What is gastroesophageal reflux disease (GERD)?

It is estimated that more than one third of the US population experiences heartburn at least once per month, 20% at least weekly and around 7% daily. Gastroesophageal reflux disease (GERD) is referred to as "heartburn" because the most common symptom is a burning discomfort in the chest under the breast bone. In fact, a burning discomfort in the chest or upper abdomen that is relieved with acid reducing medication, such as Tums® and regurgitation (burping up) of sour tasting gastric juice into the mouth are classic symptoms of GERD, which are easily recognized by physicians. However, there are many other patient symptoms that may be due to GERD, but not so easily recognized as GERD by physicians. The following topics will be discussed in this section:

1. The Causes of GERD (pathogenesis of the disease)
2. Complications of GERD (side-effects)
3. How GERD is diagnosed?
4. How GERD is treated?

Causes of GERD (heartburn)

GERD (backwashing of stomach acid and bile into the esophagus or swallowing tube) occurs as a result of the failure of the various mechanisms designed to keep stomach contents (acid and digestive juices) out of the esophagus. The lower esophageal sphincter (LES), is a muscle or valve located at the bottom of the esophagus where the esophagus joins the stomach. The LES normally maintains a higher pressure than the pressure of the stomach to keep stomach contents out of the esophagus. Transient or brief LES relaxations (intermittent lowering of LES pressure) may lead to backwashing of stomach contents into the esophagus. These transient LES relaxations account for most of the gastroesophageal reflux episodes in people, including the occasional symptoms in normal people and in most people who have GERD. However, in some people who have severe GERD, including those who have Barrett's esophagus, the LES has an abnormally low pressure, allowing stomach contents to more readily bathe the esophagus.

The ability to clear the esophagus of refluxed acid also plays a very important role in GERD and in the development of esophagitis (inflammation of the esophagus from acid and bile injury). Although most people who have mild to moderate GERD have normal esophageal contractions that clear the esophagus of refluxed acid, about half of those who have severe GERD, including many of those who have Barrett's esophagus, have weak esophageal contractions. Their esophageal contractions are not strong enough to adequately "strip" stomach contents out of the esophagus, leading to prolonged acid and bile exposure to the esophagus. This prolonged exposure allows injury to the normal squamous lining of the esophagus to occur, resulting in esophagitis and in some people, healing of the esophagus with the development a new lining, Barrett's esophagus.

Other factors that play a role in some people who have GERD include hiatal hernia, delayed gastric emptying, overproduction of acid, a bacterium called H. pylori and bile reflux. Decreased saliva production and protective mucosal factors play a role in GERD but may be less important in the vast majority of patients.

Complications of GERD (side-effects)

Most people who have GERD do not experience complications. For some who have severe GERD, complications do develop. Esophagitis (inflammation of the esophagus) with erosions and ulcerations (breaks in the lining of the esophagus) can occur from repeated and prolonged acid exposure. If these breaks are deep, bleeding or scarring of the esophagus with formation of a stricture (narrowing of the esophagus) can occur. If the esophagus narrows significantly, then food sticks in the esophagus and the symptom is known as dysphagia.

Normal squamous esophagus Photo courtesy of the Seattle Barrett's Esophagus Research Program

Erosive esophagitis with stricture The squamous esophagus has a narrowed opening (lumen) due to chronic GERD with inflammation and scarring. This narrowed opening is called a stricture. The surrounding esophageal lining has ulcerations and erosions (mucosal breaks) from chronic acid injury to the esophagus. Photo courtesy of Joel E Richter MD - Temple University

GERD has been shown to be one of the most important risk factors for the development of esophageal adenocarcinoma. In a subset of people who have severe GERD (approximately 10%), if acid exposure continues, the injured squamous lining is replaced by Barrett's metaplasia, a precancerous lining in which esophageal adenocarcinoma can develop. No one knows what causes Barrett's esophagus.

Finally, other complications of GERD may not appear to be related to esophageal disease at all. Some people with GERD may develop recurrent pneumonia (lung infection), asthma (wheezing), or a chronic cough from acid backing up into the esophagus and all the way up through the upper esophageal sphincter into the lungs. In many instances, this occurs at night, while the person is sleeping. Occasionally, a person with severe GERD will be awakened from sleep with a choking sensation. Hoarseness can also occur due to acid reaching the vocal cords, causing chronic inflammation or injury.

Diagnosis of GERD

GERD symptoms

Most people who have GERD can be diagnosed based on their symptoms alone. Typically, these symptoms include a burning pain in the high abdomen or chest that typically moves upward toward the mouth and is relieved by acid reducing medication, such as Tums®. It usually occurs after eating or is related to body position, such as bending over or lying down. It is not uncommon for gastroesophageal reflux to occur at night while lying down with resulting regurgitation of acid into the throat and sometimes the mouth. Many patients with GERD will also have the sensation of fullness in the neck when swallowing, difficulty swallowing, or excess mucous production in the throat. When the typical symptoms are present, no further testing is needed to make a diagnosis of GERD. Many patients are prescribed a course of acid suppressing (acid decreasing) drugs and if symptoms greatly improve or disappear, GERD has been successfully diagnosed and treated. However, if no further work up is done, Barrett's esophagus, if present, will be missed.

