Gastroesophageal reflux disease (GERD) is the result of a disordered valve mechanism between the esophagus (swallowing tube) and the stomach. The valve, or lower esophageal sphincter (LES), opens during swallowing to allow food to enter the stomach and then closes to prevent food and stomach secretions from moving backward into the esophagus. When the LES fails to close correctly, the stomach contents—which are acidic and contain digestive secretions—can flow back into the esophagus. This reverse flow (reflux) of food, acids and the digestive enzyme pepsin, can cause damage to the esophageal lining and resulting heartburn.

GERD is a common disorder that has a significant impact on the community. In Canada, people suffering from GERD symptoms are absent from work 16% of each year, representing $21 billion in costs or 1.7 billion hours of lost productivity annually. On average, five million Canadians experience heartburn and/or acid regurgitation at least once each week. Reflux is common during pregnancy and one-quarter of pregnant women experience daily heartburn. Recent studies show that GERD in infants and children occurs more frequently than previously thought and may produce repeated vomiting, failure to grow, coughing and other respiratory problems.

See also: What is GERD and what complications arise from it?

How can I prevent Gastroesophageal reflux disease (GERD)?

Lifestyle/dietary changes:

Your doctor will usually recommend lifestyle and dietary changes to reduce or relieve GERD symptoms and help reduce acid reflux and potential damage to the lining of your esophagus. Suggested changes may include:

• Avoid food and beverages known to lower LES pressure including chocolate, peppermint, fried or fatty foods, coffee and alcohol
• Avoid spicy and acid-containing foods that can irritate the esophageal lining
• Eat small, frequent meals, rather than large meals
• Have nothing to eat and little or nothing to drink for 3 to 4 hours before going to bed
• Raise the head of the bed or elevate the upper body with a foam wedge
• Achieve and maintain an ideal body weight
• Stop smoking

Watch our CDHF Talk on GERD and its relationship to Barrett’s Esophagus

See also: H.pylori Infections, Acid Reflux and Peptic Ulcers Video

Everyone has likely experienced common symptoms such as acid reflux, pains in the chest, a cough or a sore throat, however, if any of these issues become chronic, they could be symptoms of GERD. If you start to experience excessive or daily acid reflux, especially coupled with a sore throat and a cough that lingers, you should ask your doctor about GERD (gastroesophageal reflux disease).

See also: Heartburn – Understanding its Causes and Treatments

Though GERD symptoms can be uncomfortable, alarm symptoms are not typical of GERD and can signal additional, more severe health concerns. Consult a health care professional if you notice a change in your current symptoms or experience any of the following:

• Sudden weight loss
• Frequent heartburn
• Difficulty swallowing or a feeling of trapped food in the chest
• Nausea
• Vomiting
• Bloody stools (tarry black or red)
• Anemia

Risks Associated GERD

GERD is a chronic disease, and so treatment usually needs to be maintained on a long-term basis, even after symptoms are under control.

Untreated GERD can sometimes result in severe damage to the esophagus. A narrowing (stricture) of the throat may occur from chronic scarring, and an esophageal ulcer and bleeding may develop from repeated exposure to stomach acid.

Some patients with prolonged, uncontrolled GERD may develop Barrett’s esophagus, a condition that results in changes to the esophageal lining which increase the risk of developing esophageal cancer.

Before treating GERD, you must first be diagnosed. Most of the time, symptoms alone can provide doctors with the information they need to diagnose GERD. If symptoms respond quickly to treatment, further investigation is usually not necessary. However, if symptoms are slow to improve or persistent (long-term) treatment is required and diagnostic tests, including those listed below, may be needed.

