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GERD

Introduction

Almost everyone experiences a little acid reflux, particularly after meals. Acid reflux irritates the walls of the esophagus, inducing a secondary peristaltic contraction of the smooth muscle, and may produce the discomfort or pain known as heartburn. Evidence indicates up to 36% of otherwise healthy Americans experience heartburn at least once a month. Most episodes of acid reflux are asymptomatic.

After a meal, the lower esophageal sphincter (LES) usually remains closed. When it relaxes at an inappropriate time, it allows acid and food particles to reflux into the esophagus. Secondary peristalsis returns approximately 90% of the acid and food to the stomach. Once peristalsis ends, the LES closes again. The remaining acid in the esophagus is neutralized by successive swallows of saliva, which is alkaline in nature, and then cleared into the stomach.

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FAQ's on GERD
  1. What is GERD?
  2. I have never heard of GERD. Is it a new disease?
  3. What are some symptoms of GERD?
  4. How do people get GERD? What causes GERD?
  5. How many people are afflicted with GERD?
  6. Who is afflicted with GERD?
  7. Do children get GERD?
  8. What is the difference between GERD and GORD?
  9. What is the difference between heartburn and GERD?
  10. What is the difference between GERD and a hiatus hernia?
  11. What is endoscopy and when is it used in GERD patients?
  12. What are the complications of GERD?
  13. What makes GERD symptoms worse?
  14. Does eating spicy food cause GERD or make GERD worse?
  15. What about GERD and smoking?
  16. Do any medications make GERD worse?
  17. What should people with GERD avoid?
  18. Can GERD cause cancer?
  19. Are there long-term consequences of GERD?
  20. Is there a relationship between GERD and asthma?
  21. Can GERD cause inflammation of the throat?
  22. Can GERD be cured?
  23. I think I have GERD. What should I do?
  24. Where can I go for more information about GERD?
Mechanism - Transient LES Relaxation
Mechanism - Weak LES
Management of GERD - Lifestyle modifications
Management of GERD - Antireflux surgery
GERD - Treatment guidelines summary

