Acid Reflux / GERD (gastroesophageal reflux disease)

Acid Reflux / GERD Overview

What is GERD?

Gastroesophageal reflux disease (GERD) is a chronic medical condition caused by the flow of contents from the stomach upwards into the esophagus (food pipe) resulting in both symptoms and complications. The most common symptoms of GERD are heartburn and regurgitation. Heartburn is a burning sensation in the chest behind the breastbone. Regurgitation is a feeling of fluid or food coming up into the chest. Many people experience both symptoms; however, some patients can have one without the other.
How common is GERD?

GERD is one of the most common gastrointestinal diseases. It is thought that up to 20% of the US population has GERD. Almost everyone will experience heartburn at some point, especially after a heavy meal. However, GERD is defined as frequent symptoms (two or more times a week) or when the esophagus suffers damage from reflux such as narrowing, erosions, or pre-cancerous changes, which are best identified on endoscopy. GERD is more common amongst the elderly, obese and pregnant women.
Are Acid Reflux, GERD and Heartburn the same?

These terms are often used interchangeably, but they actually have very different meanings. GERD is the disease or diagnosis defined as regular symptoms of heartburn and/or regurgitation caused by the flow of gastric contents into the esophagus. Heartburn is one of the symptoms of GERD. Acid reflux is the reason why patients have GERD. There is actually reflux that can be non-acidic that can be seen in GERD as well.

Causes

What causes GERD?

GERD is caused by the flow of gastric contents and/or bile into the esophagus. The stomach is designed to handle these fluids. When the gastric contents come into contact with the esophagus, it can produce the classic symptoms of heartburn and regurgitation by causing injury to the lining in the esophagus. Esophagus is not designed to handle these fluids regularly. In fact, these fluids are toxic to the lining of the esophagus and can cause damage such as ulcers or even pre-cancerous changes such as Barrett’s esophagus.

GERD is almost never caused by the production of too much acid. It is caused by abnormal reflux of gastric contents into the esophagus. The body has multiple barriers to prevent gastric contents from refluxing into the esophagus, including a flap valve at the bottom of the esophagus, the breathing muscle (the diaphragm), and gravity. In GERD, certain foods, lifestyle habits, and anatomic issues (hiatal hernia) can weaken these barriers.

Treatment Options

What are the treatments for infrequent heartburn?
Infrequent heartburn is not the same as GERD. In many cases, doctors find that infrequent heartburn can be controlled by lifestyle modifications and proper use of medicines (over-the-counter and in some instances prescription).

Lifestyle Modifications
- Avoid certain trigger foods and beverages: chocolate, coffee, peppermint, greasy or spicy foods, tomato products, and alcoholic beverages. Some foods and medications trigger GERD (fats, chocolate and caffeinated drinks) and some may irritate the damaged lining of the esophagus (citrus juice, tomato juice, and probably pepper).
- Stop smoking. Tobacco may result in acid reflux and is one of the biggest risk factors for esophageal cancer.
- Stop drinking alcohol. It can contribute to acid reflux.
- Weight loss if overweight. Excess abdominal fat is one of the biggest risk factors for heartburn. Patients who are overweight are significantly more likely to have GERD compared to ideal body weight.
- Change Eating and Sleeping Habits.
- Raise the Head of the Bed. Use an under-mattress foam wedge to elevate the head about 6-10 inches. Pillows are not an effective alternative for elevating the head in preventing reflux.
- Avoid tight clothing as it can increase pressure on the abdomen and increase reflux of stomach contents into the esophagus.
Over-the-Counter Medications

There are a number of over the counter medicines available for treatment of occasional heartburn. These include medicines that neutralize acid in the stomach (TUMS, calcium carbonate, etc), medicines that block flow of fluids back into the stomach (Gaviscon), and medicines that decrease the production of fluids in the stomach itself (famotidine, ranitidine as part of the class of medications called Histamine -2 (H2 blockers). Cimetidine and ranitidine may increase the blood concentrations of anti-seizure medications, blood thinners, and anti-arrhythmic medications. Newer generations (e.g Famotidine) of this class of drugs do not cause this problem.

Over-the-counter medications have a significant role in providing relief from heartburn and other occasional GI discomforts. More frequent episodes of heartburn or acid indigestion may be a symptom of a more serious condition that could worsen if not treated. If you are using an over-the-counter product more than twice a week, you should consult a physician who can confirm a specific diagnosis and develop a treatment plan with you, including the use of stronger medicines that are only available with a prescription.
What are the treatment goals for GERD?

Treatment should be designed to eliminate symptoms, heal irritation of the esophagus and prevent the long-term complications of GERD. In most patients in addition to lifestyle modifications such as weight loss, long-term treatment to control symptoms and prevent complications may be necessary to achieve these goals. Long term use of therapy will vary in individuals ranging from lifestyle modifications to prescription medication as treatment. The medicines are treatments and not cures.

