Gastroesophageal Reflux Disease (GERD)

Introduction

You've been celebrating, perhaps a bit too heartily. You've had a great big steak for dinner, a bottle of wine, and two pieces of cake for dessert with coffee and a cigarette. As you crawl into bed and reminisce about the wonderful evening, you begin to experience a burning sensation in your chest and a sour taste in your mouth.

What is it?

More commonly called heartburn or indigestion, gastroesophageal reflux disease (GERD) is a sense of burning and discomfort between the ribs just below the sternum (breastbone). Sometimes people with GERD experience a sour or bitter taste in the back of their mouth or throat.

What causes it?

The esophagus is the passageway ("food pipe") that carries swallowed food to the stomach. GERD occurs when the muscular valve between the esophagus and the stomach does not function properly, causing acid to back up into the esophagus. The acid can then cause inflammation of the esophagus (esophagitis).

GERD can cause:

  • internal bleeding
  • esophageal ulcers

Chronic GERD can result in:

  • narrowing of the esophagus from chronic scarring, making it difficult to completely swallow
  • a condition known as Barrett's esophagus, which sometimes leads to esophageal cancer

Mechanism of GERD

GERD occurs when the muscular valve between the esophagus and the stomach does not function properly and acid backs up into the esophagus, damaging the mucosal lining of the esophagus.

The esophagus propels food toward the stomach by a rhythmic motion called peristalsis, which prevents acid-reflux by limiting the potential for the contents of the stomach to move upwards. A movement called secondary peristalsis clears the esophagus of any stomach contents that may be refluxed. The lower esophageal sphincter (LES) is a thick circular ring of smooth muscle at the bottom of esophagus. The LES relaxes before the esophagus contracts, and allows food to pass through to the stomach. After food passes into the stomach, the LES constricts, to prevent the contents from regurgitating into the esophagus.

After a meal, the LES usually remains closed. When it relaxes, it may allow acid and food particles to reflux into the esophagus. In experiments on patients with GERD, investigators found that when the stomach expands, the number of short LES relaxations increases. It is believed that these short periods of LES relaxation are the main cause of reflux episodes. As the number of LES relaxations increases, the frequency of reflux episodes increases. This increases the amount of time gastric acid spends in the esophagus, resulting in more irritation of the tissue.

Another factor that increases esophageal acid exposure time in patients with GERD is the ability of the esophagus to move food down into the stomach decreases. This happens because the esophagus is not producing strong enough secondary peristaltic movements.

Most episodes of GERD occur during the day, usually after eating, however, some sufferers also experience reflux during sleep. Nocturnal reflux is commonly associated with a higher risk and a higher degree of esophagitis. This is because acid remains in the esophagus for prolonged periods as a result of less swallowing and less saliva produced to neutralize the acid.

Who has it?

Heartburn, the primary symptom of GERD, affects about seven percent of American men and women each day. The prevalence is increased in adults older than 40 years of age. In addition, up to 25 percent of pregnant women have heartburn on a daily basis because of increased pressure from the uterus pushing up on the stomach. Since other disorders can cause heartburn (e.g., peptic ulcer disease), less people are found to actually have GERD. It is estimated that approximately 10% of Americans suffer from heartburn daily and more than one-third have occasional symptoms.

Because most patients with GERD require chronic therapy, costs associated with diagnosis and treatments are estimated to be $9.3 billion. In addition, costs for grants needed for further research are estimated around $36 million and $40 million.

What are the risk factors?

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

  • drinking alcoholic beverages and coffee
  • smoking
  • eating foods with a high acid content such as tomatoes or orange juice
  • eating fatty (e.g. chocolate, fried foods) or spicy foods
  • lying down too soon after meals
  • being overweight
  • being pregnant
  • other diseases
    • Diabetes - One of the many complications of diabetes is gastroparesis, an uncommon disorder in which your stomach takes too long to empty. If left in your stomach too long, stomach contents can regurgitate into your esophagus and cause heartburn.
    • Asthma - coughing and difficulty exhaling lead to pressure changes in your chest and abdomen, triggering regurgitation of stomach acid into your esophagus.
    • Scleroderma - can cause muscular tissue to thicken and swell which can keep digestive muscles from relaxing and contracting as they should.
    • Zollinger-Ellison syndrome - a rare disorder in which your stomach produces large amounts of acid.
    • Peptic Ulcer - an acidic open sore that occurs in the stomach and may cause heartburn and regurgitation of stomach acid into your esophagus.
  • Medicines:
    • Aspirin and other NSAIDs (may irritate the stomach, which contributes to GERD)
    • Anticholinergics (e.g. Benadryl)
    • Calcium channel blockers
    • Theophylline, bronchial inhalers, and other asthma medications
    • Quinidine
    • Tetracycline
    • Potassium and iron supplements
    • Alendronate (Fosamax)
    • Nitrates
    • Sildenafil (Viagra)
    • Alpha-adrenergic agents (e.g. pseudoephederine)
    • Meperidine (Demerol)
    • Sedatives such as diazepam (Valium)

What are the symptoms?

The back-up of acid into the esophagus causes burning pain below the sternum (i.e., the breastbone) and damages the esophagus' protective lining. GERD symptoms usually include the following:

  • burning chest pain, also known as heartburn, can last up to two hours and is often made worse by eating, lying down or bending over. The burning is usually felt below the breastbone but can travel up to the back of the throat.

Because GERD and heart disease have somewhat similar symptoms, it is important to note the differences. With heart disease, exercise may worsen pain and rest may relieve it. On the other hand, the heartburn associated with GERD is less likely to be affected by physical activity. Shortness of breath often accompanies chest pain caused by heart problems, but breathing trouble is less likely with GERD. Other symptoms that are often associated with GERD include:

  • sour or bitter taste in the throat or back of the mouth
  • excessive burning or belching
  • upset stomach and/or vomiting

How is it treated?

