or inflammation of the esophagus, is generally caused by the irritation from stomach acid in the esophagus. For people that require large doses of medicines to remain symptom free or are unable to stop medicines without recurring symptoms, surgical procedures to prevent reflux may be required.
 

The Role of Endoscopy in GERD Diagnosis

There are many ways to diagnose GERD, but because it is such a common condition that is usually accompanied by typical symptoms, treatment is often started without performing any invasive tests. In atypical cases, GERD may be diagnosed by barium esophagogram (an x-ray of the esophagus and stomach taken after a patient drinks a special liquid) and 24-hour esophageal pH testing. A 24-hour esophageal pH test records the amount of time that the end of the esophagus is exposed to acid and allows a physician to determine whether any episodes of discomfort are related to acid exposure. In addition to the above tests, more and more doctors are now relying on gastrointestinal endoscopy to make the diagnosis of GERD.

Endoscopy
Gastrointestinal endoscopy involves placing a thin tube (with an attached fiberoptic camera) through the mouth and into the esophagus and stomach to view the inner lining of the gastrointestinal tract. A patient undergoing an endoscopy is usually given a mild sedative, as the procedure is uncomfortable (though generally not painful). For the patient with GERD, endoscopy allows a gastroenterologist to determine whether the refluxed acid has produced any tissue damage.

Patients with GERD should have an endoscopy if they have any unexplained weight loss or vomiting, difficulty swallowing, evidence of bleeding from their gastrointestinal tract or anemia (low red blood cell count). These are sometimes called the “alarm signs”. It is important for these people to undergo endoscopy because they may have other explanations for their symptoms that can be found by looking inside their gastrointestinal tracts. In addition, patients who are older than 45 when they start having GERD symptoms or those who have not responded to the standard treatments mentioned above are often advised to undergo endoscopy.
 

The Rising Rate of Esophageal Cancer

Over the past decade the rate of esophageal cancer has risen at an alarming rate. The number of new cases of esophageal cancer has increased more than almost any other type of cancer. No one is quite sure why this is happening. A recent study suggested that the more frequent, more severe, and longer-lasting the symptoms of reflux, the greater the risk for esophageal cancer. It is therefore important that if you have severe GERD symptoms that does not respond to medical treatment or any of the “alarm signs” mentioned above, you should be evaluated by a physician.

Barrett’s esophagus
Esophageal cancer frequently arises in patients with Barrett’s esophagus. Barrett’s esophagus is a change in the lining of the tissue of the esophagus that is thought to be caused by chronic GERD. Approximately 12% of people with chronic GERD are found to have Barrett’s esophagus. It is more common in older white men and is rare in Asians and African Americans. Patients with Barrett’s esophagus are advised to undergo endoscopy regularly to watch for any abnormal tissue in the esophagus that may precede cancerous changes.
 

GERD and Helicobacter Pylori

In 1984 a new bacterium was discovered in people with ulcers and inflammation of the stomach. This bacterium is thought to cause the majority of ulcers that are not due to the ingestion of nonsteroidal anti-inflammatory medicines (i.e. aspirin, ibuprofen). More than 50% of the world’s population is infected with this bacterium, known as Helicobacter pylori (H. pylori for short). Infection generally occurs in childhood and humans appear to be the only animals normally infected with H. pylori.

There is some evidence that treatment of H. pylori with antibiotics can improve the discomfort that some people experience after eating, though this remains controversial. A physician may determine that a patient is infected with this bacterium in one of the following ways:

• Blood test
• Stomach biopsy (retrieval of stomach cells for study during an endoscopy)
• Breath test

Summary

GERD is a very common condition that many people experience on a frequent basis. Lifestyle changes and medicines taken on an as-needed basis usually control GERD fairly easily. If your symptoms are worsening, or you require more and more medicine to control your GERD, you should see a physician for further evaluation.