FAQ's on GERD

1. What is GERD?
GERD stands for Gastroesophageal Reflux Disease. Gastroesophageal reflux describes a backflow of acid from the stomach into the swallowing tube or esophagus. This acid can irritate and sometimes damage the delicate lining on the inside of the esophagus. Almost everyone experiences gastroesophageal reflux at some time. The usual symptom is heartburn, an uncomfortable burning sensation behind the breastbone, most commonly occurring after a meal. In some individuals this reflux is frequent or severe enough to cause more significant problems, that is a disease. Thus, gastroesophageal reflux disease is a clinical condition that occurs when reflux of stomach acid into the esophagus is severe enough to impact the patientís life and/or damage the esophagus.
2. I have never heard of GERD. Is it a new disease?
No. GERD has probably been around as long as heartburn. The term is relatively new (about 20 years), however, and has really come into common usage over the past few years. GERD is often called "reflux," "reflux esophagitis," or sometimes even "hiatus hernia" (although hiatus hernia is a specific diagnosis that may or may not have anything to do with GERD). GERD is the preferred term because it accurately describes the problem - reflux of stomach acid up into the esophagus where it can produce symptoms and sometimes damage. Many patients and health care professionals are not familiar with GERD and its potential consequences, and thus may not have heard the term previously.
3. What are some symptoms of GERD?
The four major symptoms of GERD are:
  1. Heartburn (uncomfortable, rising, burning sensation behind the breastbone).
  2. Regurgitation of gastric acid or sour contents into the mouth.
  3. Difficult and/or painful swallowing.
  4. Chest pain.
Heartburn is the most common symptom of GERD. In some patients it may be accompanied by other GERD symptoms, such as regurgitation of gastric contents into the mouth, chest pain and difficulty swallowing. Pulmonary manifestations, such as asthma, coughing, or intermittent wheezing and vocal cord inflammation with hoarseness, occur in some GERD patients. In addition, acid can be regurgitated into the lungs in some GERD patients, causing wheezing or cough. Acid refluxed into the throat can cause sore throat. If acid reaches the mouth, it can dissolve enamel of the teeth.
4. How do people get GERD? What causes GERD?
GERD is caused by reflux of stomach acid into the esophagus. In most patients this is due to a transient relaxation of the gate or sphincter that keeps the lower end of the esophagus closed when a person is not swallowing food or liquids. This transient relaxation happens a few times each day in people without GERD. Why it happens more frequently in GERD patients isnít known. The esophagus is not able to cope with acid as well as the stomach and is easily injured. It's the acid refluxing into the esophagus that produces the symptoms and potentially damages the esophagus.
5. How many people are afflicted with GERD?
Recent statistics from the US Department of Health and Human Services indicate that about seven (7) million people in the US alone suffer from GERD.
(Source: Digestive Diseases in the United States: Epidemiology and Impact, National Digestive Diseases Data Working Group, James E. Everhart, MD, MPH, Editor, US Department of Health and Human Services, Public Health Service, National Institutes of Health, NIH Publication No. 94-1447, May 1994)
6. Who is afflicted with GERD?
GERD afflicts people of every socioeconomic class, ethnic group and age. However, the incidence does seem to increase quite dramatically above the age of 40. Greater than 50 percent of those afflicted with GERD are between the ages of 45-64 (both male and female).
7. Do children get GERD?
Yes. GERD is most common in adults over age 40 but virtually anyone can get GERD, even infants.
8. What is the difference between GERD and GORD?
The British spelling of esophagus is oesophagus. Hence, GERD is GORD in many European countries.
9. What is the difference between heartburn and GERD?
GERD is a disease and heartburn is its most common symptom. Heartburn is defined as a rising, burning sensation behind the breastbone caused by reflux of stomach acid into the esophagus. Nearly everyone has or will experience heartburn on occasion. Frequent heartburn that disrupts one's lifestyle suggests the diagnosis of GERD.
10. What is the difference between GERD and a hiatus hernia?
Hiatus hernia refers to dislocation of the stomach through the "hiatus" of the diaphragm and into the chest. This is a common condition that increases in frequency with age. It may or may not be associated with GERD. When GERD is severe enough to be complicated by erosive esophagitis, seen as breaks in the lining of the esophagus, a hiatus hernia is usually present. However, most patients with a hiatus hernia do not have GERD.
Basal LES pressure often is very low in patients who have large hiatal hernias, and this LES hypotension predisposes to gastroesophageal reflux. Also, the extrasphincteric anti-reflux mechanisms can be disrupted when the stomach herniates into the chest through the diaphragmatic hiatus. With a large hiatal hernia, the distal esophagus is no longer subject to abdominal pressure. Furthermore, the diaphragmatic crurae no longer pinch the distal esophagus during inspiration. Instead, approximation of the crurae creates an intrathoracic pouch of stomach that may function as a reservoir of material available for reflux. A recent study has shown that the susceptibility to gastroesophageal reflux induced by abrupt elevations of intra-abdominal pressure correlates significantly both with weak LES pressure and with hiatal hernia size. Although it appears that hiatal hernia often contributes importantly to GERD, hiatal hernia is neither necessary nor sufficient for the development of reflux esophagitis. Patients who have no hiatal hernia can have GERD, and hiatal hernia is not always associated with reflux esophagitis.
11. What is endoscopy and when is it used in GERD patients?
Endoscopy is a diagnostic test wherein a thin, flexible tube is swallowed by the patient to allow the physician to directly inspect the lining of the upper gastrointestinal tract. This procedure can be used to identify complications of GERD and to take small samples (biopsies) for further analysis. GERD patients who have certain symptoms, such as difficulty in swallowing or painful swallowing, should be considered for endoscopy. Patients who fail to respond to therapy are also candidates for endoscopy. Some physicians advocate endoscopy for all patients with long-standing GERD in order to rule out Barrett's esophagus.
12. What are the complications of GERD?
