GERD

Symptoms

What causes GERD?

GERD is caused by the displacement of stomach acid from the stomach into the esophagus. In an optimal anatomic situation, the lower esophageal sphincter keeps the hydrochloric stomach acid from entering the esophagus, similar to a drawstring or the neck of a balloon.

However, numerous factors such as pressure on the stomach due to tight clothing or excess abdominal girth, a hiatal hernia (which inadequately keeps the stomach beneath the diaphragm), and various dietary influences can cause stomach acid to regurgitate in the wrong direction, which in turn leads to GERD.

What does GERD pain feel like?

Symptoms vary, but the primary one is a sensation of burning under the sternum. Somewhat less common is regurgitation of stomach contents (acid or undigested food).

Other symptoms may include coughing, irritation in the throat, difficulty or pain with swallowing, hoarseness, and even chest pain, which in some cases can be as severe as that associated with heart attacks.

How are GERD and acid reflux connected?

Acid reflux is a more familiar term for GERD. The terms are used interchangeably, though not everyone with GERD feels an acidic sensation or a reflux sensation.

Diagnosis

Can you self-diagnose GERD? When should you see a doctor?

In many situations, people recognize the symptoms they are having and correctly assume GERD is the problem. There is a relatively broad spectrum of severity and symptomatology, though, so accuracy of self-diagnosis isn’t perfect. To complicate matters, there are several different classes of medicines to treat GERD symptoms. Therefore, getting a professional opinion serves a few purposes: it enhances diagnostic accuracy; it determines an appropriate treatment course and timeline; and it clarifies which cases need imaging, other procedures, or referral to a GI specialist.

Discussion with a clinician is valuable even during the early stages of infrequent GERD symptoms, but it is definitely warranted if symptoms are not being well-controlled, daily medication is needed beyond a few weeks, or if there are any red flag symptoms. These include problems or pain swallowing, early satiety, vomiting, unintentional weight loss, or blood in the stool (which might be bright red or tarry and black). A person who has experienced any of these should speak to a medical professional immediately.

How is GERD diagnosed by a physician?

History of presenting symptoms is most informative initially. We ask about what symptoms exist, their severity, dietary or lifestyle triggers, and other details that help elucidate next steps.  

Is testing needed for a diagnosis?

Not usually. Subjective symptoms correlate relatively well with objective findings in studies. If symptoms improve with avoidance of triggers, that is a good sign. Often, medications are begun as a “diagnostic trial,” but that is not actually a very specific test.

The difficulty with testing is that most of it is relatively interventional, so we reserve it for certain higher risk cases: longstanding history of GERD, symptoms refractory to medication, red flag symptoms. Referral to a gastroenterologist for procedures to clarify diagnosis is needed in those cases.

Risks

Is GERD a serious condition? What are the consequences of not treating GERD?

GERD can be serious. Though some cases may amount to no more than years of discomfort, others can cause cellular changes on the inside of the esophagus over time, a condition called Barrett’s esophagus. Barrett’s esophagus is a precancerous state that, if not monitored, can progress to esophageal cancer. Research has shown consumption of meat and saturated fat to increase risk for Barret’s esophagus. Other consequences of untreated GERD include dental erosion, sore throat, hoarseness, chronic cough, asthma, chest pain, and laryngeal cancer.

Is GERD curable?

Because the causation is usually multifactorial, there isn’t a simple answer. More accurate than curable would be to say GERD is modifiable, and often goes into remission. That doesn’t mean that it’s lurking ready to strike at any trigger, but those who are prone to GERD often have recurrences if they’re not cautious about maintaining habits that keep GERD controlled.

Treatment

What’s the best approach to treatment?

In addition to lifestyle and dietary recommendations, there are multiple pharmaceutical options as well as herbs and supplements that enable us to tailor the approach to an individual’s preferences. Learning about lifestyle modifications can give people with GERD much more long-term control. This includes adjustments in timing and size of meals, food combining to mediate flares, smoking cessation, weight loss when necessary, and even adjustments to sleeping posture.

What foods should you avoid with GERD?

Most people with GERD can identify foods or drinks that make their symptoms more apparent. Traditionally, we consider the following to be common triggers: coffee; carbonated beverages; alcohol; chocolate; citrus fruits; tomatoes; peppermint; and spicy, acidic, or fried foods. Triggers are often unique to individuals, though, and do not depend only on the acidity of what’s consumed. Dairy is a trigger for some, but relieves symptoms in others.