All treatments are based on attempts to decrease the amount of acid that refluxes from the stomach back into the esophagus or make the refluxed material less irritating to the lining of the esophagus.
What are the treatments for GERD?

Similar to infrequent heartburn, it is important to incorporate lifestyle changes to reduce reflux (see above).If you are still having GERD despite lifestyle modification and using over the counter medications, then it is reasonable to try prescription medications. If you are needing over the counter medications more than 2 times per week, then it is best to switch to a prescription medication for better GERD control.
Here we will review more of the medical treatments used for GERD.
Medications for GERD

The main prescription medications to treat GERD are proton pump inhibitors (PPIs). These medicines reduce the amount of acid produced in the stomach. Proton pump inhibitors (PPI) are available over the counter and by prescription. It is important to note that the dosage available over the counter may be different from the doses available as a prescription. These are currently the main way for GERD to be managed medically.

PPIs are mostly well tolerated. The only known contraindication is very rare allergy to this drug group. The most noted side effects are headache, nausea, diarrhea, abdominal pain and in some cases constipation. Very few persons need to stop taking the medication because of side-effects. There have been several reported side effects of PPI in the press including dementia, kidney disease and bone disease. Currently, there has never been a convincing study to show that this class of medications is directly responsible for any of these diseases. The only association between these medicines that has been shown is with an intestinal infection called C. difficile infection (a colon infection that usually happens after taking certain antibiotics). The risk is perhaps related to the degree and duration of acid suppression, other conditions increasing susceptibility of the patient to this infection and nature and strength of the strain of C. difficile infection. This association should prompt the physicians to be mindful to use PPIs in patients, specifically older patients on multiple medications and on frequent antibiotics for recurrent infections, only when necessary. Also, there has been some concern for risk for pneumonia in the elderly with initiation of an acid-suppressive medication in the elderly but this risk has not been shown to be present with long-term treatment. Overall, the use of PPIs is thought to be safe when the goal is to use them at the lowest effective dose in patients who need them.
How long should prescription medications be taken for GERD?

This really depends on the severity of your symptoms and response to therapy. For example mild cases may respond to treatment and therapy can be stopped after a short course of treatment (ranging from weeks to months). If you have inflammation of the esophagus (esophagitis) or ulcers in the esophagus/stomach, you may need to continue treatment for a longer period of time and remain on maintenance (long term) therapy.

When elderly patients with reflux esophagitis were followed up for a period of 3 years, 68% of them needed treatment for more than six months and 46% needed therapy for 3 years to prevent recurrence of esophagitis. Without the therapy 80-90% of the patients suffered a relapse in a period of one year.
Is surgery a viable treatment for GERD?

Surgical management of GERD can be considered in patients who do not completely respond to medical management, patients who are unable to tolerate the medicines (e.g., due to bad side effects) or in patients who do not want to take medicine for a very long time. Surgical management prevents gastric reflux by strengthening the barrier between the stomach and the esophagus. There are a number of different surgical approaches to GERD. However, this is not a permanent solution and many patients within 5 years may still need reflux medications to manage GERD. Consultation with both a gastroenterologist and a surgeon experienced in reflux surgery is recommended prior to such a decision. Additional testing (see below in diagnosis section) is usually required before a final decision on surgery is made.

Diagnosis

What is a Gastroenterologist?

A gastroenterologist is a physician who specializes in the diagnosis and management of disorders and conditions of the gastrointestinal tract. They are trained in the conditions of the gut including the food pipe, stomach, intestines, pancreas, liver etc..
What types of tests are needed to evaluate GERD?
Your doctor may decide to conduct one or more of the following tests to better understand the symptoms. These tests can help if it is unclear whether your symptoms are caused by acid reflux, or further evaluate if you suffer from complications of GERD such as dysphagia (difficulty in swallowing), bleeding, choking, or if your symptoms fail to improve with prescription medications.

Upper GI Series/Barium esophagram

For the upper GI series, you will be asked to swallow a liquid barium mixture. The radiologist then takes a series of x-rays and videos to watch the barium as it travels down your esophagus and into the stomach.

For the esophagram, you will also be given a pill of Barium with liquid to watch and see if it gets stuck anywhere along the food pipe. This study provides information regarding the coordination of movement in the esophagus that moves the Barium. It looks for any location where the tablet might get stuck (which might identify improper function of the sphincter muscles in the esophagus), and identify the configuration of the stomach and esophagus in patients who have previously undergone surgery. You will be asked to move into various positions on the X-ray table while the radiologist watches the GI tract. Specific “timed protocol” esophagrams are sometimes performed where x-ray images are captured at timed intervals (1 min, 2 min and 5 min) to further evaluate the delay in the emptying of the esophagus.

