Gastroesophageal Reflux Disease

Gastroesophageal reflux disease affects up to one in five adults in Western countries, causing uncomfortable burning sensations in the chest and throat. While occasional acid reflux is common, when it happens frequently over time, it can damage the lining of the esophagus and lead to serious complications if left untreated.

Table of contents

• What is Gastroesophageal Reflux Disease?
• Symptoms and Warning Signs
• Causes and Risk Factors
• Potential Complications
• How Doctors Diagnose GERD
• Lifestyle Changes and Non-Medical Treatment
• Medical Treatment
• Surgical Treatment Options

What is Gastroesophageal Reflux Disease?

Gastroesophageal reflux disease, commonly called GERD, is a condition where stomach contents flow backward into the esophagus (the tube that connects your throat to your stomach)^[1]. This backward flow is known as acid reflux. When acid reflux happens repeatedly over time, it can cause GERD^[1].

Your esophagus is protected by a ring of muscle fibers at its lower end called the lower esophageal sphincter. This muscle normally prevents swallowed food from moving back up^[3]. When this muscle does not close properly, stomach contents can leak back into the esophagus^[3]. The harsh stomach acid can then damage the lining of the esophagus, since the esophagus lacks the protective lining that the stomach has^[8].

Almost everyone experiences acid reflux occasionally. However, when it occurs at least twice a week for several weeks, it is considered chronic and classified as GERD^[2]. GERD is estimated to affect about 20% of adults and 10% of children in the United States^[2]. Worldwide, the prevalence ranges from 8% to 33%^[4].

Symptoms and Warning Signs

The most common symptom of GERD is heartburn, a burning sensation in the chest that usually happens after eating and might be worse at night or while lying down^[1]. Despite its name, heartburn has nothing to do with the heart. Instead, it occurs when acid literally burns the tissues in your esophagus^[2].

Other typical symptoms include:

• Regurgitation, which is the backwash of food or sour liquid in the throat. You might notice acid, food, or liquids rising from your stomach into your throat after eating, often with a sour taste^[1][2]
• Upper belly or chest pain^[1]
• Trouble swallowing, called dysphagia^[1]
• Sensation of a lump in the throat^[1]
• Nausea and loss of appetite^[2]

If you experience nighttime acid reflux, you might also notice:

• An ongoing cough^[1]
• Inflammation of the vocal cords, known as laryngitis^[1]
• New or worsening asthma symptoms^[1]
• Sore throat or hoarseness^[2]
• Wheezing and shortness of breath^[2]

Symptoms may get worse when you bend over or lie down, or after you eat^[3]. They may also worsen at night, after a large or fatty meal, or after smoking or drinking alcohol^[2].

Some symptoms require immediate medical attention. Seek medical help right away if you have chest pain, especially if you also have shortness of breath, or jaw or arm pain, as these may be symptoms of a heart problem rather than GERD^[1]. You should also consult your doctor right away if you have bloody or dark stools, unexplained weight loss, severe trouble swallowing, or vomiting^[15].

Causes and Risk Factors

GERD occurs when the lower esophageal sphincter becomes weak or relaxes at the wrong time, allowing stomach contents to flow backward into the esophagus^[3]. The condition is not usually caused by having too much acid in your stomach. Rather, the problem is that acid is backing up into the esophagus, which cannot protect itself from the acid like the stomach can^[8].

Several factors can increase your risk of developing GERD:

• Being overweight or obese, which increases pressure on the abdomen^[3][4]
• Pregnancy, due to changes in the body that increase abdominal pressure^[3][4]
• Hiatal hernia, a condition in which part of the stomach moves above the diaphragm (the muscle that separates the chest and abdominal cavities)^[3]
• Smoking or tobacco use^[3]
• Use of alcohol^[3]
• Lying down within 3 hours after eating^[3]
• Eating large meals or certain foods such as chocolate, tomato sauce, fatty or deep-fried foods, citrus fruits, caffeine, and spicy foods^[8]

Certain medications can also cause or worsen heartburn and reflux symptoms, including pain relievers like aspirin and ibuprofen, some blood pressure medications, asthma medications, and sedatives^[3]. If you think one of your medicines may be causing heartburn, talk to your doctor before stopping or changing the medication^[3].

Potential Complications

Over time, recurring acid reflux can cause serious complications. The chronic inflammation can permanently damage the lining of the esophagus^[4]. Untreated GERD can lead to:

• Long-term inflammation of the esophagus, called esophagitis^[8]
• Ulcers, which are open sores in the esophagus^[8]
• Narrowing of the esophagus, called esophageal stricture, which can make swallowing difficult^[8]
• Barrett esophagus, a condition where abnormal cells develop in the esophagus that may become cancerous^[8][19]
• Esophageal cancer^[19]
• Problems affecting the voice box, windpipe, and lungs^[8]

Men are at higher risk than women for developing Barrett esophagus and esophageal cancer as consequences of long-standing disease^[4].

How Doctors Diagnose GERD

Your doctor might be able to diagnose GERD based on your symptoms and a physical examination^[9]. If your symptoms are mild and respond to treatment, you may not need any tests^[3].