Research studies have not been able to corroborate which dietary eliminations help most, but an emerging finding is that simple sugars should be reduced and replaced with higher fiber carbohydrates. Coffee, still thought by many to be causative, is not always a necessary elimination. Carbonated beverages have been shown to contribute to changes in lower esophageal pressure, but their role in this condition is still not clear.

Why does meal timing matter?

Studies have shown that less time between dinner and bedtime increases symptoms in those with predispositions to GERD. Avoidance of eating for the two-to-three hours prior to bedtime is recommended, especially for people whose symptoms are worse at night. This appears to be more important in people who are overweight and in those who have a hiatal hernia. The reason for this is related to increased pressure on the esophageal sphincter from the volume of food in the stomach.

Body position has an impact as well, since reflux is less likely to enter the esophagus in a sitting or standing position as compared to lying. Raising the head of the bed by 30 degrees or using a wedge pillow can also be helpful.

What medications are used for treating GERD?

Most of the medications used for GERD can be generically referred to as antacids, though the mechanism of action varies.

TUMS and milk of magnesia essentially neutralize the low pH of acid where it is causing problems since they are more alkaline (higher pH).

Histamine receptor blockers (H2RBs)–like ranitidine (Zantac) or famotidine (Pepcid)–bind histamine receptors in the stomach and reduce acid production and overall gastric secretions.

Because the antisecretory effect of H2RBs is decreased over time due to tolerance, proton pump inhibitors (PPIs), such as omeprazole (Prilosec) and esomeprazole (Nexium), are used increasingly. An eight-week course of a daily PPI 30 minutes before breakfast is a common first line pharmaceutical strategy.

Are medications safe to use long term? Is there any harm in only taking medications and not adjusting diet and/or other factors?

In some cases, taking medications is safer than not taking medications. Risks of long-term medication use depend on which medications are used. While PPIs are arguably the most effective medication class for GERD, they also probably carry the most potential for harm with long-term use. This is because they inhibit acid production in the stomach.

Stomach acid has several beneficial effects, including assisting with protein digestion, aiding in the absorption of nutrients like calcium and magnesium, and (on some level) helping to control pathogenic bacteria in the region, as evidenced by the finding that PPIs can increase the risk for pneumonia. Obviously, these medicines are widely used for their efficacy, but research into their longer-term risks have been mounting.

Is it okay to stop antacid medication abruptly?

It isn’t usually harmful, but commonly, those who have been taking antacids regularly will have symptom rebound when they are abruptly stopped. With PPIs, tapering off is the best way to modulate those symptoms. While tapering, it is more important than ever to avoid known triggers, so discipline is required. This explains why many people end up taking them indefinitely.

Prevention

Are herbs and supplements useful?

Yes, and they are not widely utilized because there are so many prominent pharmaceutical options. Some herbs have what is called a demulcent action, meaning they form a slimy coating on the intestinal tract, which helps protect the mucosal layer from erosion. Those herbs– deglycerrhinized licorice, marshmallow root, aloe pulp, and slippery elm bark–do not prevent reflux, but they do protect the mucosal lining from damage. Melatonin, the hormone associated with preparing the brain for sleep, has also been shown in some studies to attenuate the gastric mucosal damage through an antiinflammatory mechanism.

What lifestyle changes are recommended for patients with GERD?

A thorough history of presenting symptoms is valuable to customize therapeutic prioritization. People who do not recognize their dietary or behavioral triggers may benefit from keeping a symptom diary.  In smokers, tobacco reduction or cessation is recommended. Weight loss is a high-yield strategy in overweight patients.

While it is still prudent to encourage people to avoid known triggers, as we learn more about specific food eliminations for other gastrointestinal conditions that may coexist with GERD (eg. IBS), more emphasis should also be placed on eating behaviors in addition to food choice. These behaviors include chewing food well, eating mindfully and in appropriate portion sizes, and eating in environments that are conducive to proper digestion. Consuming a meal in five minutes while driving down a highway or in front of a computer screen is not an optimal environment.

Related Links

Acid Reflux (Information from the American College of Gastroenterology)

Integrative medicine for GERD (University of Wisconsin Department of Medicine and Public Health)

Functional medicine approach to GERD (The Institute for Functional Medicine)

Link to GERDQ a diagnostic scoring test (American Family Physician)

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