GastroEsophageal Reflux Disease (GERD)

When is acid reflux a disease?
When acid produced by the stomach travels back into the esophagus, you will feel a burning sensation in your central chest. This feeling is commonly called "Heartburn". Heartburn is the most common symptom of gastroesophageal reflux. When acid reflux causes persistent symptoms or results in ulcers, scar tissue or a condition called Barrett's esophagus, it is appropriate to call this a disease or GERD.

How common is GERD and what are the symptoms?
Heartburn occurs in 10-44% of our population. Most people do not need prescription medications, but as many as 1 person out of 10,000 requires surgery. The esophagus can experience burning from stomach acid and acidic beverages and foods, even though endoscopy will not show erosions or ulcers. Typically, heartburn occurs after meals, lying down, during sleep and may be associated with regurgitation of stomach contents and a bitter taste in the mouth. Many patients who have GERD may have "atypical" symptoms such as cough, asthma and hoarseness.

What is the long-term outlook for people with GERD?
Usually once you start having heartburn, it can become a chronic problem. A study carried out between 1960-70 looked at 142 untreated persons observed for up to 8 years - esophagitis was worse in 28%, unchanged in 20%, reduced in 17% and disappeared in 35%. A study reported in 1997 had followed 64 persons over 20 years - symptoms were better in 75%; 33% needed antacids; and 27% required either surgery or prescription medications.

What are the natural protective factors against acid reflux?
Most people do not get reflux because of natural protective factors. These include: a normal production of saliva which has a buffering effect against acid; normal esophageal muscular peristaltic activity which quickly strips food and acid down and out of the esophagus; normal lower esophageal sphincter integrity (this muscle stays closed and opens only for food, liquid and saliva to pass); a normal angle of the esophagus and stomach junction and the effect at the diaphragmatic ring (this acts like a belt); normal stomach function moves food and acid out at a normal rate.

What are the factors that promote acid reflux?
Why is heartburn so common in our society? Think about the statement "you are what you eat". Many dietary factors provoke reflux - big meals overload the stomach, fat slows stomach activity, many foods relax the lower esophageal sphincter (caffeine, coffee, chocolate, onions and peppermint). Lying down after a meal defies gravity and increases the risk of acid and food rolling up into the esophagus. Many medications also weaken the sphincter and decrease saliva production. The sphincter strength may decrease with aging. Smoking injures the lining of the esophagus and stomach and can predispose to delayed healing of acid injury. A structural condition known as a hiatal hernia is a common abnormality that can lead to GERD. This may be inherited or develop with heavy lifting or straining. The hernia occurs when the diaphragm ring enlarges and the upper part of the stomach moves up into the chest cavity. The area of the stomach that is within the chest cavity is called the hiatal hernia. There are uncommon diseases that have alterations in the protective factors and include: Sjogren’s syndrome, scleroderma, gastroparesis and a rare hormonal condition called Zollinger Ellison's syndrome, which causes excess acid production.

How is GERD diagnosed?
Various tests may be necessary to diagnose GERD. These include upper GI barium x-rays and upper endoscopy. When surgery is considered or when medical therapy is failing, further testing with a 24-hour acid monitor (24-hour pH test) and esophageal muscular strength and coordination test (esophageal manometry) is often indicated. Endoscopy is required for symptoms of difficulty swallowing, pain with swallowing, weight loss or after 10-year period of heartburn in order to screen for Barrett's esophagus.

How is GERD treated?
The standard treatment for GERD includes medication as well as behavioral modification (how, when and what you eat). Antacids and H2 blocker medications can be used for treatment of mild symptoms but usually are not very effective for significant or long-term management of significant GERD. The H2 blocker medications are available over-the-counter in doses half the strength of those that require a prescription. Reglan, a medication that can speed up the stomach emptying, can help GERD patients but has side effects in 10 - 15%. Domperidone is a similar medication but is only sold in Canada. Specialists in Gastroenterology can obtain this through a pharmacy for our patients. Laparoscopic hiatal surgery is an excellent, effective, long-term approach to GERD. Propulsid was taken off of the market but is available by qualified investigators for people with severe reflux or other motility disorders. This medication is available at Specialists in Gastroenterology.

For more information regarding GERD surgery, visit www.sages.org.