However, if your symptoms are severe or come back after treatment, your doctor may recommend tests to confirm the diagnosis or check for complications:

• Upper endoscopy: A thin, flexible tube with a tiny camera on the end, called an endoscope, is inserted down your throat into your esophagus and stomach. This allows the doctor to visually examine the upper digestive system and look for inflammation or other complications^[9]. During this procedure, the doctor can also collect a sample of tissue, called a biopsy, to test for complications such as Barrett esophagus^[9].
• Ambulatory acid (pH) probe test: A monitor is placed in the esophagus to measure when and for how long stomach acid flows back there. The monitor connects to a small computer worn around the waist or over the shoulder^[9]. It might be a thin catheter threaded through the nose into the esophagus, or a clip placed during an endoscopy that passes naturally after about two days^[9].
• X-ray of the upper digestive system: This imaging test can help identify problems with the structure of the esophagus and stomach^[9].
• Esophageal manometry: This test measures the pressure inside the lower part of the esophagus to see if the muscle is working properly^[3].

A positive stool test for hidden blood may indicate bleeding from irritation in the esophagus, stomach, or intestines^[3].

Lifestyle Changes and Non-Medical Treatment

Changes in your lifestyle are the first line of treatment for GERD symptoms^[3]. Many people can manage the discomfort of GERD with lifestyle modifications alone^[1].

Weight loss and tobacco smoking cessation are particularly important. In clinical trials, weight loss reduced the time with esophageal acid exposure^[23]. In a large study, stopping smoking reduced reflux symptoms in people of normal weight^[23].

Other lifestyle changes that can help include:

• Eating small, frequent meals instead of a few large meals^[3]
• Eating slowly and chewing thoroughly^[3]
• Avoiding foods that trigger your symptoms, such as chocolate, tomato sauce, fatty or deep-fried foods, citrus fruits, spicy foods, garlic, onions, peppermint, and vinegar^[8][22]
• Avoiding alcohol, coffee, and acidic drinks such as colas and orange juice^[8]
• Not eating for 2 to 3 hours before going to bed^[3][8]. In research trials, eating early in the evening reduced acid exposure compared to late evening meals^[23]
• Elevating the head of your bed by 6 to 8 inches using blocks or a wedge pillow^[3][8]. Studies show this decreases nighttime acid exposure^[23]
• Wearing loose-fitting clothes to reduce pressure on the abdomen^[13]
• Avoiding heavy lifting and bending over after meals^[13]
• Not smoking^[3][8]

You should also avoid medicines such as aspirin, ibuprofen, or naproxen, as these can make symptoms worse. Take acetaminophen instead to relieve pain^[3]. When your doctor gives you a new medicine, ask whether it will make your heartburn worse^[3].

Medical Treatment

If lifestyle changes do not resolve your symptoms, your doctor might recommend medications^[3]. Many medications can help alleviate the pain and discomfort of GERD, and several are available without a prescription^[3].

The main types of medications used to treat GERD include:

Antacids provide quick relief by neutralizing stomach acid. Examples include Alka-Seltzer, Maalox, Mylanta, Rolaids, and Tums^[3]. While they may relieve mild symptoms, they do not heal any damage that stomach acid has caused in the esophagus^[15].

H2 receptor antagonists (also called H2 blockers) reduce the amount of acid your stomach produces. They offer short-term relief and are effective for healing milder cases of esophagitis^[12]. Examples include cimetidine (Tagamet), famotidine (Pepcid), and nizatidine (Axid)^[3]. These are available both over the counter and in prescription strength^[3].

Proton pump inhibitors (PPIs) are the most effective medications for GERD. They work by blocking the acid pumps in the stomach’s acid-producing cells, significantly reducing acid production^[4]. PPIs offer stronger treatment than H2 blockers^[3]. Examples include omeprazole (Prilosec), esomeprazole (Nexium), lansoprazole (Prevacid), and pantoprazole (Protonix)^[3]. You may need to take the medicine for 4 to 12 weeks or longer so your esophagus has time to heal^[8].

Prokinetics strengthen the lower esophageal sphincter and help the stomach empty faster. Examples include bethanechol (Urecholine) and metoclopramide (Reglan)^[3]. However, these medications have side effects that may limit their usefulness^[3].

Your doctor may suggest taking a combination of medications. For example, taking an antacid along with an H2 blocker can first neutralize the acid in your stomach and then limit additional acid production^[3]. Despite the overall safety and effectiveness of GERD medications, approximately 10% to 40% of people do not improve with these treatments^[20].

Surgical Treatment Options

For some people, surgery may be considered instead of long-term medication use or when medications do not provide adequate relief^[3][16]. Surgery is an option for patients who develop complications or those who do not respond well to medical therapy^[1].

The main surgical procedures for GERD include:

Nissen fundoplication is the most common anti-reflux surgery. During this procedure, the upper part of your stomach is wrapped around the lower esophageal sphincter to strengthen the sphincter and prevent acid reflux^[16]. This surgery can be performed using a laparoscope, a thin, lighted tube inserted into the abdomen through tiny incisions, which allows for faster recovery^[3].

LINX procedure involves implanting a small ring of magnetic beads at the level of the lower esophageal sphincter. This ring creates a barrier that prevents reflux^[16].

Surgery should only be considered after a proper evaluation by your doctor to determine if it is appropriate for your specific situation^[11].