GERD (Gastroesophageal reflux disease)

(Heartburn)

The Facts

GERD stands for gastroesophageal reflux disease, which is the backflow of stomach contents (including stomach acid) upward into the esophagus (the swallowing tube that extends from the mouth to the stomach and sits behind the breast bone).

The lining of the stomach protects the stomach from the effects of its own acids. Because the esophagus lacks a similar protective lining, stomach acid that flows backward (refluxes) into it causes heartburn (also called dyspepsia).

Many people experience heartburn occasionally; however, people who get heartburn or other GERD symptoms persistently are considered to have GERD. GERD is the most common acid-related condition in Canada, affecting 5% to 12% of the population. Adults, children, and even infants can have GERD.

The Causes

GERD occurs when the valve located at the bottom of the esophagus (called the lower esophageal sphincter, or LES) that normally keeps acid in the stomach isn't functioning properly. Acid that moves from the stomach into the esophagus damages its lining and can cause burning and pain.

Risk factors are characteristics that may increase your chance of developing a condition. Risk factors for GERD include:

age (over 50 years old)
being overweight or obese
eating and drinking certain types of foods and drinks (see below)
having excess abdominal fat
pregnancy
smoking
taking certain medications (e.g., NSAIDs, some antidepressants, calcium channel blockers, corticosteroids)

The following foods can cause symptoms of GERD, but may not necessarily cause GERD itself:

alcoholic drinks
chocolate
coffee, tea
carbonated drinks
foods with high acid content (e.g., tomatoes, orange juice)
fried or fatty foods
garlic
onions
peppermint
spicy foods

GERD may sometimes be associated with a condition called hiatus hernia in which a portion of the stomach lining pushes up through the diaphragm into the chest cavity. People with severe GERD almost always have a hiatus hernia.

Symptoms And Complications

The main symptom of GERD is heartburn, which is a burning pain behind the breastbone that can travel to the back of the throat. The pain can last up to 2 hours and is often worsened by eating, lying down, or bending over. Infants with GERD show signs of irritability, vomiting, and loss of appetite.

Because heartburn and a heart attack have similar symptoms, it is important to note their differences. For someone having a heart attack, burning pain generally travels progressively down the left arm or both arms. For someone with GERD, the burning pain is localized to the upper chest. In addition, exercise may worsen the chest pain for someone having a heart attack (or someone with heart disease), while rest and certain medications may help to relieve it. On the other hand, the burning pain associated with GERD is usually not affected by physical activity. In any case, even people with characteristic features of GERD may require tests to ensure the symptoms are not being caused by a heart attack.

Other symptoms of GERD include regurgitation (swallowed food or liquid going back up into the throat or mouth), a sour or bitter taste in the throat or back of the mouth, excessive saliva, belching, upset stomach, nausea, or vomiting. Both adults and infants who inhale the reflux acid may experience coughing, hoarseness, or wheezing. Symptoms of GERD are generally worse after meals.

If GERD is not managed well, other complications can arise over time. These include:

esophageal strictures (scarring of the lining of the esophagus), which reduce the diameter of the esophagus and make swallowing difficult
esophagitis (inflammation of the esophagus), which can make swallowing painful
pharyngitis (inflammation of the throat), which affects the vocal cords and can alter a person's voice and speech
dental problems, such as an increased risk of cavities or tooth damage due to the acid reflux
asthma or chronic cough, especially in adults
Barrett's hyperplasia or Barrett's esophagus, which occurs when abnormal healing takes place after an ulcer has destroyed an area of the esophageal lining (The usual lining is replaced with tissue like that found in the stomach or intestine. People with this condition may be at a higher risk of developing cancer of the esophagus over time.)

Making A Diagnosis

Doctors usually diagnose GERD by assessing symptoms. Only people with severe chronic heartburn are likely to be tested for GERD.

Endoscopy is the test of choice for people who need further testing. A diagnostic tool called an endoscope is used, which is a fibre-optic tube passed down the throat that permits the doctor to see the inside of the esophagus.

There are also tests to measure the pH (acidity) of the esophagus and the internal pressure of the lower esophageal sphincter (LES).

People who have had regular or daily heartburn for more than 5 years have an increased risk of Barrett’s esophagus. People over the age of 50 who also have other risk factors such as smoking or obesity, may be tested using endoscopic biopsy (endoscopy with biopsy). For other patients, many doctors perform regular checkups to look for changes that may eventually develop into cancerous growths.

Treatment And Prevention

Most symptoms of GERD can be managed with a combination of medications and lifestyle changes. Surgery is reserved for people with severe complications but is needed only rarely.

Medications* that can be used to neutralize stomach acid are antacids (e.g., aluminum or magnesium hydroxide, calcium carbonate, bismuth subsalicylate). Medications* that keep stomach acid away from the esophagus are alginates (sodium alginate). Medications* that can be used to reduce the production of stomach acid include H2-antagonists (e.g., cimetidine, ranitidine, famotidine, nizatidine) and proton pump inhibitors (e.g., dexlansoprazole, omeprazole, lansoprazole, pantoprazole, esomeprazole, rabeprazole). When prescribing proton pump inhibitors, your doctor may put you on an 8-week trial and then assess your symptoms.

In addition to medications, symptoms of GERD can be improved by making one or more lifestyle changes. For example:

Eat meals earlier, especially dinner.
Eat smaller meals more frequently, instead of 2 or 3 large meals.
Avoid lying down within 2 or 3 hours after meals.
Reduce alcohol and caffeine intake.
Avoid chocolate, acidic citrus juices and large fatty meals
Stop smoking.
Try not to wear tight clothing.
Lose excess weight.
Exercise regularly.
Place the head of your bed 10 cm to 20 cm higher than the foot of the bed.

Most people can have successful treatment by taking medications and making lifestyle and diet changes.