Only a minority of patients develop complications of GERD. These complications include breaks in the lining of the esophagus (esophageal erosions), esophageal ulcer, and narrowing of the esophagus (esophageal stricture). In some patients, the normal esophageal lining or epithelium may be replaced with abnormal (Barrett's) epithelium. This condition (Barrett's esophagus) has been linked to cancer of the esophagus and must be carefully watched. Lung (pulmonary) aspiration, asthma and inflammation of the vocal cords or throat may also be caused by GERD.
13. What makes GERD symptoms worse?
The major factor is meals. Meals stimulate the stomach to produce more acid that can reflux up into the esophagus. In some patients, lying down or taking certain medications can worsen acid reflux.
14. Does eating spicy food cause GERD or make GERD worse?
Spicy foods do not cause GERD, although they do seem to worsen GERD symptoms in some people. Food (in general) can make GERD worse. This is because food fills the stomach and induces more transient relaxations of the lower esophageal sphincter. In addition, all meals stimulate acid production in the stomach to aid digestion and can increase reflux into the esophagus in GERD sufferers. Any very large meal might be expected to produce heartburn in some people. The spicy food story is so compelling, however, that GERD sufferers often relate a spicy (or greasy) meal to their symptoms. Often they are told to avoid certain foods whether or not these foods have anything to do with their symptoms. In this way, many GERD sufferers end up on a very restricted diet or end up blaming their symptoms on dietary indiscretion. If avoiding spicy foods and/or other dietary advice helps, that's great. If it doesn't, GERD sufferers shouldn't feel that they are doing something wrong. They should seek medical advice on managing their disease.
15. What about GERD and smoking?
Smoking doesn't cause GERD and there is little evidence that smoking significantly worsens GERD. Stopping smoking is a good idea anyway.
16. Do any medications make GERD worse?
Yes. Medicines that delay emptying of acid from the stomach or that increase acid backup into the esophagus can worsen GERD. If you have, or suspect you have, GERD and you require medication for other conditions, you should make sure you inform your doctor about all medications you are taking including prescription and over-the-counter medications.
17. What should people with GERD avoid?
GERD is a disease that is caused by gastric acid. However, certain foods can trigger symptoms in some patients. Lying down after a meal, wearing tight-fitting clothing, and even performing certain activities, such as bending over, can also trigger symptoms in patients. A good way to identify these "triggers" is to keep a diary of GERD symptoms noting when they occur. If symptoms follow a pattern and occur after certain foods or activities, these foods or activities should be avoided. A diary will also help patients continue to enjoy those foods or activities that do not seem to provoke symptoms, so that their lifestyle is not restricted unnecessarily. Patients should review their symptoms with their doctor, who can evaluate their condition and advise an appropriate treatment plan.
18. Can GERD cause cancer?
Severe, long-standing GERD can damage the esophagus and cause a condition known as Barrett's esophagus wherein the normal lining of the esophagus is replaced by a lining more like that of the stomach or intestine. It is thought that this replacement may be an attempt by the body to protect itself from further injury by acid. The risk of esophageal cancer appears to increase significantly in patients with Barrett's esophagus. The only way to diagnose Barrett's esophagus is by endoscopy. Some studies suggest that intensive treatment of Barrett's esophagus can reduce the amount of abnormal lining in the esophagus. It is not yet clear whether such treatment will prevent esophageal cancer in GERD patients, but this is under active investigation.
19. Are there long-term consequences of GERD?
Long-standing GERD can lead to damage of the esophagus. This damage usually consists of breaks in the lining of the esophagus. In some cases ulcers can develop. In some patients, such damage can result in scarring and narrowing of the esophagus, making swallowing painful or difficult. A condition called Barrett's esophagus is thought to result from long-standing GERD in some patients. Barrett's esophagus is a risk factor for the development of esophageal cancer. In some patients, acid backup caused by GERD is thought to result in damage to the vocal cords or teeth and may even cause asthma.
20. Is there relationship between GERD and asthma?
Many investigators believe that there is a link between asthma and reflux of stomach acid up into the throat and then down into the lungs in some patients. It appears that some patients who suffer from asthma might benefit from treatment of GERD. This is a topic of active research at the moment.
21. Can GERD cause inflammation of the throat?
In some patients, acid can reflux into the throat causing inflammation of the back of the throat which can lead to pharyngitis, or into the vocal cords, which can lead to laryngitis and hoarseness. Although there are many other causes for sore throat and laryngitis, GERD should be suspected in a patient with chronic sore throat or other GERD symptoms or when no other cause can be found.
22. Can GERD be cured?
Unfortunately, GERD, in general, cannot be cured at present. In some cases, it may be a temporary condition associated with a specific aggravating factor such as pregnancy. In such cases, GERD will go away on its own when the pregnancy has ended. In most cases GERD is a chronic condition. However, it can be effectively managed with medications and lifestyle modifications in almost everybody. In severe cases, surgery is an option. Surgery does not cure the underlying problem, but wraps part of the stomach around the lower end of the esophagus to help keep acid from getting back up into the esophagus. A doctor can evaluate the condition and advise on an appropriate treatment plan.
23. I think I have GERD. What should I do?
See your doctor. Your doctor can establish the diagnosis and work with you to get you symptom-free. Primary care and physicians of many specialties are becoming increasingly familiar with GERD. Gastroenterologists and some gastrointestinal surgeons are usually very familiar with GERD and its treatment.
24. Where can I go for more information about GERD?
If you think you might have GERD - see your doctor who can determine if you have GERD and, if so, can evaluate its severity. Additional information is also available from the following organizations:

