Gastroesophageal Reflux Disease (GERD)

Gastroesophageal reflux disease (GERD) is a common digestive disorder that affects millions of people worldwide. It occurs when the lower oesophageal sphincter (LES), a ring of muscle at the bottom of the oesophagus, fails to close properly, allowing stomach acid to flow back into the oesophagus. This can cause a variety of symptoms, including heartburn, epigastric distress, and regurgitation.

What is GERD?

GERD is a chronic condition characterised by the regurgitation of stomach contents into the oesophagus. The LES, a circular band of muscle at the junction of the oesophagus and stomach, normally prevents acid reflux by maintaining a tight seal.

However, in individuals with GERD, the LES becomes weak or relaxes inappropriately, allowing stomach acid and digestive juices to flow back up into the oesophagus. This repeated exposure to acidic contents can cause irritation and inflammation of the oesophageal lining, leading to the hallmark symptoms of GERD, such as heartburn and regurgitation.

Common Symptoms

• Heartburn (a burning sensation in the chest, neck, and throat)

• Regurgitation (a sour or bitter taste in the mouth due to the backflow of stomach contents)

• Difficulty swallowing (dysphagia)

• Pain when swallowing (odynophagia)

• Nausea and vomiting

• Chest pain, which may be mistaken for a heart attack

• Chronic cough

• Hoarseness or voice changes

• Bad breath

Less Common Symptoms

• Dental erosions caused by repeated exposure to stomach acid

• Laryngitis, or inflammation of the voice box

• Asthma, which may be triggered or worsened by GERD

• Globus sensation, or the feeling of a lump in the throat

• Dysphonia, or changes in voice quality

Recognising the various symptoms of GERD is crucial for prompt diagnosis and treatment. If you experience any of these symptoms regularly, it is essential to consult a healthcare professional for an accurate assessment and appropriate management.

Here are the different stages of GERD:

Stage 1: Mild GERD

In this stage, patients experience mild symptoms once or twice a month, which can usually be managed with lifestyle modifications and over-the-counter acid-suppressive medications.

Stage 2: Moderate GERD

Patients in this stage experience more frequent symptoms, often requiring daily prescription acid suppressive medications. If left untreated, GERD symptoms can affect daily activities and lead to oesophageal inflammation.

Stage 3: Severe GERD

In severe GERD, patients experience poorly controlled symptoms despite the use of prescription medications, significantly impacting their quality of life. They are more likely to develop erosive oesophageal inflammation and may require a thorough evaluation by a GERD specialist.

Stage 4: Reflux-induced Precancerous Lesions or Oesophageal Cancer

Patients in this advanced stage experience severe symptoms, including dysphagia (difficulty swallowing), and are at risk of developing precancerous lesions or oesophageal cancer. Close monitoring and management by a reflux expert are crucial in this stage.

Understanding the stages of GERD can help patients and healthcare providers determine the appropriate course of treatment and monitor the progression of the disease. Let's now explore the various symptoms associated with GERD.

The development of GERD can be attributed to a combination of intrinsic and extrinsic factors.

1. Impaired Lower Esophageal Sphincter (LES) Function

Impaired lower oesophageal sphincter (LES) function allows stomach contents to reflux into the oesophagus. Additionally, transient LES relaxations (TLESRs) are brief, spontaneous relaxations of the LES not associated with swallowing, and these also might cause GERD symptoms.

2. Anatomical Factors

Conditions like hiatal hernia, where part of the stomach protrudes through the diaphragm, can also contribute to GERD by compromising the LES's ability to function properly. Oesophageal dysmotility, or impaired movement of the oesophagus, can lead to prolonged exposure of the oesophageal lining to stomach acid. Increased intra-abdominal pressure from obesity is another significant risk factor, as it can push stomach contents upwards.

3. Lifestyle and Dietary Influences

Certain lifestyle choices, such as smoking, excessive alcohol consumption, and dietary habits (e.g., high-fat meals, chocolate, caffeine), can trigger or worsen GERD symptoms. Additionally, lying down shortly after eating can hinder digestion and increase reflux episodes.

Understanding the causes of GERD and epigastric distress can help individuals make lifestyle changes and seek appropriate treatment to manage their symptoms and prevent further complications.

Here are some risk factors for GERD:

• Obesity: Being overweight or obese puts extra pressure on your abdomen, which can lead to stomach acid flowing back up into the oesophagus.

• Pregnancy: Hormonal changes during pregnancy can relax the lower oesophageal sphincter (LES), allowing stomach acid to reflux into the oesophagus. Additionally, the growing uterus puts pressure on the stomach, increasing the risk of GERD.

