Gastroesophageal Reflux – Causes, Symptoms, Treatments

What is Gastroesophageal Reflux Disease?

Gastroesophageal reflux disease, or GERD, is a digestive disorder that arises when stomach acid backs up into the esophagus. This acid reflux can irritate the esophageal lining, leading to heartburn, that burning feeling in your chest, and acid regurgitation, a sour or bitter taste in your mouth.

While not life-threatening, GERD can significantly impact a person’s quality of life. The constant discomfort of heartburn and other symptoms can disrupt sleep, make eating difficult, and even lead to anxiety and depression. In some cases, GERD can cause more serious complications like esophageal ulcers or Barrett’s esophagus, a precancerous condition.

Common Symptoms of Gastroesophageal Reflux Disease

Heartburn is the most well-known symptom of GERD and often feels like a burning discomfort behind the breastbone. The intensity can vary from mild to severe, and the burning sensation may travel up the chest and into the throat. This burning typically occurs after eating, especially large meals, or when lying down.

For many, regurgitation is the unpleasant experience of stomach contents, including acid, rising back up into the esophagus and sometimes even into the mouth. This can cause a sour or bitter taste in your mouth and a feeling of something being stuck in your throat. Regurgitation can be especially bothersome at night, interrupting sleep and causing a choking sensation.

GERD can mimic heart-related chest pain, causing a burning or aching discomfort in the chest that can be quite alarming. Unlike heart pain, however, this discomfort isn’t related to blocked arteries and usually improves with sitting up or taking antacids. 

The irritation caused by stomach acid refluxing into the esophagus can trigger nausea, a feeling of general unease and discomfort in the stomach. This nausea might be accompanied by a lack of appetite or a feeling of fullness even after eating a small amount.

When stomach acid reaches the throat, it can irritate the delicate tissues, leading to a sore throat or a feeling of rawness. You might also experience hoarseness or a change in your voice due to the inflamed throat tissues.

GERD can sometimes present with less obvious symptoms that might not be readily associated with digestive issues. These can include a chronic cough that doesn’t respond to typical treatments, difficulty swallowing (dysphagia), or even asthma-like symptoms such as wheezing and trouble breathing.

Risk Factors for GERD

GERD risk factors can be broadly categorized into two main groups: modifiable and non-modifiable factors.

Non-Modifiable Risk Factors for GERD:

• Age: As we age, the lower esophageal sphincter (LES) naturally weakens. This muscular valve acts as a one-way gate between the esophagus and stomach, preventing stomach acid from flowing back up. A weak LES allows stomach acid to creep up into the esophagus, leading to heartburn and other GERD symptoms.
• Hiatal Hernia: This condition occurs when the upper part of the stomach pushes through the diaphragm, the muscle separating the chest from the abdomen. This weakens the LES and creates a pathway for stomach acid to reflux into the esophagus. Hiatal hernias can be present at birth or develop later in life due to factors like obesity or straining during heavy lifting.
• Genetics: While the exact genes responsible for GERD are not fully understood, research suggests a genetic component may play a role. If you have close relatives with GERD, you might be more susceptible due to inherited tendencies towards a weaker LES or higher stomach acid production.

Modifiable Risk Factors for GERD:

• Obesity and overweight: Carrying excess weight increases pressure within the abdomen. This pressure pushes on the stomach, forcing its contents upwards and potentially weakening the LES, allowing stomach acid to backflow into the esophagus. Losing weight can significantly reduce GERD symptoms and improve overall health.
• Diet: Certain foods and drinks can relax the LES or irritate the esophageal lining, triggering or worsening GERD. Common culprits include:
  • Fatty or fried foods: These foods take longer to digest and can delay stomach emptying, increasing pressure on the LES.
  • Citrus fruits and tomato-based products: The acidity in these foods can irritate the esophagus.
  • Chocolate, peppermint, and caffeine: These can relax the LES, allowing stomach acid to reflux more easily.
  • Alcohol and carbonated beverages: Both can irritate the esophagus and weaken the LES.
• Smoking: Smoking weakens the LES and irritates the esophageal lining in several ways. Nicotine relaxes the LES, allowing stomach acid to flow back up. Smoking also decreases saliva production, which normally helps neutralize stomach acid and protect the esophagus.
• Pregnancy: Hormonal changes during pregnancy, particularly progesterone, can relax the LES, leading to heartburn and GERD. These symptoms typically resolve after childbirth.
• Certain medications: Some medications, such as aspirin, ibuprofen, and some antidepressants, can irritate the esophagus or weaken the LES, contributing to GERD. If you experience GERD while taking medication, consult your doctor about alternative options.
• Large meals: Overeating can overwhelm the stomach and increase pressure on the LES, promoting reflux. Eating smaller, more frequent meals can help ease digestion and reduce GERD symptoms.
• Lying down after eating: Lying down soon after eating allows gravity to work against you. Stomach acid can more easily flow back up into the esophagus when lying down compared to sitting or standing upright. Waiting at least 2-3 hours after eating before lying down can significantly reduce the risk of reflux.
• Tight clothing: Wearing tight-fitting clothing around the waist can put extra pressure on the abdomen and worsen GERD symptoms. Opting for looser-fitting clothing allows for better digestion and reduces pressure on the LES.

