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Gastroesophageal Reflux Disease (Gerd)

Basic Information

Gastroesophageal reflux disease (GERD) is a common ailment with nearly 35% of Americans having symptoms of this condition on a monthly basis with 13% using indigestion aids at least twice a week or more. It is more usually referred to as heartburn, sour stomach or acid indigestion and its symptoms can vary from mild to moderate to severe; when symptoms are severe it is referred to as a disease.

GERD is caused by the reflux of gastric or undigested stomach content such as acid or bile into the esophagus. Stomach acid moves up into the esophagus or food pipe (which connects the stomach and mouth) and the esophagus becomes irritated over time by the repeated reflux or backwash of the acid.

GERD can be caused by:

  • inadequate emptying of the stomach into the small intestine
  • inadequate or poor clearing of food from the esophagus
  • weakness of the sphincter muscle between the stomach and esophagus
  • lessened resistance of the surface of the esophagus

GERD is almost always associated with a hiatal hernia (which protrudes from the stomach into the esophagus) which can be a cause of the dysfunctions named above by having an effect on the smooth movement of the esophagus. Also lying down right after a meal, especially a large one, can stop gravity from doing its job by keeping food in the stomach.

Other causes that can disrupt or aggravate the normal function of the stomach and esophagus include:

  • thyroid disease, diabetes
  • a diet high in fat which slows down emptying of the contents of the stomach into the small intestine
  • scarring between the stomach and small intestine usually due to an ulcer can also delay stomach emptying
  • medications for blood pressure and antihistamines can be irritants
  • pregnancy
  • the lining of the esophagus can be irritated by NSAIDs (nonsteroidal anti-inflammatory drugs) such as aspirin and ibuprofin

While one-third of adults in the U.S. experience symptoms associated with heartburn, only 10% have daily symptoms.

Symptoms

Symptoms vary greatly with GERD depending on the severity of your condition.

Common symptoms include:

  • heartburn -- This burning, sometimes painful pressure most often comes on within an hour after eating and can last as long as two hours. It can wake a patient up in the middle of the night with symptoms that mimic a heart attack with intense pain that can radiate down both arms and around the back and can be a frightening experience. If you have GERD it is well to remember that this can be a symptom -- even if it does not occur often and can take you by surprise -- and that pain associated with heart attack often is exacerbated by exercise and lessened with rest whereas intense pain associated with GERD does not involve exercise or physical activity, though moderate pain or discomfort can be experienced when bending over. Many patients assume that the severity of tissue damage depends on the severity or frequency of heartburn but there is no correlation.
  • regurgitation -- when patients do heavy lifting, bending or lying down, food or liquid can rise to the throat
  • belching
  • sour or bitter taste in the mouth

Less common symptoms include:

  • chronic cough -- often awakening a patient at night as gastric contents rise into the throat
  • pain or difficulty when swallowing
  • asthma
  • hoarseness
  • sore throat
  • constant clearing of the throat

Diagnosis/Treatment

Symptoms described above are usually enough for the health care provider to make a diagnosis but a medical history of the patient should be taken in case the patient has additional undescribed symptoms that could point to a different problem or disease. Additionally, for those patients who present the less common symptoms of GERD, a complete physical, lab tests, pulmonary function tests, and chest X-rays should be done to rule out other diseases, especially neoplastic disease, peptic ulceration and stricture and Barrett's esophagus which puts a patient at risk for cancer due to the chronic reflux. Treatment should not necessarily include an endoscopy on first visit (small, light tube with a small video camera on the end) inserted into the esophagus because 50% of patients with mild symptoms will have a normal endoscopy. But for patients with severe GERD and who have iron deficiency-anemia, weight loss, dysphagia or suspected Barrett's esophagus, an endoscopy is indicated.

Treatment is generally suggestive of lifestyle modifications. Eating small, frequent meals instead of large ones is recommended, and not eating four to six hours before lying down is important.

You should avoid:

  • tobacco
  • alcohol
  • nonsteroidal anti-inflammatory drugs
  • tight-fitting clothes
  • fatty foods
  • citrus fruits
  • caffeine
  • peppermint
  • chocolate

You should sleep with your head elevated on a six-inch block.

Take antacids for mild or intermittent heartburn.

Lose weight if overweight.

And a stepwise approach if dietary and other changes are not symptom-relieving, H2 receptor antagonists should be tried such as cimetidine, rantidine, famotidine and nizapidine. Treatment for mild cases usually lasts from four to eight weeks. Ask your health care provider about the appropriate dosage to use and be aware that you could have hypersensitivity reactions such as muscle pain as well as headaches or dizziness.

Patients with esophagitis that is erosive and does not respond to the above treatment should try proton pump inhibitors -- the most potent acid suppressing agents available. Usually omeprazole at twenty to forty milligrams for six to eight weeks promotes healing although most patients with moderate to severe GERD will relapse and can:

  • take high doses of H2 receptor antagonists
  • be maintained on 20 milligrams of omeprazole
  • take omeprazole on alternate days

Omeprazole works well because it inhibits an enzyme needed for stomach secretion.

Patients with bloating, nausea, and vomiting may benefit from a prokinetic agent that helps gastric emptying.

Surgery needed to increase pressure in the lower esophagus so acid will not back up into the stomach may be indicated for the minority who do not respond to medication.

If you have GERD or symptoms of GERD please see your health care provider.