Definition: Defining the Meaning of GERD
Gastroesophageal reflux disease, or GERD, is a digestive disorder that affects the lower esophageal sphincter (LES), the ring of muscle between the esophagus and stomach. Gastroesophageal refers to the stomach and esophagus. Reflux means to flow back or return. Therefore, gastroesophageal reflux is the return of the stomach's contents back up into the esophagus. Both acid reflux and heartburn are common digestive conditions that many people experience from time to time. When these signs and symptoms occur at least twice each week or interfere with your daily life, or when your doctor can see damage to your esophagus, you may be diagnosed with GERD.
What is GERD
GERD, also referred to as, 'Acid Reflux,' is a condition in which the liquid contents of a person's stomach regurgitates into their esophagus. The liquid may inflame and damage the lining of the person's esophagus, causing esophagitis, although any visible signs of this inflammation happen in a small number of people. The liquid commonly contains both pepsin and acid which are produced by the person's stomach. 'Pepsin,' is an enzyme that begins the process of digesting proteins in the stomach. The, 'refluxed,' liquid from the person's stomach can also contain bile which has backed-up into their stomach from their duodenum, which is the first part of their small intestine and is attached to their stomach. Acid is thought to be the most injurious part of refluxed liquid. Both bile and pepsin can also injure a person's esophagus; their role in causing esophageal damage and inflammation is not as clear as that of acid.
GERD is a chronic condition; once it starts it is usually a life-long condition. Should injury to the lining of a person's esophagus occur, causing esophagitis; the esophagitis is a chronic condition as well. Once the esophagus has healed after treatment and the treatment is discontinued, the injury will return in most persons within a few months. Treatment for GERD, once begun, will usually need to be continued indefinitely.
What Causes GERD
There are most likely several potential causes of GERD.
Various causes can be operative in different people, or in the same person at different times. A few people with GERD produce abnormally large amounts of acid; this is not common, or a contributing factor in the large majority of people. The factors which contribute to GERD are emptying of the person's stomach, lower esophageal sphincter, hiatal hernias, and esophageal contractions.
Symptoms of Uncomplicated GERD
The symptoms of Uncomplicated GERD include nausea, heartburn and regurgitation. Additional symptoms happen when there are complications of GERD.
Heartburn is commonly described as a burning sensation in the middle of the person's chest, and may start high in their abdomen or can extend up into their neck. Some people experience pressure or sharp pain instead of burning. At times heartburn can mimic heart pain. Heartburn is common after meals.
Regurgitation is an appearance of refluxed liquid in the person's mouth. In the majority of person's with GERD, only small amounts of liquid usually reach their esophagus. On occasion, some persons with GERD experience larger amounts of liquid which reaches their upper esophagus.
Nausea is not a common symptom of GERD. Some persons with GERD do experience nausea resulting in vomiting. In persons with unexplained nausea or vomiting, GERD is one of the first conditions considered by a doctor. Why some persons with GERD develop mainly heartburn, while others develop mainly nausea, is not yet understood.
Complications of GERD
Ulcers: Liquid from the person's stomach that refluxes into their esophagus, damaging the lining in the esophagus may cause an ulcer to form. An ulcer is a break in the lining of the esophagus occurring in an area which has become inflamed. Esophageal ulcers may erode into blood vessels, causing bleeding into the person's esophagus.
Strictures: Esophageal ulcers heal with time, forming scars. Over time, this scar tissue shrinks, and narrows the inner cavity of the person's esophagus. The scarred narrowing is referred to as a, 'Stricture.' Food persons with strictures swallow may get stuck in their esophagus once the narrowing become severe, requiring this narrowing to be stretched.
Barrett's Esophagus: Persons with long-standing or severe GERD that causes changes in the cells in the lining of their esophagus may find that these cells have become either pre-cancerous or cancerous. The condition is referred to as, 'Barrett's Esophagus,' and occurs in about ten-percent of persons with GERD. It is not understood why some persons with GERD develop Barrett's Esophagus, while the majority do not.
Cough/Asthma: There are a number of nerves in the lower esophagus. Some of these nerves are stimulated by acid reflux, resulting in coughing. These same nerves may stimulate other nerves going to the person's lungs, causing the smaller breathing tubes to narrow; resulting in an asthma attack.
