Gastroesophageal Reflux Disease (GERD)/Heartburn

Definition

Gastroesophageal reflux disease (GERD) results when gastric acid, food, and liquid from the stomach chronically flow up into the esophagus (the tube that connects the mouth to the stomach).

GERD is caused by a weakness or transient relaxation of the lower esophageal sphincter (LES) muscle. The LES sits at the juncture between the esophagus and the stomach. When you eat, food and liquid travel down the esophagus to the stomach. Once they arrive, the resting tone of the LES helps keep stomach contents from refluxing or moving backward into the esophagus. But when the LES is weakened, it does not work properly. Stomach contents may reflux into the esophagus, which can cause the burning sensation in the chest known as heartburn.

While most Americans suffer from heartburn at one time or another, it is estimated that 17 million Americans suffer from chronic GERD. Possible long-term complications of GERD include esophagitis, Barrett’s esophagus, esophageal narrowing, and cancer of the esophagus.

Causes

GERD results when the lower esophageal sphincter (LES) muscle becomes weakened. The LES sits at the juncture between the esophagus and the stomach and prevents food and stomach liquids from flowing back up into the esophagus.

Weakening of the LES can be caused by the following factors and conditions:

• Hiatal hernia: When the stomach and the LES protrude into the chest through the opening in the diaphragm normally occupied by the esophagus
• Surgical destruction of the LES
• Neurologic disorders or complications (from diabetes, for example) affecting the LES
• Scleroderma: A disorder that affects esophageal motility
• Congenital defects of the gastrointestinal or respiratory tracts
• Certain medications, such as:
  • Bronchodilators
  • Calcium channel blockers
  • Aminophylline
  • Nitrates
  • Sildenafil (Viagra)

Other factors that contribute to LES weakening include the following:

• Smoking
• Caffeinated beverages
• Alcohol
• Fatty foods, especially chocolate and fried foods

Once the LES is weakened, other factors, such as an increase in pressure in the abdomen relative to the chest, can increase the risk of reflux.

Risk

A risk factor is something that increases your likelihood of getting a disease or condition.

It is possible to develop GERD with or without the risk factors listed below. However, the more risk factors you have, the greater your likelihood of developing GERD. If you have a number of risk factors, ask your healthcare provider what you can do to reduce your risk.

GERD or heartburn can occur in men, women, and children of all ages, including infants.

Risk factors include:

Specific Lifestyle Factors

The following habits can increase the risk of heartburn or GERD:

• Obesity
• Exercising immediately after eating (especially jogging or strenuous activity)
• Smoking
• Lying down soon after meals
• Bending over or straining, especially soon after meals
• Alcohol (especially excess) use
• Eating chocolate
• Drinking carbonated beverages, caffeinated beverages, and decaffeinated coffee
• Eating spicy foods or acidic foods like citrus or tomatoes

Medical Conditions

The following medical conditions may increase the risk of developing GERD:

• Peptic ulcer
• Prior surgery for heartburn, including gastric reflux surgery and vagotomy
• Asthma or other respiratory problems
• Diabetes
• Cancer
• Scoliosis
• Cystic fibrosis
• Certain nervous system disorders
• Gastrointestinal disorders
• Food allergies
• In-dwelling nasogastric tube
• Chest trauma
• Certain congenital problems such as:
  • Down syndrome and other types of intellectual disabilities
  • Cerebral palsy

Medications and Supplements

The use of certain medications and supplements can increase the risk of GERD. These medications include:

• Aspirin and other NSAIDs (may irritate the stomach, which contributes to GERD)
• Anticholinergics
• Calcium channel blockers
• Theophylline, bronchial inhalers, and other asthma medications
• Quinidine
• Tetracycline
• Potassium and iron supplements
• Nitrates
• Sildenafil (Viagra)
• Alpha-adrenergic agents
• Meperidine (Demerol)
• Sedatives such as diazepam (Valium)
• Hormone replacement therapy

Symptoms

GERD symptoms can occur at any time. However, they usually occur after overeating, or lying down after a big meal. Symptoms may last for a few minutes or a few hours. People who have possible symptoms of GERD should seek medical care.

