A Patient’s Guide to GERD

Ever have the sense that your heart is on fire? It happens to many of us, especially after a big, spicy meal or when you lie down to sleep after having eaten something. Called heartburn, this sensation will usually go away on its own or with the help of an over-the-counter antacid tablet.

For many of us, heartburn is a once-in-a-while occurrence, but for some, it can become a much more frequent problem. People who experience heartburn often may be dealing with a condition called gastroesophageal reflux disease.

"GERD is a disorder where stomach contents come back up through the lower esophageal sphincter, which is the lower valve of the esophagus," says Dr. Scott Gabbard, a gastroenterologist with the Cleveland Clinic in Ohio. These stomach contents, which can include food, stomach acid and enzymes, leak back into the esophagus through "the lower esophageal sphincter back up into the esophagus and cause problems. GERD is truly a valve disorder where the lower esophageal sphincter opens when it’s not supposed to."

The National Institute of Diabetes and Digestive and Kidney Diseases reports that some doctors may also refer to the condition by a number of other names including:

GERD is a very common problem in the United States. The American College of Gastroenterology reports that "more than 60 million Americans experience heartburn at least once a month and some studies have suggested that more than 15 million Americans experience heartburn symptoms each day." Simple heartburn becomes GERD when it happens two or more times per week.

"Up to 20 percent of the U.S. population has GERD, depending on which study you read," Gabbard says. "So, it’s actually very common for the valve to open when it’s not supposed to," and in fact even in healthy patients who have no symptoms, it’s normal for reflux to occur for up to an hour per day, he says.

There are lots of factors that can go into the development of a case of GERD, but some of the most common include: Diet. "Eating fatty meals triggers the valve to open more," Gabbard says. It’s believed that occurs so that you’ll be able to belch to accommodate more food as happens when taking in a large meal. "If you’ve eaten a large meal there’s some sort of nerve signaling that’s probably mediated by nitric oxide. That allows the muscle to relax," and allows the valve to open more easily. "Theoretically these high-fat meals trigger more nitric oxide release, which then allows the sphincter to open. It’s probably a trait that has evolved to allow people to belch so they don’t feel so much pain after eating a large meal."

Obesity . Dr. Lisa Lih-Brody, M.D. a gastroenterologist at ProHEALTH Care in New York City, says that America’s growing weight problem is part of why the incidence of GERD is on the rise. "Unfortunately, GERD is becoming a worsening problem in the United States. Many of the reasons why this is happening is because the weight of people in America is going up. The average weight has been increasing and obesity is an epidemic. Obesity is a risk factor for reflux," she says.

Age. GERD is more common among adults over age 50. Over time, the elasticity of the esophageal sphincter declines, and that can lead to it opening when it shouldn’t. "Some studies suggest the valve becomes leakier as you age and doesn’t quite work as well as you get older," Gabbard says.

Sex and race. Caucasian men are more likely to get GERD.

Pregnancy. The simple fact of accommodating a baby in your belly can cause crowding among your internal organs and for some women, this means the development of GERD because stomach contents have nowhere else to go but up.

Frequent use of nonsteroidal pain relievers. Over-the-counter medications like ibuprofen (Advil, Motrin) and naproxen sodium (Aleve) can cause inflammation in the upper gastrointestinal tract, which can trigger or exacerbate symptoms of GERD.

Having a hiatal hernia. A hiatal hernia occurs when the top part of the stomach pushes through the diaphragm muscle and balloons into the chest cavity. This can force stomach contents where they don’t belong, leading to symptoms of GERD.

Smoking. Using tobacco is also considered a risk factor for GERD.

"A burning sensation in the center of the chest that usually occurs after a meal or when the patient lies down at night is the first typical symptom of GERD," Gabbard says. "The second typical symptom is regurgitation. You may not have burning but you’ll have the sensation of stomach contents and food coming up through the stomach and into the throat and mouth."

Lih-Brody adds that "burning in the upper part of the stomach radiating into the chest, burping, nausea, a feeling of fullness or of getting full quickly" can also be signs of GERD. "Rarely you can have extra esophageal manifestations such as a sore throat, hoarse voice, pneumonia and a cough ." These are less common symptoms that could signal other complications are present.

If you’re experiencing frequent heartburn, it may be time to see your doctor, particularly if you have any so-called "alarm symptoms," such as bleeding, weight loss and anemia, which may signal the presence of ulcers or strictures. "Unintentional weight loss, signs of bleeding, such as black tarry stools and if you’re having profound vomiting – these are alarm symptoms that should prompt someone to visit a physician. Also, if the heartburn and regurgitation becomes a regular and bothersome symptom, then clearly they need to visit the physician," Gabbard says.

Lih-Brody agrees that seeing a doctor sooner rather than later is always smart. "If you’re having symptoms more than two to three times a week for more than several months at a time, don’t sit on it," she says. See your doctor for evaluation and treatment. Most patients start by visiting their primary care doctor . But you may also be referred to a gastroenterologist for additional evaluation and treatment.

Although symptoms can guide your doctor to a GERD diagnosis, in some cases your gastroenterologist may want to conduct additional tests to rule out any other conditions that can produce similar symptoms and to look for any complications that are associated with GERD. These tests may include endoscopy, a type of imaging test where the doctor threads a thin tube with a camera attached to it into your mouth and down into your esophagus to get a good look at what’s going on.

In some cases, if there’s a suspicion of another gastrointestinal disorder such as Crohn’s disease or colitis , you may also undergo a colonoscopy. This procedure is similar to an endoscopy in that a thin tube with a camera is threaded into the body, but the colonoscopy is inserted through the anus and rectum into the colon to look at the lower end of the gastrointestinal tract. Ulcers. These sores develop from the constant washing of stomach acid on the inside of the esophagus.

Esophageal strictures. Over time, the esophagus can narrow, which may make swallowing very difficult.

Barrett’s esophagus. Barrett’s esophagus is a benign condition in which cells on the inside of the esophagus are replaced with intestinal cells. While the condition isn’t harmful in and of itself, it’s considered precancerous as it can develop into esophageal cancer. Therefore, "it needs to be diagnosed and monitored," Lih-Brody says.

Esophageal cancer . The big concern about GERD is that it can set the stage for esophageal cancer. As stomach acid causes inflammation, that can lead to genetic mutations in cells in the esophagus which could one day lead to cancer.

Respiratory problems. It’s believed that there’s an association between GERD and worsening of asthma symptoms in some patients. In other cases, the acid moves far enough up the esophagus to infiltrate the windpipe, causing a cough and sore throat. Some people may develop pneumonia as a result of poorly managed GERD.

Sleep disturbances. Constant heartburn can lead to difficultly sleeping for many people. Many doctors also advise patients to sleep sitting up to prevent reflux from entering the esophagus, and this change in position can also disrupt sleep.

Dental problems. These problems can include halitosis (bad breath) and cavities if stomach acid reaches back into the mouth and damages tooth enamel.

"In 2019, there’s still no FDA-approved medicine that helps prevent the valve from opening," Gabbard says, so "all of our therapies stop the stomach from making acid." A class of drugs called proton pump inhibitors, such as omeprazole (Prilosec), esomeprazole (Nexium) and lansoprazole (Prevacid) all reduce the amount of acid manufactured in the stomach. "The problem is you still have the valve opening and the contents coming back up, but there’s no acid in that content, so patients don’t feel it," Gabbard says. Therefore, in general, "provided that a patient doesn’t have any alarm features, our typical first-line approach would be a proton pump inhibitor to prevent the stomach from secreting acid." For many patients, simply reducing the stomach acid takes care of the symptoms.

While some of these medications are available […]

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