Throat/Larynx Inflammation: Should refluxed liquid get past the person's upper esophageal sphincter, it may enter their throat or voice box and cause inflammation. The inflammation may lead to either hoarseness or a sore throat. It is not understood how commonly GERD is responsible for what may be otherwise unexplained inflammation of a person's throat or larynx.
Inflammation/Infection of the Lungs: Liquid that has been refluxed, passing the larynx, may enter a person's lungs as well. This is referred to as, 'Aspiration,' of the refluxed liquid, and may lead to an infection in the lungs resulting in pneumonia. Pneumonia of this type is a serious problem that requires immediate treatment.
Liquid in the Sinuses and Middle Ears: Refluxed liquid that enters a person's upper throat can inflame the adenoids in a child's upper throat, causing them to swell. The swollen adenoids may block the passages to the child's sinuses and Eustachian tubes, causing fluid buildup. Accumulation of fluid can cause a child to be rather uncomfortable.
GERD is usually diagnosed through its most characteristic symptom - heartburn. Heartburn is commonly described as burning in the middle of a person's chest which occurs after eating and worsens upon lying down. In order to confirm a diagnosis a doctor often treats a person with medications designed to suppress the production of acid in their stomach. Should the person's heartburn diminish to a large extent, the diagnosis of GERD is considered to be confirmed.
Treatment of GERD
A change in lifestyle is one of the simplest treatments for GERD; changes in eating habits in particular. Because acid reflux is more injurious at night than during the day, it is recommended that persons with GERD sleep with their upper body elevated.
A GERD Diet: Smaller, earlier evening meals can reduce the amount of acid reflux a person with GERD experiences. There are some specific foods persons with GERD should avoid because they promote reflux. These foods include peppermint, chocolate, caffeinated drinks, alcohol, fatty foods, and spicy or acid-containing foods.
Antacids: Antacids are a mainstay of GERD treatment, despite the development of potent medications for the treatment of GERD. The best way to take antacids is about one hour after meals, or just prior to symptoms of reflux after a meal. A second dose of antacids about two hours after a meal replenishes the acid-neutralizing capacity in the stomach.
Surgery: When antacids and other medications become ineffective, surgery may become an option for the treatment of GERD. Surgery is very effective at relieving symptoms of GERD, as well as in treating the complications of it. Despite having surgery for GERD, approximately fifty-percent of the persons who have had surgery for it will continue to take medications for reflux. On rare occasion it is necessary to re-operate in order to revise a prior surgery.
Endoscopy: Endoscopic techniques exist for the treatment of GERD. One type involves stitching the area of lower esophageal sphincter which tightens the sphincter. A second type involves the application of radio frequency waves to the lower part of the person's esophagus right above their sphincter, with the goal of creating scar tissue which tightens the person's sphincter and the area above it. A third type of endoscopic treatment involves injection of materials into the person's esophageal wall in the area of the LES. The material increases pressure in the LES, preventing reflux. The benefit of endoscopic treatment is that it does not involve surgery, or hospitalization.
Facts: GERD (Heartburn)
GERD sometimes causes injury of the esophagus. These injuries may include:
- Esophageal adenocarcinoma - a rare form of cancer
- Esophageal strictures - the persistent narrowing of the esophagus caused by reflux-induced inflammation
- Reflux esophagitis - necrosis of esophageal epithelium causing ulcers near the junction of the stomach and esophagus
- Barrett's esophagus - intestinal metaplasia (changes of the epithelial cells from squamous to intestinal columnar epithelium) of the distal esophagus
Factors that can contribute to GERD:
- The use of medicines such as prednisolone.
- Obesity: increasing body mass index is associated with more severe GERD.
- Scleroderma and systemic sclerosis, which can feature esophageal dysmotility.
- Hypercalcemia, which can increase gastrin production, leading to increased acidity.
- Hiatal hernia, which increases the likelihood of GERD due to mechanical and motility factors.
- Zollinger-Ellison syndrome, which can be present with increased gastric acidity due to gastrin production.
- Visceroptosis or Glenard syndrome, in which the stomach has sunk in the abdomen upsetting the motility and acid secretion of the stomach.
Statistics: GERD (Heartburn)
- An estimated 3.4 million to 6.8 million Canadians are GERD sufferers.
- In the United States 20% of people have symptoms in a given week and 7% every day.
- In Western populations GERD affects approximately 10% to 20% of the population and 0.4% newly develop the condition.
- The prevalence rate of GERD in developed nations is also tightly linked with age, with adults aged 60 to 70 being the most commonly affected.