Printable List of GERD symptoms

Many people do not have the typical symptoms of GERD and may have vague or atypical symptoms due to GERD. Some of these people may have chest pain without a burning component. In some cases this chest pain due to GERD may radiate down the arms, into the jaw, ear or neck and mimic heart disease. Other people with GERD have vague abdominal pain or burning abdominal pain, bloating and belching and may take a lot of antacids for these symptoms. Sometimes these symptoms are confused with gallbladder disease or peptic ulcer disease. In patients who have atypical symptoms of GERD, it may become necessary to perform tests to distinguish GERD from heart disease, gallbladder disease or peptic ulcer disease. Even more challenging for the physician, it is not rare for patients to have more than one of these diseases, making it extremely important to sort out the cause of a patient's symptoms. In the case of atypical chest pain that could be indicative of heart disease, it is wise practice to have the patient evaluated for heart disease prior to evaluation for GERD.

Unfortunately, a large number of people who have significant complications of GERD will go undiagnosed, many of them with resultant lung disease or Barrett's esophagus. Most of these people never seek medical attention for their symptoms and some self medicate with over-the-counter acid reducing medications such as Tums®, Maalox™ Pepcid® AC or Prilosec OTC. Others have symptoms that do not involve the digestive tract, such as asthma, cough or hoarseness, that may not be recognized as GERD by their physician. Still in others with severe GERD, their symptoms have disappeared after years of chronic heartburn.

A small number of people who have severe GERD will be prompted to see a doctor because they are vomiting blood, passing black or bloody bowel movements, or getting food stuck in their esophagus. These symptoms are serious and need immediate medical attention.

Diagnostic tests for GERD

Most patients who have typical GERD symptoms can be diagnosed based on symptoms alone and if they respond favorably to medical therapy, may need no further tests to diagnose GERD. In fact, if a patient is treated with a high-dose of a medication called a proton pump inhibitor, and their symptoms go away, this confirms that the patient's symptoms are caused by GERD and other more expensive tests to diagnose GERD may not be needed. Diagnostic testing may be necessary to determine whether a patient's atypical heartburn symptoms are due to GERD, and is necessary to diagnose Barrett's esophagus, or as part of an evaluation for anti-reflux surgery.

The initial test may be a barium esophagram (an esophageal x-ray study) that can detect large defects in the esophageal lining, such as some ulcers or strictures or tumors, but cannot reliably diagnose GERD or Barrett's esophagus. Esophagogastroduodenoscopy (EGD or upper endoscopy with biopsy) is the most sensitive test for esophageal injury (esophagitis) and the only test to confirm the presence of Barrett's esophagus.

Endoscopic diagnosis of esophagitis or Barrett's esophagus confirms that the patient has GERD and no further testing is necessary. However, upper endoscopy does not detect those GERD patients who do not have esophagitis or Barrett's esophagus. To confirm the diagnosis of GERD, these patients may need pH monitoring, This test measures the number of acid reflux episodes and is also used to tell whether the patient's symptoms are caused by acid reflux. Patients who are considering anti-reflux surgery also undergo pH monitoring and esophageal manometry in addition to upper endoscopy.

Treatment of GERD

For patients with GERD, with or without Barrett's esophagus, the goal of therapy is to achieve relief of heartburn symptoms as well as to prevent the complications or adverse side-effects of GERD. Treatment of GERD includes life-style changes to lessen the opportunity for acid reflux, medical therapy and anti-reflux surgical therapy. Recently, endoscopic therapies for the treatment of GERD are being offered to patients who have mild or uncomplicated GERD, as an alternative to medical or surgical therapies. However, the long-term outcome of these therapies is unknown and have not been evaluated in patients who have Barrett's esophagus. Most experts agree that these therapies should only be offered in the setting of a clinical trial.

Medical therapy involves the use of acid suppressive drugs, the most potent of which belong to the class of proton pump inhibitors or PPIs. Examples of these drugs are esomeprazole (Nexium®), lansoprazole (Prevacid®), omeprazole (Prilosec®  and Zegerid and now available without a prescription as Prilosec OTC), pantoprazole (Protonix®) and rabeprazole (Aciphex®). These drugs have become the mainstay of treatment of GERD and have an excellent safety record. Anti-reflux surgery, particularly laparoscopic surgery, has an important role in the treatment of GERD, especially in patients who continue to have complications of GERD despite medical therapy. Herbal remedies for the treatment of GERD are beyond the scope of this site.