Gastroesophageal Reflux Disease (GERD)

Gastro-esophageal reflux disease (GERD) – What is GERD?

GERD stands for Gastro-esophageal reflux disease or “acid reflux” and is a common condition when the acid produced in the stomach leaks out and seeps back into the esophagus or food pipe.

The esophagus is a muscular tube than runs from the mouth to the stomach. The seepage of the stomach’s acid into the esophagus leads to heartburn or burning chest pain or discomfort, a sour or bitter taste in the back of the mouth and in severe cases pain and difficulty swallowing. (1-7)

How common is GERD?

GERD is a common condition and most people experience occasional episodes of the condition from time to time that resolves on its own or on self-medication with over-the counter drugs.

However, for those with a more persistent condition with severe symptoms, treatment on the long term is usually needed. It is estimated that 1 in 5 people will experience at least one episode of GERD per week and 1 in 10 people will have symptoms of GERD daily.

Up to four in ten people have symptoms of GERD each year in the United Kingdom.

Population-based studies have shown that between 21 and 40% of people report suffering from symptoms of heartburn and GERD in any 6 to 12 months' period. More than 60 million adult Americans suffer from symptoms of heartburn at least once a month and over 25 million experience heartburn daily.

GERD affects all age groups including children but those over 40 are more at risk. Although the condition affects both men and women equally, GERD is two to three times more common in men than women and men develop more complications than women.

Causes of GERD

GERD is caused due to multiple factors. The esophagus is guarded at its lower end by a valve-like gate called the lower esophageal sphincter (LES). The LES acts like a valve, opening to allow food to be pushed into the stomach by the propulsive movements of the esophagus and closing to prevent acid leaking out of the stomach and into the esophagus.

In patients with GERD the muscle of this sphincter may not be working properly. Those who are obese, overweight, pregnant, smokers, take pain relievers like Ibuprofen and consume a spicy or high fat diet are at an increased risk of GERD.

GERD is more common among pregnant women and a higher complication rate exists among the elderly. Patients with GERD usually have decreases in productivity, quality of life and overall well-being.

Treatment of GERD

For treatment of GERD lifestyle and diet needs to be addressed first. Once this fails, therapy is stepped up to include antacids that help to neutralise effects of stomach acid.

Medications that reduce the secretion of the stomach acid called Proton Pump Inhibitors are one of the mainstays of therapy in GERD. Surgery may be recommended when medication fails to control the symptoms.

Treatment of GERD is usually successful but relapses are common. Nearly half of the treated individuals experience a return of symptoms after a year. This mandates a long term course of medications.

If left untreated the stomach acid can irritate the inner lining of the esophagus and cause esophagitis. In more severe cases this may lead to open sores or ulcers that cause pain and difficulty swallowing.

For patients presenting with GERD symptoms, 40-60% or more have reflux esophagitis. Up to 10% of these patients will have erosive esophagitis after investigation that shows ulcers at the lower end of the esophagus. Over time in rare cases this may turn into cancers (esophageal cancer).

Causes of Gastro-Esophageal Reflux Disease (GERD)

GERD or Gastro-esophageal reflux disease is one of the most common digestive problems worldwide. Nearly 1 in 5 persons will have the symptoms any time in a year and 1 in 10 will suffer the symptoms of the condition regularly or daily. As patients age, the symptoms worsen. Symptoms are also worse in pregnant women, smokers, obese and overweight individuals. 1-6

The lower esophageal sphincter (LES) muscle

In most cases gastro-esophageal reflux disease (GERD) is said to be caused if there is a problem with the lower esophageal sphincter (LES) muscle.

The LES is placed at the lower end of the esophagus where it joins the stomach. The esophagus is a muscular tube that contracts and pushes the food into the stomach. This movement of the food into the stomach requires opening of the sphincter.

Once the food bolus is pushed into the stomach the sphincter firmly closes again to stop the contents of the stomach from moving backwards into the gullet. In this way the LES acts as a valve.

In patients with GERD the LES becomes weakened and allows some of the stomach’s contents and acid to seep back into the esophagus. This causes symptoms of heartburn and chest pain in patients with GERD.

The exact causes of weakening of the LES are unknown but there are a number of risk factors that may lead to this condition.

Risk factors for GERD

Risk factors that lead to GERD include pregnancy, obesity, a high fat diet and so forth.

Pregnancy and GERD

Pregnant women are at risk of GERD. It is found that changes in hormone levels during pregnancy, especially the raise in levels of Progesterone, can weaken the LES.

In addition, due to the growing fetus the upward pressure on the stomach rises. This may push contents of the stomach into the esophagus.

Overweight and obese persons and GERD

Due to increased pressure on the LES and on the stomach there may be symptoms of GERD in these individuals. This increased pressure also weakens the LES.

High fat diet and GERD

Those on a high fat diet may also develop GERD. The fat in the stomach takes longer to be digested and moved into the intestines. This causes stagnation of food in the stomach. This increased pressure turns backwards and may weaken the LES.

Tobacco, alcohol and caffeine and GERD

Smoking tobacco, alcohol, caffeine containing products, like coffee or chocolate, all relax and weaken the LES leading to symptoms of GERD.