The goals of treatment for GERD are to:

  • alleviate or eliminate symptoms
  • decrease the frequency or recurrence and duration of the disease
  • promote healing of the injured tissues of the esophagus

Patients with mild symptoms are treated as needed with non-prescription remedies like antacids, a non-prescription H2 blocker, or the non-prescription proton pump inhibitor (PPI), omeprazole (brand name: Prilosec OTC). For patients with more severe symptoms, or for those who do not respond adequately to non-prescription therapies, continuous treatment with a prescription-strength H2 blocker or PPI is recommended. H2 blockers and PPIs both work by decreasing the production of stomach acid that causes many of the symptoms of GERD.

In patients where GERD may be due to slow movement of food through their gastrointestinal system, the next step is to try a pro-motility agent such as Reglan (metoclopramide) that increases the rate at which food moves throughout the gastrointestinal system. Maintenance therapy with an acid suppressing agent (like an H2 blocker, PPI, or antacid), a pro-motility agent, or both may be needed to control symptoms and prevent complications of GERD. It is recommended that you consult your doctor to decide which therapy is needed for you.

In cases where the esophagus has been badly injured by GERD, or when medical therapy fails, surgery is considered on an individual basis. In April 2003, the Food and Drug Administration approved Enteryx, a permanently implanted device to help patients with symptoms of GERD. Enteryx must be inserted through a surgical procedure. This device prevents the reflux of stomach acid into the throat, potentially allowing patients with chronic GERD to avoid daily medications.

Helping Yourself

  • Eat smaller meals. Do not eat within two hours of going to bed.
  • Avoid foods that bring on your heartburn. Common culprits include chocolate, citrus fruits and juices, tomatoes and tomato juice, peppermint or spearmint flavored foods or drinks, fried or fatty foods, spicy foods, coffee, and carbonated beverages.
  • Avoid alcohol. Alcohol irritates the esophagus and can promote symptoms of GERD.
  • Stop smoking.
  • Lose weight. Losing weight can take pressure off the valve between the esophagus and stomach.
  • Raise the head of your bed (e.g., by placing the legs on thick telephone books). This may help to decrease the backward flow of acid from the stomach to the esophagus while you are sleeping.
  • Do not take aspirin, ibuprofen, naproxen or other NSAIDs. Try acetaminophen instead, if needed for pain or fever.
  • Try an over-the-counter antacid such as Maalox or Mylanta to neutralize the painful stomach acid. If it is not effective, consider trying over-the-counter acid-blockers such as Pepcid AC or Tagamet HB, or an over-the-counter proton pump inhibitor, Prilosec OTC. Be sure to follow the package instructions carefully and inform your doctor.

What is on the horizon?

GERD may often be missed in children. The FDA has approved omeprazole (Prilosec) for children aged one year and older. Esomeprazole (Nexium) was also recently approved for children aged one to eleven years. Currently, a study is being performed to assess the efficacy of another PPI, pantoprazole (Protonix), to treat GERD in children. Another study is looking at the safety of nizatidine (Axid), an H2 blocker, in infants.

Baclofen, a muscle relaxant and a pro-motility drug similar to Reglan, is being studied in patients with slow gastric emptying. This medication may be another option for patients with GERD when therapy with H2 blockers or PPIs does not work.

As of May 2006, research suggests that patients who failed surgery for severe GERD can opt for another surgery. The study showed that reoperation for failed anti-reflux surgery is safe and effective.

References

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Heartburn. Mayo Clinic. Diseases and Conditions. Available at URL: http://www.mayoclinic.com/invoke.cfm?retryCount=1&objectid=EA5EDE79-8C89-40EB-8D46C714D1E91710 Accessed June 1, 2005, June 1, 2006, April 11, 2007, and March 31, 2008.

Heartburn, Hiatal Hernia, and Gastroesophageal Reflux Disease (GERD). National Digestive Diseases Information Clearinghouse. Available at: http://digestive.niddk.nih.gov/ddiseases/pubs/gerd/index.htm#1. Accessed June 1, 2005, June 1, 2006, April 11, 2007, and March 31, 2008.

Scott M, Gelhot AR. Gastroesophageal Reflux Disease: Diagnosis and Management. American Academy of Family Physicians. Available at: http://www.aafp.org/afp/990301ap/1161.html Accessed June 1, 2005, June 1, 2006, April 11, 2007, and March 31, 2008.

DeVault K, Castell D. Guidelines for the diagnosis and treatment of gastroesophageal reflux disease. Archives of Internal Medicine 1995;155:2165-2173.

Fennerty M, et al. The diagnosis and treatment of gastroesophageal reflux disease in a managed care environment. Archives of Internal Medicine 1996; 156:477-484.

Gastroesophageal reflux disease. The American Gastroenterological Association; December 1997.

Kahrilas P. Gastroesophageal reflux disease. Journal of the American Medical Association 1996;276(12):983-987.

New Medical Therapies:GERD. Available at: http://www.centerwatch.com/bookstore/nmt/GERD.pdf. Accessed June 1, 2005, June 1, 2006, April 11, 2007, and March 31, 2008.

Gastroesophageal Reflux Disease (GERD) Health Condition Last Updated: April 2008

Note: The above information is intended to supplement, not substitute for, the expertise and judgment of your physician, pharmacist, or other healthcare professional. It is not intended to diagnose a health condition, but it can be used as a guide to help you decide if you should seek professional treatment or to help you learn more about your condition once it has been diagnosed.

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