• Hiatal hernia: A hiatal hernia occurs when the upper part of your stomach bulges through the diaphragm into your chest cavity. This can cause the LES to weaken and allow stomach acid to flow back into the oesophagus.

• Smoking: Cigarette smoking can relax the LES, allowing stomach acid to reflux into the oesophagus. It can also decrease saliva production, which helps neutralise stomach acid.

• Certain medications: Some medications, such as calcium channel blockers, antihistamines, and sedatives, can relax the LES and increase the risk of GERD.

These risk factors can lead to various complications, which will be discussed in the next section.

If left untreated, GERD can lead to several complications, including:

• Oesophagitis: Inflammation of the oesophagus due to chronic acid exposure can lead to pain, difficulty swallowing, and potential scarring.

• Oesophageal stricture: Repeated exposure to stomach acid can cause scar tissue to form in the oesophagus, narrowing the passage and making it difficult to swallow.

• Barrett’s Oesophagus: A condition where the oesophageal lining changes due to prolonged acid reflux, increasing the risk of oesophageal cancer.

• Peptic Ulcers: Chronic irritation from stomach acid can cause ulcers in the stomach or duodenum, leading to severe pain and bleeding.

• Gastrointestinal Bleeding: Erosions caused by acid can result in bleeding, which may manifest as vomiting blood or black stools.

• Respiratory problems: Stomach acid reflux can irritate the throat and airways, leading to chronic cough, asthma, and laryngitis.

• Dental Erosion: Frequent acid exposure can erode tooth enamel, leading to dental problems.

• Reduced Quality of Life: Persistent GERD can significantly impact daily activities, work productivity, and overall well-being.

While not all cases of GERD can be prevented, there are several lifestyle changes that can help reduce your risk or manage symptoms:

1. Dietary Adjustments:

• Avoid trigger foods such as chocolate, coffee, spicy foods, fatty foods, and carbonated beverages.

• Limit acidic foods like citrus fruits and tomato-based products.

• Eat smaller, more frequent meals to reduce stomach pressure.

2. Weight Management:

• Achieve and maintain a healthy weight to decrease abdominal pressure that can exacerbate symptoms.

3. Posture and Positioning:

• Avoid lying down for at least two to three hours after eating to prevent reflux.

• Elevate the head of the bed by 6 to 8 inches to minimise nighttime symptoms.

4. Clothing Choices:

• Wear loose-fitting clothing to reduce pressure on the abdomen and lower esophageal sphincter.

5. Lifestyle Changes:

• Quit smoking, as it can increase stomach acid production and weaken the esophageal sphincter.

• Limit alcohol consumption, which can irritate the esophagus and stimulate acid production.

6. Stress Management:

• Practice relaxation techniques such as deep breathing or yoga to help manage stress, which can aggravate symptoms.

7. Medication Awareness:

• Be cautious with medications that may worsen GERD symptoms, such as certain sedatives or calcium channel blockers. Always consult a healthcare provider about any medications you are taking.

By addressing risk factors and implementing effective prevention strategies, healthcare organisations can promote the well-being of their physicians and ensure the delivery of high-quality patient care.

Apart from symptom observation, the following diagnostic steps may be taken by your doctor to diagnose GERD:

1. Diagnostic Tests

• Upper Gastrointestinal (GI) Endoscopy: This procedure involves inserting a flexible tube with a camera into the esophagus to visually examine the esophageal lining for signs of inflammation, ulcers, or other abnormalities.

• Ambulatory Acid Probe Tests: These tests measure the acid levels in the esophagus over a 24-hour period to determine if acid reflux is occurring, helping to diagnose GERD.

• Barium Swallow: In this test, the patient swallows a barium solution that is visible on X-rays, allowing doctors to visualise the esophagus and stomach to identify any structural issues or abnormalities.

• Oesophageal Manometry: This test assesses the muscle contractions of the esophagus to check for problems with the esophageal sphincter, which can contribute to the development of GERD.

2. Laboratory Tests

While not definitive, blood tests can help rule out other conditions that may cause similar symptoms to GERD, such as anemia from chronic bleeding or infections. These tests can provide valuable information to guide the diagnostic process and ensure an accurate diagnosis.

Once a diagnosis of GERD has been established, healthcare professionals can develop an appropriate treatment plan to manage the condition and alleviate epigastric pain and other associated symptoms.

Effective treatment and management of gastroesophageal reflux disease often involve a combination of lifestyle modifications and medication. Here are a few treatment and management methods:

1. Lifestyle Modifications

• Dietary Changes: Avoid trigger foods such as citrus fruits, tomatoes, chocolate, spicy foods, and fatty or fried foods to reduce heartburn frequency and severity.

