Gastroesophageal reflux disease (GERD) is a digestive disorder that occurs when acidic stomach juices, or food and fluids back up from the stomach into the esophagus. GERD affects people of all ages—from infants to older adults.
People with asthma are at higher risk of developing GERD. Asthma flare-ups can cause the lower esophageal sphincter to relax, allowing stomach contents to flow back, or reflux, into the esophagus. Some asthma medications (especially theophylline) may worsen reflux symptoms.
What Is GERD?
Gastroesophageal reflux disease, or GERD, is a digestive disorder that affects the ring of muscle between your esophagus and your stomach. This ring is called the lower esophageal sphincter (LES). If you have it, you may get heartburn or acid indigestion. Doctors think that some people may have it because of a condition called hiatal hernia. In most cases, you can ease your GERD symptoms through diet and lifestyle changes. But some people may need medication or surgery.
Your doctor may also use these names for GERD:
- Acid indigestion
- Acid reflux
- Acid regurgitation
- Heartburn
- Reflux
GERD can interfere with daily living, but most people can get relief from it through lifestyle changes, home remedies, and medical treatment.
GERD is a chronic condition. Once it begins, it usually is life-long. If there is an injury to the lining of the esophagus (esophagitis), this also is a chronic condition. Moreover, after the esophagus has healed with treatment and treatment is stopped, the injury will return in most patients within a few months. Once treatment for GERD is begun it will need to be continued indefinitely although. However, some patients with intermittent symptoms and no esophagitis can be treated only during symptomatic periods.
In fact, reflux of the stomach’s liquid contents into the esophagus occurs in most normal individuals. One study found that reflux occurs frequently in normal individuals as in patients with GERD. In patients with GERD, however, the refluxed liquid contains acid more often, and the acid remains in the esophagus longer. It has also been found that liquid refluxes to a higher level in the esophagus in patients with GERD than normal individuals.
As is often the case, the body has ways to protect itself from the harmful effects of reflux and acid. For example, most reflux occurs during the day when individuals are upright. In the upright position, the refluxed liquid is more likely to flow back down into the stomach due to the effect of gravity. In addition, while individuals are awake, they repeatedly swallow, whether or not there is reflux. Each swallow carries any refluxed liquid back into the stomach.
Finally, the salivary glands in the mouth produce saliva, which contains bicarbonate. With each swallow, bicarbonate-containing saliva travels down the esophagus. The bicarbonate neutralizes the small amount of acid that remains in the esophagus after gravity and swallowing has removed most of the acidic liquid.
Signs and Symptoms of GERD
GERD has increasingly become a personalized disease,” says Abraham Khan, MD, gastroenterologist and medical director of the Center for Esophageal Health at NYU Langone Health in New York City. Not everyone with GERD has the same underlying causes, symptoms, or amount of injury to the esophagus or aerodigestive tract, he says.
Still, there are some typical telltale signs of GERD.
The most common symptom of GERD is frequent heartburn, felt by a painful, burning sensation in the middle of your chest. “Usually, if the heartburn is mild and less than two times a week, it is considered mild GERD,” says Saleem Chowdhry, MD, a gastroenterologist at the Cleveland Clinic. “Symptoms more than two times a week and where there is concern for inflammation in the esophagus is considered moderate or severe GERD.”
Other common symptoms of GERD:
- Chest pain
- Regurgitating your stomach’s contents
- Difficulty swallowing
- Bad breath
- Nausea and vomiting
- Sore throat or an irritated feeling in your esophagus
What Causes GERD?
The cause of GERD is complex and may involve multiple causes. Moreover, different causes may affect different individuals or even in the same individual at different times. A small number of patients with GERD produce abnormally large amounts of acid, but this is uncommon and not a contributing factor in the vast majority of patients.
The factors that contribute to GERD are:
- lower esophageal sphincter abnormalities,
- hiatal hernias,
- abnormal esophageal contractions, and
- slow or prolonged emptying of the stomach.
Lower esophageal sphincter
The action of the lower esophageal sphincter (LES) is perhaps the most important factor (mechanism) for preventing reflux. The esophagus is a muscular tube that extends from the lower throat to the stomach. The LES is a specialized ring of muscle that surrounds the lower-most end of the esophagus where it joins the stomach. The muscle that makes up the LES is active most of the time, that is, at rest. This means that it is contracting and closing off the passage from the esophagus into the stomach.
This closing of the passage prevents reflux. When food or saliva is swallowed, the LES relaxes for a few seconds to allow the food or saliva to pass from the esophagus into the stomach, and then it closes again.
Several different abnormalities of the LES have been found in patients with GERD. Two of them involve the function of the LES. The first is abnormally weak contraction of the LES, which reduces its ability to prevent reflux. The second is abnormal relaxations of the LES, called transient LES relaxations. They are abnormal in that they do not accompany swallows and they last for a long time, up to several minutes. These prolonged relaxations allow reflux to occur more easily. The transient LES relaxations occur in patients with GERD most commonly after meals when the stomach is distended with food. Transient LES relaxations also occur in individuals without GERD, but they are infrequent.
The most recently-described abnormality in patients with GERD is laxity of the LES. Specifically, similar distending pressures open the LES more in patients with GERD than in individuals without GERD. At least theoretically, this would allow easier opening of the LES and/or greater backward flow of acid into the esophagus when the LES is open.
Hiatal hernia
Hiatal hernias contribute to reflux, although the way in which they contribute is not clear. A majority of patients with GERD have hiatal hernias, but many do not. Therefore, it is not necessary to have a hiatal hernia in order to have GERD. Moreover, many people have hiatal hernias but do not have GERD. It is not known for certain how or why hiatal hernias develop.
