Introduction to Gastroesophageal Reflux Disease

 

Gastroesophageal reflux disease (GERD) (also known as gastro-oesophageal reflux disease, the British spelling, and clinically as gastroesophageal reflux GER) is a common digestive disorder where stomach acid repeatedly flows back into the esophagus, the tube connecting your mouth and stomach. This backflow, known as acid reflux, happens when the lower esophageal sphincter (LES), a muscular ring at the bottom of the esophagus, does not close tightly enough. As a result, stomach contents, including acid, can move upward into the esophagus, leading to irritation and discomfort. The most common symptoms of acid reflux include a burning sensation in the chest called heartburn, regurgitation of food or sour liquid, and a persistent sour taste in the mouth. GERD, also referred to as gastroesophageal reflux or acid reflux disease, can cause symptoms that range from mild to severe and may occur occasionally or frequently. Recognizing the signs and understanding how the lower esophageal sphincter functions are key to managing gastroesophageal reflux disease and preventing complications.

Gastroesophageal Reflux Disease (GERD)

The esophagus carries food from the mouth to the stomach (also known as the food pipe). The lower esophageal sphincter is a ring of muscle at the bottom of the esophagus, located at the lower esophagus, that acts like a valve between the esophagus and stomach.

Gastroesophageal reflux disease, or GERD, is a chronic disease that occurs when the lower esophageal sphincter does not close properly, and stomach contents leak back, or reflux, into the esophagus. When food passes from the esophagus into the stomach, the LES should close to prevent reflux.

When refluxed stomach acid touches the lining of the esophagus, it causes a burning sensation or burning feeling in the chest or throat called heartburn. The reflux of stomach acid is what causes heartburn. The fluid may even be tasted in the back of the mouth, and this is called acid indigestion. Certain foods, such as fatty or spicy foods, are known triggers for acid reflux. Acidic foods and fatty foods are common dietary triggers that can worsen GERD symptoms, as they can increase stomach acid and slow digestion, making reflux more likely. Occasional heartburn is common but does not necessarily mean one has GERD. Heartburn that occurs more than twice a week may be considered GERD, and it can eventually lead to more serious health problems.

Anyone, including infants, children, and pregnant women, can have GERD.

Risk Factors

Gastroesophageal reflux disease (GERD) develops when stomach acid frequently flows back into the esophagus, leading to uncomfortable GERD symptoms and potential complications. Several risk factors can increase the likelihood of experiencing gastroesophageal reflux or make existing reflux disease worse. One of the most significant risk factors is being overweight or obese, as excess body weight puts additional pressure on the stomach, making it easier for stomach acid to escape into the esophagus. Pregnancy is another common risk factor, since hormonal changes and the growing baby can push the stomach upward, leading to more frequent acid reflux episodes.

A hiatal hernia, where part of the stomach pushes through the diaphragm into the chest cavity, can also contribute to gastroesophageal reflux disease GERD by weakening the lower esophageal sphincter and allowing stomach contents to move upward. Certain foods, especially fatty or spicy foods, are known to trigger GERD symptoms in many people. Smoking and the use of certain medications, such as those for high blood pressure or other chronic conditions, can further relax the lower esophageal sphincter or irritate the esophagus, increasing the risk of reflux disease. Additionally, individuals with connective tissue disorders may be more prone to developing GERD due to changes in the structure and function of the esophagus. Understanding these risk factors can help individuals make informed choices to reduce their risk and better manage their symptoms.

Symptoms

The main symptoms are persistent heartburn and acid regurgitation, with heartburn symptoms being a key indicator of acid reflux. Some people have GERD without heartburn. Instead, they experience pain in the chest, hoarseness in the morning, or trouble swallowing. You may feel like you have food stuck in your throat or like you are choking, or your throat is tight. GERD can also cause a dry cough and bad breath. Other symptoms, such as cough, wheezing, or hoarseness, may also be associated with GERD.

The most frequent GERD symptoms are so common that they may not be associated with a disease. GERD symptoms can include more than just heartburn, such as chest pain, regurgitation, and throat discomfort. Self-diagnosis can lead to mistreatment. Consultation with a physician is essential to the proper diagnosis and treatment of GERD.