Complications of GERD

Chronic GERD, if left untreated, can lead to various complications that can damage the esophagus and potentially increase the risk of esophageal cancer. 

Esophagitis is the inflammation of the esophageal lining caused by prolonged exposure to stomach acid. It can cause symptoms like heartburn, chest pain, and difficulty swallowing. Chronic inflammation from acid reflux can erode the esophageal lining, leading to painful ulcers. These ulcers can bleed and further worsen symptoms.

Repeated scarring from esophagitis can cause the esophagus to narrow, making swallowing difficult. This condition, called Barrett’s esophagus, might require dilation procedures to open up the esophagus. In some cases, the chronic irritation of the esophagus from acid reflux can cause the esophageal lining to transform into tissue similar to the intestinal lining. While not cancerous itself, Barrett’s esophagus is considered a precancerous condition, as it slightly increases the risk of esophageal adenocarcinoma, a type of esophageal cancer.

Laryngopharyngeal reflux (LPR) occurs when stomach acid backs up into the throat and larynx (voice box). This can cause chronic cough, hoarseness, sore throat, and even respiratory problems. Acid reflux erosion can also damage tooth enamel, increasing the risk of cavities and tooth sensitivity.

How is GERD Diagnosed?

GERD diagnosis often involves a two-pronged approach. Your doctor will likely start by discussing your symptoms in detail, including their frequency, severity, and any potential triggers like certain foods or activities. They will also inquire about your medical history, including any medications you take and any history of conditions like hiatal hernia or asthma.

While a detailed discussion of symptoms is often sufficient for an initial GERD diagnosis, some cases might require further investigation through diagnostic tests. 

Upper Endoscopy (EGD) is a procedure involving inserting a thin, flexible tube with a camera attached (endoscope) down your throat and into your esophagus, stomach, and upper small intestine. It allows the doctor to directly visualize the lining of these organs and check for signs of inflammation, ulcers, or narrowing (strictures) caused by GERD. During an endoscopy, your doctor might also take a small tissue sample (biopsy) for further analysis if necessary.

Ambulatory pH monitoring measures the acidity level (pH) in your esophagus over a 24-hour period. A thin catheter with a sensor is passed through your nose and positioned in your lower esophagus. The sensor records the pH level throughout the day and night, allowing doctors to correlate your symptoms with acid reflux episodes. This helps determine the severity of your GERD and the effectiveness of treatment.

Esophageal Impedance-pH Testing combines pH monitoring with esophageal impedance technology.  Similar to a pH test, a catheter is placed in the esophagus. However, this test can also measure the movement of fluids and air within the esophagus. This allows for a more comprehensive picture of reflux events, including non-acidic reflux which can also cause GERD symptoms.

The Barium Esophagram (Upper GI Series) is an X-ray imaging technique involving swallowing a liquid containing barium, a chalky white contrast material. The barium coats the lining of your esophagus, stomach, and upper small intestine, allowing the doctor to identify any abnormalities like strictures or hiatal hernias on X-ray images. While less commonly used than endoscopy or pH monitoring, it can be a helpful initial test in some cases.

How is GERD Treated?

Gastroesophageal reflux disease (GERD) treatment strategies typically progress from least invasive to more invasive depending on the severity of symptoms and response to initial interventions. Here’s a breakdown of the different options:

Lifestyle Modifications:

• Dietary Changes: Avoiding foods and beverages known to trigger GERD symptoms is a crucial first step. This might include limiting fatty or fried foods, citrus fruits, spicy foods, chocolate, peppermint, caffeine, alcohol, and carbonated drinks.
• Weight Management: If you’re overweight or obese, losing weight can significantly reduce pressure on the abdomen and lessen reflux symptoms.
• Quitting Smoking: Smoking weakens the LES and irritates the esophagus, worsening GERD. Quitting smoking can significantly improve symptoms.
• Eating Habits: Eating smaller, more frequent meals can help with digestion and reduce pressure on the stomach. It’s also advisable to avoid lying down for at least 2-3 hours after eating to allow for proper digestion and prevent reflux.
• Sleeping Position: Elevating the head of your bed by 6-8 inches with pillows or a wedge can help prevent stomach acid from flowing back up into the esophagus while you sleep.
• Loose-fitting Clothing: Wearing loose-fitting clothing around the waist can reduce pressure on the abdomen and potentially lessen reflux symptoms.

Medications:

• Over-the-counter (OTC) medications: Several readily available medications can help neutralize stomach acid and provide relief from GERD symptoms. These include antacids (e.g., Tums, Rolaids), H2 blockers (e.g., cimetidine, famotidine), and proton pump inhibitors (PPIs) (e.g., omeprazole, lansoprazole).
• Prescription medications: If OTC medications aren’t effective, your doctor might prescribe stronger PPIs or other medications to manage your GERD.