Upper GI Endoscopy

An upper endoscopy is usually the first step in evaluating symptoms such as trouble with swallowing, pain with swallowing, atypical symptoms (c, heartburn that is not going away with medication or if there are any “red flag symptoms” (eg. weight loss, bleeding). Gastroenterologists perform an upper endoscopy that uses a light and camera on a long flexible scope to evaluate the food-pipe, stomach and the first part of the small intestine called the duodenum while the patient is asleep with help of anesthesia. In evaluation of GERD, an upper endoscopy is useful to:
1. Look for inflammation of the esophagus due to reflux from the stomach into the esophagus.
2. Rule out obstruction in the esophagus due to a mass/narrowing due to scar tissue that can form from having GERD over many years (i.e. peptic stricture).
3. Evaluate for precancerous changes that can occur in some patients with severe reflux disease (also known as Barrett’s esophagus. For more info, refer to ACG's resources on Barrett's esophagus here).
4. Measure how much abnormal amount of reflux a patient is experiencing prior to surgery using Bravo pH capsule attachment (more information at https://gi.org/topics/esophageal-physiologic-testing/).
More information regarding upper GI endoscopy can be found here.

GERD Testing

The diagnosis of GERD is often made based on physical and history alone. However direct measurement of the amount of acid/fluid refluxed into the esophagus is sometimes necessary to help diagnose and treat GERD if symptoms are not adequately controlled with medical treatment or if your doctor is considering surgical treatment. Reflux testing can be performed in two different ways: a wireless capsule attached during endoscopy used to detect the change in pH of the esophagus vs. a nasal catheter based pH-impedance test worn for 24 hours. Both of these tests record reflux events using wireless recorders that the patient wears while patient is at home carrying out their typical activities, eating their usual diet to mimic their day-to-day lifestyle as much as possible.

More information regarding these tests can be found here.
Can GERD masquerade as other diseases?

Besides heartburn and regurgitation, GERD can result in a number of other symptoms outside of the esophagus. Increasingly, we are becoming aware that the irritation and damage to the esophagus from continual presence of acid can prompt an entire array of symptoms other than simple heartburn. In some instances, patients have never reported heartburn, and in others the potential causal link between reflux and the onset of these so-called "extra-esophageal manifestations" has not been fully recognized.

Chest Pain: Patients with GERD may have chest pain similar to angina or heart pain. Usually, they also have other symptoms like heartburn and acid regurgitation. If your doctor says your chest pain is not coming from the heart, do not forget about the esophagus. On the other hand, if you have chest pain, you should not assume it is your esophagus until you have been evaluated for a potential heart cause by your physician.

Asthma: Acid reflux may aggravate asthma. Recent studies suggest that the majority of asthmatics have acid reflux. Clues that GERD may be worsening your asthma include: 1) asthma that appears for the first time during adulthood; 2) asthma that gets worse after meals, lying down or exercise; and 3) asthma that is mainly at night. Treatment of acid reflux may cure asthma in some patients and decrease the need for asthmatic medications in others.

Ear, Nose, and Throat Problems: Experts recognize that often the role of acid reflux has been overlooked as a potential factor in the diagnosis and treatment of patients with chronic cough, and hoarseness. Physicians are increasingly becoming aware that it is good clinical practice to evaluate the possible presence of reflux in patients with chronic cough, sore throat, laryngitis with hoarseness, frequent throat clearing. If these symptoms do not respond to the usual treatments, it is important to consult a gastroenterologist to evaluate for underlying reflux as that can potentially improvesuch symptoms in these patients.

Risk/Complications

What are the complications in patients with longstanding GERD?

Peptic Stricture: This results from chronic acid injury and scarring of the lower esophagus. Patients complain of food sticking in the lower esophagus. Heartburn symptoms may actually lessen as the esophageal opening narrows down, preventing acid reflux. Stretching of the esophagus during an upper endoscopy and proton pump inhibitor medication are needed to control and prevent peptic strictures.

Barrett's Esophagus: A serious complication of chronic GERD is Barrett's esophagus. In Barrett’s esophagus, the lining of the esophagus changes to resemble the intestine due to chronic acid exposure. Barrett’s esophagus is a recognized potential risk factor for cancer of the esophagus and needs long-term follow up by a gastroenterologist who will monitor this condition with upper endoscopy at regular intervals. Research was conducted to determine whether the duration of heartburn symptoms increases the risk of having esophageal complications. The study found that inflammation in the esophagus not only increased with the length of time someone had reflux symptoms, but that Barrett's esophagus was more frequently found in these patients too. Those patients with reflux symptoms and a history of severe inflammation in the past (esophagitis) were more likely to have Barrett's esophagus than those without a history of esophagitis.

