What is Gastroesophageal Reflux Disease (GERD)?
Gastroesophageal reflux disease (GERD) is the most common gastrointestinal disorder in the United States, affecting 25 - 40 million people, including infants and children. GERD occurs when the stomach’s acidic contents rise up into the esophagus, the tube that carries food from the mouth to the stomach. GERD typically causes heartburn (pain behind the sternum or in the abdomen and is often accompanied by a sour taste in the throat, belching, dysphagia (pain or difficulty with swallowing), and other serious problems. Almost everyone experiences acid reflux at some time, but a doctor’s visit is warranted if reflux occurs two to three times or more per week for a period of three months.
Causes of Gastroesophageal Reflux Disease (GERD)
GERD is often caused by a malfunctioning lower esophageal sphincter (LES), a ringed muscle that acts as a valve between the esophagus and stomach. The stomach produces acids to digest food, and the LES normally keeps those acids out of the esophagus. GERD can have multiple contributing factors:
- A malformed or dysfunctional LES or esophagus.
- A hiatal hernia, in which the stomach slips upward, out of the abdominal cavity through an enlarged hole in the diaphragm, repositioning the LES.
- Obesity, in which excess fat pushes on the stomach, repositioning or pressuring the LES.
- Inadequate emptying of acid and bile by the stomach.
Other factors contributing to GERD’s onset include diet (spicy/fatty/citrus foods, caffeine and chocolate); lifestyle factors (eating large meals, eating close to bedtime, tobacco and alcohol intake); medications; and restrictive clothing.
Excessive secretion of acid in the stomach and, perhaps surprisingly, insufficient secretion of acid both can contribute to GERD.
Diabetes and asthma also are both associated with GERD, though asthma’s connection is not well documented. Diabetes can cause a delay in the emptying of the stomach, called gastroparesis.
When acid reaches the esophagus, heartburn is the predominant symptom, with accompanying bad breath. Patients also might experience regurgitation of food, difficulty or pain with swallowing, chest pain, coughing, throat-clearing, hoarseness, voice changes, nausea, and ear or sinus pain.
Chronic reflux can cause other health problems. Esophagitis – inflammation harmful to the esophagus’ sensitive mucosal lining – can develop and, over time, lead to esophageal ulcers or change the esophagus’ cell structure to that of the stomach and intestinal wall. This condition, called Barrett’s Esophagus, is associated with higher risk of esophageal adenocarcinoma (cancer), particularly in older adults.
Chronic inflammation also can cause scarring that shortens the esophagus, which could contribute to development of a hiatal hernia by pulling the stomach upward through the esophageal hiatus, a passageway in the diaphragm. A hiatal hernia also is a risk factor for developing GERD.
Complications of chronic GERD include esophagitis, Barrett’s esophagus, narrowing or shortening of the esophagus, scarring of the lungs, cancer of the esophagus or larynx, and asthma.
Risk Factors & Prevention
Women are slightly more prone to develop GERD than men, research suggests, and the average patient is in his/her early to mid-50s. GERD can emerge in people of all ages but its prevalence rises sharply in people over 40 due to their reduced saliva production and peristalsis (contractions that move food through the esophagus). Diet and lifestyle choices play an important role in likelihood of developing acid reflux. Obesity, pregnancy, hiatal hernia and diabetes are other potential risk factors.
Physicians diagnose GERD through a detailed patient history and medical tests, including barium swallows, manometry (measuring pressure in the esophagus) and an endoscopic exam of the patient’s esophagus and stomach through a flexible tube inserted in the patient’s mouth.
The first line of treatment for GERD typically includes antacids and prescribed changes to diet and lifestyle – such as eating smaller meals, not eating near bedtime, and elevating the head-end while sleeping. When these treatments do not relieve symptoms, laparoscopic surgery is an option.
Comprehensive Diagnostic Tests
Patients can be grouped by those with typical symptoms (heartburn and regurgitation) and those with atypical ones (airway symptoms, chest pain, etc.). For both groups, an adequate diagnostic evaluation includes upper endoscopy, manometry, 48 -hr esophageal pH monitoring, and a series of images of the upper gastrointestinal tract.
These tests can help evaluate people with symptoms and establish a diagnosis of GERD, as well as detect corresponding medical issues. The tests are performed with instruments gently inserted through a patient’s mouth or nose.
Physicians commonly prescribe dietary and lifestyle changes as first responses to symptoms of GERD. Several types of medication are employed to reduce the potential for acid to reflux into the esophagus. Ultimately, surgery is recommended if other efforts fail.
Typical Diet Recommendations: Keep your weight in the normal range. Reduce fatty, fried, and spicy foods, such as peppers and onions, citrus, chocolate and caffeinated beverages.
Lifestyle recommendations: Exercise, eat smaller meals, and eat your last meal at least two to three hours before bedtime. Raise the head-end of the bed and use a pillow to elevate your head above your chest level while sleeping.
Medication recommendations: Medications aim to reduce gastric acids by neutralizing them chemically or suppressing their production.
- Proton pump inhibitors (such as Prilosec, Prevacid and others) are potent prescription drugs that suppress the secretion and release of stomach acids and their release. They are effective against moderate to severe cases of GERD as long as a tolerance for them has not developed from excessive, long-term use. The medications work for several days, so they do not have to be taken daily.
- Antacids (prescription or over-the-counter, such as TUMS) neutralize acid, and can help control mild to moderate heartburn. Overuse of antacids can negatively affect the stomach’s ability to digest food – the stomach needs acid to work properly.
- Histamine type 2 receptors (such as Zantac, Pepcid, Tagament) block histamine’s ability to produce acid in the stomach and are effective for mild, occasional reflux, however, regular use would require the medication to be taken in increasingly greater doses.
- Mucosal protective agents - Alginic acid and sucralfate suspension are gels or foams that protectively coat the mucous lining in the esophagus and reduce the acid rising out of the stomach.
Minimally Invasive Surgical Treatments for GERD
If a patient has moderate to severe GERD and has unsatisfactory results after making lifestyle changes and taking high doses of medication, or if diagnosed with Barrett’s disease or a hiatal hernia, they are likely candidates for surgery. Patients who have never responded to medications, especially those with symptoms not classically associated with GERD such as abdominal pain, bloating, and nausea, are less likely to benefit from an operation as those who initially responded well. These patients may not even have GERD. It’s important to have thorough testing to help identify which patients are more likely to respond to surgery.
An effective anti-reflux procedure should address the muscle function of the lower esophageal sphincter (LES), its position in the abdomen, and its junction with the diaphragm’s esophageal hiatus.