Normally, the LES is located at the same level where the esophagus passes from the chest through a small opening in the diaphragm and into the abdomen. (The diaphragm is a muscular, horizontal partition that separates the chest from the abdomen.) When there is a hiatal hernia, a small part of the upper stomach that attaches to the esophagus pushes up through the diaphragm. As a result, a small part of the stomach and the LES come to lie in the chest, and the LES is no longer at the level of the diaphragm.
It appears that the diaphragm that surrounds the LES is important in preventing reflux. That is, in individuals without hiatal hernias, the diaphragm surrounding the esophagus is continuously contracted, but then relaxes with swallows, just like the LES. Note that the effects of the LES and diaphragm occur at the same location in patients without hiatal hernias. Therefore, the barrier to reflux is equal to the sum of the pressures generated by the LES and the diaphragm. When the LES moves into the chest with a hiatal hernia, the diaphragm and the LES continue to exert their pressures and barrier effect.
However, they now do so at different locations. Consequently, the pressures are no longer additive. Instead, a single, high-pressure barrier to reflux is replaced by two barriers of lower pressure, and reflux thus occurs more easily. So, decreasing the pressure barrier is one way that a hiatal hernia can contribute to reflux.
Esophageal contractions
As previously mentioned, swallows are important in eliminating acid in the esophagus. Swallowing causes a ring-like wave of contraction of the esophageal muscles, which narrows the lumen (inner cavity) of the esophagus. The contraction, referred to as peristalsis, begins in the upper esophagus and travels to the lower esophagus. It pushes food, saliva, and whatever else is in the esophagus into the stomach.
When the wave of contraction is defective, refluxed acid is not pushed back into the stomach. In patients with GERD, several abnormalities of contraction have been described. For example, waves of contraction may not begin after each swallow or the waves of contraction may die out before they reach the stomach. Also, the pressure generated by the contractions may be too weak to push the acid back into the stomach. Such abnormalities of contraction, which reduce the clearance of acid from the esophagus, are found frequently in patients with GERD. In fact, they are found most frequently in those patients with the most severe GERD.
The effects of abnormal esophageal contractions would be expected to be worse at night when gravity is not helping to return refluxed acid to the stomach. Note that smoking also substantially reduces the clearance of acid from the esophagus. This effect continues for at least 6 hours after the last cigarette.
Emptying of the stomach
Most reflux during the day occurs after meals. This reflux probably is due to transient LES relaxations that are caused by distention of the stomach with food. A minority of patients with GERD, about, has been found to have stomachs that empty abnormally slowly after a meal. This is called gastroparesis. The slower emptying of the stomach prolongs the distention of the stomach with food after meals. Therefore, the slower emptying prolongs the period of time during which reflux is more likely to occur. There are several medications associated with impaired gastric emptying, such as:
- narcotics,
- tricyclic antidepressants,
- calcium channel blockers (CCBs),
- clonidine,
- dopamine agonists,
- lithium (Eskalith, Lithobid), nicotine and progesterone.
Individuals should not stop taking these or any drugs that are prescribed until the prescribing doctor has discussed the potential GERD situation with them.
How is GERD Diagnosed?
Usually your provider can tell if you have simple acid reflux (not chronic) by talking with you about your symptoms and medical history. You and your provider can talk about controlling your symptoms through diet and medications.
If these strategies don’t help, your provider may ask you to get tested for GERD. Tests for GERD include:
- Upper gastrointestinal GI endoscopy and biopsy: Your provider feeds an endoscope (a long tube with a light attached) through your mouth and throat to look at the lining of your upper GI tract (esophagus and stomach and duodenum). The provider also cuts out a small bit of tissue (biopsy) to examine for GERD or other problems.
- Upper GI series: X-rays of your upper GI tract show any problems related to GERD. You drink barium, a liquid that moves through your tract as the X-ray tech takes pictures.
- Esophageal pH and impedance monitoring and Bravo wireless esophageal pH monitoring: These tests both measure the pH levels in your esophagus. Your provider inserts a thin tube through your nose or mouth into your stomach. Then you are sent home with a monitor that measures and records your pH as you go about your normal eating and sleeping. You’ll wear the esophageal pH and impedance monitor for 24 hours while the Bravo system is worn for 48 hours.
- Esophageal manometry: A manometry tests the functionality of lower esophageal sphincter and esophageal muscles to move food normally from the esophagus to the stomach. Your provider inserts a small flexible tube with sensors into your nose. These sensors measure the strength of your sphincter, muscles and spasms as you swallow.
Treatment
GERD will often be treated with medications before attempting other lines of treatment.
Proton pump inhibitors are one of the main pharmaceutical treatment options for people with GERD. They decrease the amount of acid produced by the stomach.
Other options include:
- H2 blockers: These are another option to help decrease acid production.
- Antacids: These counteract the acid in the stomach with alkaline chemicals. Side effects can include diarrhea and constipation. Antacids are available to purchase online.
- Prokinetics: These help the stomach empty faster. Side effects include diarrhea, nausea, and anxiety.
- Erythromycin: Ths is a type of antibiotic that also helps empty the stomach.
Surgical options
If lifestyle changes do not significantly improve the symptoms of GERD, or medications do not have the desired effect, a gastroenterologist may recommend surgery.
Surgical treatments include:
- Fundoplication: The surgeon sews the top of the stomach around the esophagus. This adds pressure to the lower end of the esophagus and is generally successful at reducing reflux.
- Endoscopic procedures: This is a range of procedures include endoscopic sewing, which uses stitches to tighten the sphincter muscle, and radiofrequency, which uses heat to produce small burns that help tighten the sphincter muscle.