What is an Acid Reflux Attack

An acid reflux attack is a sudden episode where stomach acid escapes into the esophagus, causing a burning sensation or pain in the chest, often described as heartburn. These attacks can be triggered by eating large meals, consuming spicy foods, or lying down soon after eating. During an acid reflux attack, the lower esophageal sphincter relaxes when it shouldn’t, allowing acid to move up from the stomach and irritate the lining of the esophagus. Common symptoms during an acid reflux attack include heartburn, chest pain, and sometimes difficulty swallowing. While occasional acid reflux attacks are common, frequent or severe episodes may indicate an underlying condition like GERD, and seeking medical treatment can help relieve symptoms and prevent further issues.

Chronic Acid Reflux

Chronic acid reflux, also known as gastroesophageal reflux disease (GERD), occurs when symptoms of acid reflux persist over time and interfere with daily life. Unlike occasional heartburn, chronic acid reflux can lead to ongoing discomfort and may cause damage to the esophagus. Over time, repeated exposure to stomach acid can result in inflammation, narrowing of the esophagus, or even precancerous changes such as Barrett’s esophagus. Barrett’s esophagus is a precancerous condition that requires regular monitoring, such as endoscopy, to detect changes in the esophageal tissue. Chronic acid reflux can also lead to the formation of scar tissue in the esophagus, which may cause esophageal stricture—a narrowing of the esophagus that makes swallowing difficult. Factors that contribute to chronic acid reflux include a weakened lower esophageal sphincter, obesity, and certain prescription medications. Managing chronic acid reflux often involves lifestyle changes like losing weight, eating smaller meals, and avoiding foods that trigger symptoms. In more severe cases, prescription medications such as proton pump inhibitors are used to reduce acid reflux and protect the esophagus from further damage. Addressing chronic acid reflux early is important to reduce the risk of complications and improve quality of life.

Causes

There are several risk factors for GERD, including physiological issues like hiatal hernia, lifestyle factors such as being overweight or pregnant, and environmental contributors like smoking and alcohol use.

  • Hiatal hernia – Hiatal hernia occurs when the upper part of the stomach is above the diaphragm, the muscle wall that separates the stomach from the chest
  • Alcohol use
  • Overweight: Being overweight increases the risk of acid reflux. Weight loss is recommended as an effective way to reduce the risk and severity of acid reflux.
  • Pregnancy: Pregnancy hormones can relax the lower esophageal sphincter (LES) and contribute to reflux. Pregnancy GERD is common due to both hormonal and physical changes during pregnancy.
  • Smoking

Also, certain foods and drinks are associated with reflux. Certain medicines can also increase the risk of reflux or cause heartburn. Some foods and lifestyle habits can make heartburn worse, especially after large meals or when lying down. Temporary acid reflux can occur during pregnancy due to hormonal and physical changes. To reduce risk, individuals should try to lose weight and eat smaller, more frequent meals.

Diagnoses

Medical history

  1. Response to Omeprazole: A recent study demonstrated a potential role for a proton pump inhibitor, omeprazole, in the diagnosis of GERD
  2. Barium swallow radiograph: Uses X-rays to help spot abnormalities such as a hiatal hernia and severe inflammation of the esophagus
  3. Upper endoscopy: An upper endoscopy (esophagogastroduodenoscopy) is performed using a flexible tube with a camera to examine the esophagus. During this procedure, a tissue sample (biopsy) may be taken to check for changes such as Barrett’s esophagus or to rule out other underlying diseases.
  4. Esophageal manometry: This test evaluates esophageal motility and function, and is often used when other tests are inconclusive or before surgical intervention to assess for structural or functional abnormalities that may contribute to reflux symptoms.

The ACG clinical guideline recommends upper endoscopy for certain patients with GERD symptoms or possible complications. Chronic GERD can lead to possible complications such as Barrett’s esophagus, which may require ongoing monitoring.

Treatment

Conservative treatment

Lifestyle modification

  • Over-the-counter medications are often the first line of treatment for managing mild acid reflux symptoms.
  • Medications including antacids, Foaming agents, H2 receptor blockers, and Proton Pump Inhibitors

Surgical Treatment

Surgery is an option when medicine and lifestyle changes do not work. Surgery may also be a reasonable alternative to a lifetime of drugs and discomfort.