The most common symptoms of GERD include:

• Heartburn – a burning feeling that starts in the lower chest and may move up the throat
• Frequent, persistent, recurrent, or chronic indigestion. Symptoms of indigestion include:
  • Upper abdominal pain or discomfort following a meal
  • Burping, bloating, heartburn, nausea, and vomiting
• Regurgitation of stomach contents into the back of the mouth or throat
• Sour or bitter taste in the back of mouth or throat
• Symptoms worsen when bending over, lying down, exercising, or lifting heavy objects

Other symptoms of GERD may include:

• Sore throat or earache
• Bad breath
• Hoarseness
• Chronic cough
• Choking
• Wheezing or trouble breathing
• Insomnia
• Feeling of a lump in the throat
• Hoarse voice (laryngitis)
• Difficulty or painful swallowing
• Chest pain. Note: GERD can feel like the pain associated with a heart attack. Do not assume that chest pain is GERD or indigestion. If you have chest pains or other symptoms of a possible heart attack, call 911 immediately for emergency medical care.
• Sleep apnea (stopping breathing repeatedly throughout the night)
• Recurrent vomiting or failure to thrive in infants

Long-term complications of GERD may include:

• Esophagitis – inflammation of the esophagus
• Bleeding and ulcers in the esophagus
• Dental problems (due to the effect of stomach acid on tooth enamel)
• Chronic laryngitis
• Asthma attacks and/or pneumonia (During sleep, acid may reflux from the stomach into the throat, drain into the lungs, and cause irritation.)
• Barrett’s esophagus – a precancerous condition that can lead to esophageal cancer
• Esophageal cancer – may develop in patients who have Barrett’s esophagus

Diagnosis

Your doctor will ask about your symptoms and medical history, and perform a physical exam. He or she will usually make an initial diagnosis of GERD based on your symptoms. In some cases, other tests will be done to confirm the diagnosis or exclude other disorders.

These tests may include:

Upper GI Series – A series of X-rays of the upper digestive system are taken after drinking a barium solution.

24-hour pH Monitoring – A probe is placed in the esophagus to keep track of the level of acidity in the lower esophagus. This is done over a 24-hour period.

Manometry – This test measures muscle pressures in the lower esophagus.

Endoscopy – A thin, lighted tube with a tiny camera attached is passed down the throat to examine the esophagus and stomach.

Biopsy – A small sample of tissue from the esophagus is removed. It is then studied to check for inflammation, cancer, or other problems.

Treatment

Treatment of GERD (heartburn) usually includes lifestyle changes and medications. In more severe cases, surgery may be needed.

Lifestyle Changes

Lifestyle changes can control the symptoms of GERD. Lifestyle changes include:

• Avoid certain foods and drinks.
• Quit smoking.
• Wait to lie down or exercise after eating.
• Lose weight or maintain a healthy weight.
• Keep your head elevated while sleeping.

• Avoid overeating and eating too fast.
  
• Avoid large amounts of fluid with meals.
• Avoid alcohol, caffeine, carbonated drinks and coffee.
  
• Avoid spicy foods, foods that are high in fat and chocolate.

Medication

Your doctor may recommend over-the-counter medications or prescription medications to treat your GERD.

Prescription Medication

• Proton pump inhibitors
• Prokinetics
• Mucosal protectors

Over-the-Counter Medications

• Antacids
• H2 blockers (also prescription strength)

Surgery

Surgery is only performed in severe cases of GERD.

Incisionless Surgery

UVA is the first medical center is this area to offer a surgical procedure called transoral incisionless fundoplication (TIF), which doesn’t require any abdominal incisions. This innovative procedure allows doctors to reconstruct the antireflux valve, which is the barrier between the esophagus and the stomach.