Esophageal Cancer: Based on research, GERD is the biggest risk factor for the most common type of esophageal cancer in the US (adenocarcinoma). Over the past 20 years, the frequency of esophageal adenocarcinoma, has rapidly increased in the United States. Despite understanding and research in this area, it continues to be a highly fatal form of cancer. Research has linked chronic, untreated heartburn with risk of developing esophageal cancer. As reportedin medical research, patients with chronic, unresolved heartburn have a higher risk of esophageal cancer. The diagnosis of adenocarcinoma of the esophagus was nearly eight times more likely among frequent heartburn sufferers (two times a week or more) compared to individuals without symptoms. For patients with longstanding, severe and unresolved heartburn (e.g. frequent symptoms 20 years duration), the risk of developing esophageal cancer was 43.5 times as great as for those without chronic heartburn (article – Lagergren et al., NEJM 1999 - Symptomatic Gastroesophageal Reflux as a Risk Factor for Esophageal Adenocarcinoma | New England Journal of Medicine).

In addition to GERD, there are other risk factors recognized that affect patient profile for esophageal cancer. Therefore, patients with chronic heartburn, obesity, male biological gender, White Race ethnicity and multiple other risk factors, should see their doctor to get advice, on whether they would benefit from an endoscopy . So, do not ignore your heartburn. If you are having heartburn two or more times a week, it is time to see your physician or a gastroenterologist.

Key Points

What are Some Key Points to Remember about GERD?
- Heartburn is a common, but not trivial condition. In fact, if left untreated, longstanding, severe and chronic heartburn has been linked with esophageal cancer. Don't ignore frequent heartburn — instead consult with your physician regarding an endoscopy and treatment to achieve early symptom resolution.
- If you suffer infrequent heartburn, antacids, or H2 blockers or proton pump inhibitors may provide the relief you need.
- If you are experiencing heartburn two or more times a week, you may have acid reflux disease, also known as GERD, which, if left untreated for a long time, is potentially serious and can even predispose to precancerous condition called Barrett’s esophagus or esophageal cancer..
- If you are self-medicating for heartburn two or more times a week, or if you still have symptoms on your over-the-counter or prescription medication, you need to see a doctor and perhaps be referred to a gastroenterologist.
- GERD has a physical cause that's not your fault and can only be treated by a physician.
- GERD can sometimes play a significant role in asthma, chronic cough and ear, nose and throat problems — all referred to as extra-esophageal manifestations although this connection may often go unrecognized. GERD should be actively considered in physician evaluations of these conditions, or it could go undetected.
- With effective treatment, using the range of prescription medications and other treatments available today, you can become symptom free, avoid potential complications and restore the quality of life you deserve.
Why is it important to discuss GERD with your physician?
GERD can result in serious complications including severe chest pain that can mimic a heart attack, esophageal stricture (a narrowing or obstruction of the esophagus), chronic injury resulting in ulcers and bleeding, or a pre-cancerous change in the lining of the esophagus called Barrett's esophagus.

When symptoms of heartburn are not controlled with lifestyle modifications or over-the-counter medicines are needed two or more times a week, you should see your doctor. You may have GERD and be at risk for complications of GERD. You will need better medical treatment of your GERD which can only be best assessed by a medical professional.

Symptoms suggesting that serious damage may have already occurred include:
- Difficulty swallowing or a feeling that food is trapped behind the chest.
- Bleeding: vomiting blood (coffee grounds colored or red clots), or having tarry, black bowel movements.
- Choking: sensation of acid refluxed into the windpipe causing shortness of breath, coughing, or hoarseness of the voice.
- Weight Loss with inability to tolerate foods
If you have any of these symptoms, you should speak to your doctor immediately.

Self-Test

Do you have GERD?
Measure Yourself on the Richter Scale/Acid Test

How significant is your heartburn? What are the chances that it is something more serious? If you need a yardstick, here's a simple self-test developed by a panel of experts from the American College of Gastroenterology.

Remember, if you have heartburn two or more times a week, or still have symptoms on your over-the-counter or prescription medicines, see your doctor.

Take this "Richter Scale/Acid Test" to see if you're a GERD sufferer and are taking the right steps to treat it.
1. Do you frequently have one or more of the following:
2. an uncomfortable feeling behind the breastbone that seems to be moving upward from the stomach?
3. a burning sensation in the back of your throat?
4. a bitter acid taste in your mouth?
5. Do you often experience these problems after meals?
6. Do you experience heartburn or acid indigestion two or more times per week?
7. Do you find that antacids only provide temporary relief from your symptoms?
8. Are you taking prescription medication to treat heartburn, but still having symptoms?
If you said yes to two or more of the above, you may have GERD. To know for sure, see your doctor or a gastrointestinal specialist. They can help you control your symptoms and avoid complications.