Some surgical procedures, such as vagotomy, can impact how the stomach empties its contents into the intestine (stomach emptying). Vagotomy, which involves cutting nerve branches that innervate the stomach lining, may lead to delayed stomach emptying and affect the way the stomach moves during digestion. These changes in gastric motility and the condition of the stomach lining can influence digestion and may contribute to symptoms related to acid reflux.

Lifestyle Changes for Managing Acid Reflux

Making simple lifestyle changes can significantly help manage acid reflux symptoms and reduce the frequency of acid reflux episodes. Eating smaller, more frequent meals instead of large meals can prevent excess stomach acid production and reduce pressure on the lower esophageal sphincter. Avoiding trigger foods—such as spicy foods, citrus fruits, and carbonated drinks—can also help minimize acid reflux symptoms. For those who are overweight, losing weight can decrease the likelihood of stomach acid refluxing into the esophagus. Other helpful strategies include not lying down immediately after eating, elevating the head of the bed to prevent nighttime symptoms, and wearing loose-fitting clothing to avoid pressure on the stomach. Quitting smoking and managing stress are also important lifestyle changes that can relieve symptoms and improve overall digestive health. Incorporating breathing exercises as part of a comprehensive lifestyle modification plan may also help alleviate acid reflux symptoms. By adopting these habits, individuals can take control of their acid reflux and enjoy a better quality of life.

Non-Surgical Treatment

  • Transoral incisionless fundoplication (TIF) is a nonsurgical procedure to cure chronic acid reflux. The TIF procedure treats the underlying cause of GERD without incisions. This innovative procedure rebuilds the antireflux valve and restores the body’s natural protection against reflux.

Laparoscopic Nissen Fundoplication

This surgery is performed under general anesthesia.

If a combination of lifestyle changes and drug therapy does not remedy reflux symptoms, a Nissen Fundoplication can be a very effective surgical procedure to correct reflux. This procedure involves wrapping the upper portion of the stomach around the base of the esophagus to reinforce the strength of the lower esophageal sphincter. Until recently, the procedure required a large abdominal incision. A hospital stay of 3-5 days was usually required, and the time to full recovery and return to work was measured in weeks.

A laparoscopic Nissen Fundoplication is a minimally invasive approach that involves specialized video equipment and instruments that allow a surgeon to perform the procedure through four tiny incisions, most of which are less than a half-centimeter in size. One advantage of this method is a brief hospitalization. Most of the time, it will require an overnight stay. Other advantages include less pain (less of a need for pain medication), fewer and smaller scars, and a shorter recovery time.

Laparoscopic Nissen Fundoplication is a safe and effective treatment for GERD. However, in rare cases, the laparoscopic approach is not possible because it becomes difficult to visualize or handle organs effectively. In such instances, the traditional incision may need to be made to safely complete the operation.

Special Considerations

While most people with GERD experience typical symptoms like heartburn and regurgitation, some groups require special attention when it comes to managing gastroesophageal reflux. Pregnant women, for example, often notice their GERD symptoms become more frequent or severe due to pregnancy hormones and the physical pressure of the growing baby on the stomach. For these individuals, lifestyle changes such as losing weight before pregnancy, eating smaller meals, and avoiding trigger foods can make a significant difference in comfort and health.

People with severe symptoms or those who do not respond to initial treatment may need further evaluation, such as an upper endoscopy, to rule out complications or other gastrointestinal and liver diseases. In some cases, prescription medications like proton pump inhibitors are necessary to reduce acid secretion and control symptoms of GERD. For those with chronic or severe GERD, anti-reflux surgery may be considered to strengthen the lower esophageal sphincter and prevent future episodes.

Individuals with underlying health conditions, such as digestive and kidney diseases, liver disease, or high blood pressure, should work closely with their healthcare provider to tailor their GERD management plan. Certain medications used for these conditions can sometimes worsen reflux, so adjustments may be needed. The National Institute of Diabetes and Digestive and Kidney Diseases offers valuable resources and guidelines for managing GERD, especially for those with complex medical histories. By staying informed and making appropriate lifestyle changes, people with GERD can reduce their symptoms and improve their overall quality of life.