Stress and emotional upset and GERD

Stress and emotional upsets are cause for weakening of the LES leading to symptoms of GERD.

Patients with hiatus hernia and GERD

In patients with hiatus hernia there is a risk of GERD. This is a condition where part of the stomach pushes up through the diaphragm, that is a muscle layer that separates the chest cavity from the abdominal cavity. Usually the lower part of the esophagus passes through a hole in this diaphragm. In patients with hiatus hernia this hole is enlarged and part of the stomach pushes into the chest cavity.

Patients with gastroparesis and GERD

In patients with gastroparesis, where the stomach takes longer to dispose of stomach acid, the acid can seep back into the esophagus causing symptoms of GERD.

This is seen in patients with diabetes. Diabetics have a high blood sugar that can damage the nerves that control the muscles of the stomach and the esophagus.

Medications and GERD

Some medications may also lead to symptoms of GERD. These may relax the LES or may increase gastric acid secretion. They include:

  • calcium-channel blockers (e.g. Amlodipine, Nifedipine etc. used in high blood pressure control)

  • Pain relievers or Nonsteroidal anti-inflammatory drugs (NSAIDs like Ibuprofen

  • antidepressants (Selective serotonin reuptake inhibitors SSRIs e.g. Fluoxetine, Paroxetine etc.)

  • tricyclic antidepressants (e.g. Amitriptyline), anticholinergics, corticosteroids (e.g. prednisolone)

  • bisphosphonates (used in bone diseases like osteoporosis)

  • nitrates (used in treatment of angina or chest pain)

Other factors that increase the risk of GERD

Other factors that increase the risk of GERD symptoms include:

  • wearing tight clothes

  • having big meals

  • having citrus fruits (orange, grapefruit, or cranberry juice)

  • garlic

  • black pepper and onions

  • mint flavorings

  • spicy foods

  • tomato-based foods, like spaghetti sauce, salsa, chili, and pizza etc.

Disease conditions that raise risk of GERD include systemic sclerosis, esophageal dysmotility, scleroderma, decreased salivary production etc.

Symptoms of Gastro-Esophageal Reflux Disease (GERD)

Gastro-Esophageal Reflux Disease (GERD) is one of the most common digestive disorders. The most frequent symptoms are heart burn and discomfort in the chest.

Although symptoms of the condition are varied they may be characterized by three cardinal features – heart burn, acid reflux or regurgitation in the mouth and difficulty swallowing.

Heartburn

Heartburn refers to a feeling of discomfort or burning pain that occurs beneath the breast bone. The pain is caused due to irritation of the inner lining of the esophagus by the acid that has seeped back.

The pain worsens after eating or when bending over or lying down. This causes back pressure over the lower esophageal sphincter that guards the entry of the stomach. This back pressure yields the sphincter and causes reflux of the acid.

Regurgitation of reflux

This leads to reflux of the acid from the stomach into the back of the mouth. This causes a sour or bitter taste at the back of the mouth or throat.

Swallowing problems

Around a third of individuals with GERD may suffer from swallowing problems or dysphagia. This happens when long term acid exposure leads to irritation and inflammation of the inner linings of the esophagus causing esophagitis.

This esophagitis may progress to open ulcers and sores. As the ulcers heal they may lead to narrowing of the esophagus and scarring. This causes difficulty in food to pass through and leads to dysphagia.

People with GERD-associated difficulty in swallowing feel like a piece of food has become stuck somewhere near their breastbone.

Other symptoms of GERD

Other symptoms of GERD include:

  • Some patients may experience nausea and some may even vomit due to persistent back pressure on the esophagus.

  • A persistent regurgitation of the acid into the throat and back of the mouth particularly at night may lead to a persistent dry cough. This occurs because the back of the throat is irritated. In 6 to 10% of patients with chronic cough, GERD is the underlying cause.

  • There may be repeated burping in some individuals.

  • Some patients experience water brash or excessive salivation.

  • Chest pain from GERD may mimic a heart attack or pain from angina.

  • Seepage of the acid into the wind pipe may lead to inflammation of the larynx or voice box. This leads to laryngitis and manifests as a hoarse and raspy voice.

  • If the acid seeps into the airways, it may lead to worsening of symptoms of asthma and cause wheezing. This occurs due to irritation of the linings of the airways.

  • Persistent effects of the acid in the mouth lead to decaying and erosion of the enamel of the teeth. This is outer hard, white layer of the tooth. Thus tooth decay may be seen in patients of GERD.

  • There may be pain over the abdomen and bloating in some individuals.

  • In some patients seepage of acid into the lungs may lead to pneumonia, lung abscess, and interstitial pulmonary fibrosis.

  • Most children under 12 years with GERD, and some adults, have GERD without heartburn or other common symptoms. Instead, they may experience a dry cough, asthma symptoms, or difficulty in swallowing. (1-7)

Symptoms may occur once or twice a month usually after a triggering factor like a high fat or spicy meal or after a particularly heavy meal. In these patients symptoms may be controlled by lifestyle measures and occasional over the counter medications.

However, when symptoms are more frequent prescription medication may be needed to control the condition and prevent complications.