• Meal Frequency: Eat smaller, more frequent meals to decrease stomach pressure and minimise acid reflux.

• Weight Management: For overweight individuals, losing weight can significantly alleviate GERD symptoms by reducing pressure on the stomach.

• Elevating Bed: Raise the head of the bed by about 6 inches to prevent nighttime acid reflux.

2. Medications

• Over-the-Counter Options: Antacids neutralise stomach acid for quick relief. Additionally, H2 blockers such as famotidine reduce acid production and help heal esophageal erosions.

• Prescription Medications: Proton Pump Inhibitors (PPIs) like omeprazole and lansoprazole significantly lower stomach acid production and are often used for long-term management.

3. Additional Treatments

• Surgical Options: For severe cases that do not respond to medication, surgical interventions like Nissen fundoplication may be considered to strengthen the anti-reflux barrier.

• Endoscopic Procedures: Techniques such as Transoral Incisionless Fundoplication (TIF) offer less invasive options for managing GERD.

By combining lifestyle changes with appropriate medication, patients can achieve significant relief from GERD symptoms and enhance their quality of life.

Sometimes, when your symptoms become severe or prolonged, you might need to visit your doctor. Look out for these symptoms:

1. Persistent Symptoms

If you experience persistent symptoms of GERD, such as heartburn, acid reflux, or chest pain, that do not respond to lifestyle changes or over-the-counter medications, it is important to consult a doctor. Persistent symptoms may indicate a more serious underlying condition, which requires proper diagnosis and treatment.

2. Severe or Frequent Symptoms

If your GERD symptoms are severe or occur frequently, even if they respond to medication, it is advisable to seek medical attention. Severe symptoms may include intense chest pain, difficulty swallowing, or the feeling of food getting stuck in your throat. Frequent episodes of heartburn or acid reflux, occurring more than twice a week, should also be evaluated by a doctor.

3. Nighttime Symptoms

Experiencing symptoms such as discomfort at night, particularly if they wake you up from sleep, can be a sign of more severe GERD. Nighttime reflux can lead to complications such as inflammation of the oesophagus (oesophagitis) or respiratory problems like chronic cough or asthma. If you regularly experience nighttime symptoms, it is important to consult a doctor for proper evaluation and treatment.

4. Difficulty Swallowing or Painful Swallowing

If you have difficulty swallowing (dysphagia) or experience pain when swallowing, it is crucial to see a doctor. These symptoms may indicate a more serious condition, such as oesophageal stricture (narrowing of the oesophagus) or oesophageal ulcers, which can be complications of untreated GERD. In rare cases, difficulty swallowing may also be a sign of oesophageal cancer, making prompt medical evaluation essential.

5. Unexplained Weight Loss

Unintentional weight loss, particularly when accompanied by other symptoms of GERD, should be evaluated by a doctor. While GERD itself does not typically cause weight loss, it may be a sign of an underlying condition that requires medical attention, such as peptic ulcers or stomach cancer.

6. Vomiting Blood or Passing Black Stools

If you experience vomiting blood or passing black, tarry stools (melena), seek immediate medical attention. These symptoms may indicate bleeding in the digestive tract, which can be a complication of severe GERD or other serious conditions such as peptic ulcers or gastrointestinal cancers. Prompt diagnosis and treatment are essential in such cases.

7. Persistent Symptoms Despite Treatment

If you have been diagnosed with GERD and are receiving treatment, but your symptoms persist or worsen despite following the prescribed treatment plan, it is important to follow up with your doctor. Your doctor may need to adjust your medication, recommend additional lifestyle changes, or investigate further to rule out other potential causes of your symptoms.

• Gastroesophageal reflux disease (GERD) is a chronic digestive disorder characterised by the backflow of stomach contents into the oesophagus.

• Common symptoms of GERD include heartburn, regurgitation, chest pain, difficulty swallowing, and epigastric distress or discomfort.

• Risk factors for GERD include obesity, pregnancy, smoking, certain medications, and a hiatal hernia.

• Lifestyle modifications, such as maintaining a healthy weight, avoiding trigger foods, and elevating the head of the bed, can help manage GERD symptoms.

• Over-the-counter antacids, H2 receptor blockers, and proton pump inhibitors (PPIs) are common treatments for GERD.

• In severe cases or when medications are ineffective, surgical options like fundoplication may be considered.

• If you experience persistent symptoms, severe epigastric pain, or any alarming signs, consult a doctor for an accurate diagnosis and appropriate treatment.