The American Gastroenterological Association (AGA)
7910 Woodmont Avenue, 7th Floor
Bethesda, MD 20814
301-654-2055
E-mail the AGA at aga001@aol.com

The American College of Gastroenterology (ACG)
P.O. Box 3099
Alexandria, VA 22302
(703) 820-7400

Mechanism - Transient LES Relaxation

Transient, inappropriate relaxation of the LES appears to be the most important LES mechanism for gastroesophageal reflux. Unlike the brief (3 to 10 seconds in duration), appropriate LES relaxations that accompany primary peristalsis, so-called transient LES relaxations do not occur during normal peristalsis and last for up to 30 seconds. In normal individuals, brief episodes of gastroesophageal reflux (called physiologic reflux) occur almost exclusively through the mechanism of transient LES relaxation. In patients with GERD, transient LES relaxation is the most frequent, but not necessarily the exclusive, cause of reflux. Transient LES relaxations can occur spontaneously, after primary peristalsis, or with failed peristalsis.

In transient LES relaxation there is no swallow (absent pharyngeal wave) and no activity in the body of the esophagus. For no apparent reason, LES pressure collapses to O at which point the esophageal pH records an episode of acid reflux.

Transient LES relaxation after primary peristalsis - there is a swallow (evidenced by a pharyngeal wave) followed by peristalsis in the body of the esophagus. The LES relaxes appropriately during the primary peristaltic sequence and, when the peristaltic wave reaches the LES, the muscle contracts appropriately. Rather than returning to baseline pressure as is normal, however, the LES again relaxes completely after the primary peristaltic sequence at which time acid reflux occurs (indicated by the drop in esophageal pH).

Transient LES relaxation during failed peristalsis. There is a swallow evidenced by the pharyngeal wave, and peristalsis proceeds to the proximal esophagus. The peristaltic sequence fails, however, and does not advance beyond the proximal esophagus. Nevertheless, the LES relaxes in anticipation of a bolus that never arrives, and acid reflux follows.


Mechanism - Weak LES

In some patients with GERD, the resting pressure in the LES is so weak that the sphincter does not pose an effective barrier to reflux. LES pressure remains at or near 0, and the esophageal pH records multiple episodes of acid reflux.

Acid reflux can be associated with a sudden increase in abdominal pressure in a patient with a weak LES. Normally, increases in abdominal pressure are attended by commensurate increases in LES pressure. This mechanism ordinarily prevents gastroesophageal reflux during coughing, sneezing, and straining. In patients whose LES is weak, however, sudden increases in abdominal pressure may not be accompanied by similar elevations in LES pressure. Note that the abrupt rise in abdominal pressure exceeds the rise in LES pressure, and acid is propelled into the esophagus as evidenced by the drop in esophageal pH.


Management of GERD - Lifestyle modifications

Management of GERD begins with lifestyle modifications aimed at reducing acid reflux and minimizing the duration of contact between refluxed material and the esophageal mucosa.

The head of the bed is elevated on 4" to 6" blocks to exploit the effect of gravity on esophageal clearance.

Obese patients are advised to lose weight with the rationale that obesity may promote reflux by increasing abdominal pressure.

Tobacco and alcohol consumption should be avoided because these agents may decrease LES pressure. Also, cigarette smoking decreases salivation that is important for esophageal acid clearance.

Bedtime snacks can stimulate gastric acid production and trigger transient LES relaxation, thereby promoting the nocturnal reflux of gastric acid.

Certain medications can decrease LES pressure and delay gastric emptying, and these agents should be avoided if possible. These include drugs that have anticholinergic effects (e.g. phenothiazines, tricyclic antidepressants), theophylline preparations, and calcium channel blocking agents. NSAIDS can be caustic to the esophageal mucosa, and these agents also should be avoided if possible.

Fatty foods, chocolate, and peppermint contribute to GERD by decreasing LES pressure, and fatty foods delay gastric emptying. Other restrictions in diet and activities may be helpful in individual patients.