Endoscopic Procedures:

• Endoscopic fundoplication: This minimally invasive procedure involves tightening the lower esophageal sphincter (LES) using stitches or a small implantable device. This strengthens the LES and prevents stomach acid from refluxing into the esophagus. This procedure is typically considered for patients who don’t respond well to medication or lifestyle changes.

Surgery:

• Laparoscopic Nissen fundoplication: This is a more invasive surgical approach similar to endoscopic fundoplication but performed laparoscopically through small abdominal incisions. It’s typically reserved for severe GERD cases where other treatments haven’t been successful.

Non-Acid Reflux

In GERD, the focus is often on stomach acid refluxing into the esophagus, causing heartburn and irritation. However,  research has shown that not all reflux episodes involve acid. This is where  non-acid reflux comes in.

Here’s a breakdown of non-acid reflux and its contribution to GERD symptoms:

What is Non-Acid Reflux?

Non-acid reflux refers to the backflow of stomach contents into the esophagus, but without the presence of a significant amount of stomach acid. This refluxate can include:

• Food particles: Undigested or partially digested food particles can travel back up into the esophagus.
• Liquids: Stomach liquids other than acid, like digestive enzymes and bile, can reflux as well.
• Gas: Air swallowed during eating or drinking can also be part of non-acid reflux.

How Does Non-Acid Reflux Contribute to GERD Symptoms?

Even without the burning sensation of acid reflux, non-acid reflux can irritate the esophageal lining and contribute to GERD symptoms in several ways:

• Mechanical Irritation: The physical presence of food particles, liquids, and gas in the esophagus can directly irritate the delicate esophageal lining, leading to discomfort.
• Stimulation of Esophageal Sensors: The esophagus has hypersensitive nerves that can be triggered by the refluxate, even if it’s not acidic. This stimulation can cause heartburn-like chest pain, even in the absence of significant acid.
• Inflammation: Chronic non-acid reflux can cause inflammation in the esophagus, similar to acid reflux. This inflammation can heighten sensitivity and worsen symptoms like pain and discomfort.

Why is Non-Acid Reflux Important in GERD?

Understanding non-acid reflux is crucial because:

• It can explain GERD symptoms in some patients who don’t experience typical heartburn. Not everyone with GERD has the classic burning chest pain. Non-acid reflux might be the culprit behind their symptoms.
• It highlights the need for a broader approach to GERD management. Treatment plans shouldn’t solely focus on reducing stomach acid. Managing reflux itself, regardless of acidity, is important.

Diagnosing and Treating Non-Acid Reflux:

Diagnosing non-acid reflux can be more challenging than diagnosing acid reflux. However, esophageal impedance-pH testing, which measures both acidity and esophageal movement, can be helpful in identifying non-acid reflux episodes.

Treatment for non-acid reflux often involves a combination of strategies used for managing GERD in general, including lifestyle modifications like dietary changes, weight management, and avoiding trigger foods. Medications that help strengthen the lower esophageal sphincter (LES) or promote faster stomach emptying might also be beneficial.

Which Medications are Most Often Prescribed for GERD?

When it comes to medications for GERD, there are two main categories commonly prescribed:

1. Over-the-counter (OTC) medications: These are readily available at pharmacies and grocery stores without a prescription. They offer temporary relief from mild GERD symptoms.
2. Prescription medications: These are stronger medications that require a doctor’s prescription and are typically used for more severe or persistent GERD.

Here’s a breakdown of the most often prescribed medications for GERD in each category:

Over-the-Counter (OTC) Medications:

• Antacids: These medications work quickly to neutralize stomach acid, providing prompt relief from heartburn and indigestion. Common antacids include Tums, Rolaids, Maalox, and Mylanta.  However, their effects are short-lived, and frequent use can cause side effects like constipation or diarrhea.
• H2 blockers: These medications work by reducing stomach acid production. They are generally more effective than antacids for providing longer-lasting relief. Common H2 blockers include cimetidine (Tagamet), famotidine (Pepcid), ranitidine (Zantac), and nizatidine (Axid). While effective, H2 blockers may take longer to work than antacids and can lose effectiveness over time with frequent use.

Prescription Medications:

• Proton pump inhibitors (PPIs): These are the most commonly prescribed medications for GERD, particularly for more severe or persistent cases. PPIs work by significantly reducing stomach acid production for a longer duration compared to H2 blockers. They are highly effective in healing damaged esophageal tissue caused by acid reflux and preventing further complications. Common PPIs include omeprazole (Prilosec), lansoprazole (Prevacid), esomeprazole (Nexium), dexlansoprazole (Dexilant), and pantoprazole (Protonix). While very effective, PPIs can have some side effects with long-term use, so it’s crucial to follow your doctor’s instructions carefully.