Management of GERD - Anti-reflux Surgery

There are a number of different anti-reflux operations (e.g. Nissen fundoplication, Belsey Mark IV repair, Hill posterior gastropexy), but most share the common features. The hiatal hernia that usually accompanies severe reflux esophagitis is reduced, a segment of intra-abdominal esophagus is restored, and the diaphragmatic crurae are approximated. Also, a portion of the gastric fundus is wrapped around the distal esophagus (fundoplication). The operations differ primarily in the degree of fundoplication.

The mechanisms whereby these operations prevent reflux are disputed. The surgery narrows the angle of His (the angle formed by the junction of esophagus with stomach) which may create an anti-reflux flap-valve effect, and restoration of the distal esophagus to the positive pressure environment of the abdomen also may help to prevent reflux. With reduction of the hiatal hernia and approximation of the diaphragmatic crurae, the normal antireflux function of the crural diaphragm may be restored. The fundoplication may act as a one-way valve and may prevent distention of the gastric fundus that can trigger transient LES relaxations. Finally, LES pressure increases after fundoplication for reasons that are not clear. The importance of the latter mechanism also is disputed, however, because the efficacy of antireflux surgery is not directly proportional to the postoperative increase in LES pressure.


GERD - treatment guidelines summary

Current recommendations from the American College of Gastroenterology regarding treatment guidelines for gastroesophageal reflux disease include the following:

Patients who present with symptoms of gastroesophageal reflux disease with mild symptoms should be treated with:
1. Lifestyle changes as previously described
2. Initial trial of patient-directed therapy with over-the-counter H2 antagonists or antacids

Lifestyle modifications include:
1. Accomplish weight loss if obese
2. Avoid lying down after meals
3. Avoid late night meals
4. Elevate the head of your bed by 6 inches. Preferably using wooden blocks placed under the head of the bed.
5. Avoid wearing tight-fitting clothes
6. Avoidance of dietary irritants such as:
A. Fat
B. Chocolate
C. Caffeine
D. Spearmint/peppermint
7. Avoid agents which lower the lower esophageal sphincter pressure:
A. Calcium channel blockers
B. Theophylline
C. Anticholinergic medications
8. Discontinuance of tobacco use
9. Stop or reduce alcohol use
10. Avoid non-steroidal antiinflammatory drugs

Should initial treatment with over-the-counter antagonists/antacids and lifestyle modifications be effective, this treatment regimen is recommended to be continued for an indefinite period.

If the patient develops more symptoms or has an inadequate response then the following recommendations are made.
1. Continue lifestyle changes as previously noted
2. Initiation of prescription strength histamine 2 antagonist therapy, proton pump inhibitor therapy or pro-motility agents

The medications used in this group are usually prescribed in the following doses:
1. Histamine 2 receptor antagonist therapy:
A. Cimetidine 400 mg po bid
B. Ranitidine 150 mg po bid
C. Nizatidine 150 mg po bid
D. Famotidine 20 mg po bid
2. Proton pump inhibitors are usually prescribed in the following doses.
A. Omeprazole (Prilosec) 20 mg po qd
B. Lansoprazole (Prevacid) 30 mg po qd
C. Rabeprazole (Aciphex) 20 mg po qd
D. Pantoprazole (Protonix) 40 mg po qd

Pro-kinetic agents are of limited availability. The single agent in this class that will be available during the rest of the year 2000 is metoclopramide. Metoclopramide is prescribed as 10 mg ½ hour before meals and at hours of bed.

Assessment of response is then reevaluated at 8-12 weeks worth of treatment. If the patient does have an adequate response during this period of time, patients may then be discontinued from this treatment regimen. Should the patient relapse, reinstitution with this treatment regimen for 8-12 weeks, endoscopic evaluation and consideration to maintenance therapy with either histamine 2 receptor antagonists or proton pump inhibitors is recommended. Titration of medication dose to the lowest possible dose is recommended.

If patients do not have an adequate response to this, endoscopy should be performed. Proton pump inhibitors should be prescribed if they have not already been instituted. Consideration to increasing the dose of proton pump inhibitors to a bid basis may be necessary. Some patients respond to increasing the dose of histamine 2 receptor antagonists. This may also be affective.

Jonathan E. Jensen, MD FACP
Colorado Center for Digestive Disorders
July 9, 2000