• Endoscopy: This safe test involves passing a slim, flexible tube (endoscope) equipped with a light and tiny camera into the esophagus. The endoscope allows your doctor to examine the esophagus and stomach and collect tissue samples (biopsies) for further examination under a microscope.
• Barium X-ray: (upper GI series): A barium drink coats the lining of the upper digestive tract so it can be seen on an X-ray. X-rays allow your doctor to visualize the esophagus, stomach, and small intestine and locate areas of damage or inflammation.
• 24-hour pH monitoring: A small tube (catheter) equipped with a one or two pH sensors is positioned in the esophagus. The sensor monitors the acidity in the esophagus over a 24-hour period and the data is stored on a small recorder worn around the waist for later analysis.
• Capsule-based pH testing: A capsule equipped with a pH sensor is positioned in the esophagus. The sensor monitors the acidity in the esophagus over a period of up to 96-hours and the data is stored on a small recorder worn around the waist for later analysis.
• Esophageal motility study (EMS): A small tube (catheter) equipped with sensors is positioned in the esophagus. During this test, the sensors measure movement and pressure within the esophagus and can evaluate if the LES is functioning properly.

For more information of the types of tools used for diagnostics, visit Medtronic’s website.

Treating GERD

Once you begin treatment, your GERD symptoms should become less frequent and less severe. However, in some cases, reflux symptoms may be made worse or confused by abnormal motility or other conditions such as Helicobacter pylori gastritis (a common bacterium that can cause stomach inflammation and peptic ulcers), celiac disease (wheat or gluten intolerance), diabetes mellitus, gastroparesis (delayed gastric emptying), gallstones or pancreatitis (inflammation of the pancreas).

If your GERD symptoms persist, speak to your doctor, as you may need further investigation to rule out other causes or complications or alternative treatment options.

Managing Gastroesophageal reflux disease (GERD)

Along with medications, your doctor may recommend dietary and lifestyle changes which are an important part of effective GERD Disease management. Achieving and maintaining a healthy weight, eating small, frequent meals, raising the upper body during sleep, avoiding trigger foods and not smoking can reduce reflux and the discomfort associated with GERD symptoms.

What to Ask Your Doctor

Create a list of 3 to 6 questions to ask your doctor during your appointment. Specifically, you may want to ask your doctor some of the following:

• Do you think I have GERD?
• What diagnostic tests do I need?
• How serious is my condition? Am I at risk for additional complications?
• Are there other possible causes for my condition?
• What do you think is causing my symptoms?
• What lifestyle or diet changes can I make to improve my condition?
• What treatment approach do you recommend trying first?
• Do these tests require any special preparation?
• What are the treatment options for GERD?
• Does my medical history limit any of my treatment options?
• Will over-the-counter medicines help? If so, which would you recommend?
• Would prescribed medications be better? Why or why not?
• How long should I expect to take this medication?
• Should I be referred to a gastroenterologist (GI)?
• Am I at risk for Barrett’s esophagus?
• Should I consider testing for Barrett’s esophagus?

Communicating with your doctor is important for GERD disease management. Keeping the lines of communication open allows your healthcare professional to closely follow your symptoms and determine which steps should be taken to ensure that your GERD symptoms do not develop into Barrett’s esophagus, which is the primary risk factor for esophageal cancer. Furthermore, up to 15% of people who develop GERD will develop Barrett’s esophagus. So make sure you have a treatment plan set up with your doctor, complete with regular screening and always report new or worsened symptoms.

• Gastroesophageal reflux disease (GERD) is characterized by heartburn and acid regurgitation, where there is reflux of stomach contents into the esophagus.
•  GERD symptoms are widespread in the community and range from 2.5% to more than 25%. (Savarino et al. 2017)
•  The history and prevalence of GERD is difficult to establish because of the lack of a standard and universally accepted definition.
•  In North America, it is estimated that the prevalence of GERD is 15%. (Eusebi et al. 2018)
•  GERD has detrimental societal consequences, and negatively impacts quality of life and work productivity. (Hunt et al. 2017)
• Proton pump inhibitors are one type of drug that can be used to reduce stomach acid and relieve GERD symptoms.
•  Proton pump inhibitors are one of the most common drugs prescribed in Canada. In 2012, there were more than 11 million prescriptions dispensed nationwide. (Farrell et al. 2017)
•  In 2017, spending on proton pump inhibitors by public drug programs totaled $198.2 million in Canada, ranking the drug seventh in terms of public drug program spending. (Canadian Institute for Health Information 2017)
•  A Canadian study estimated that patients with GERD lose 16% of their work time due to their symptoms. (Fedorak et al. 2010)

Use this easy to digest GERD infographic to learn about GERD and its connection to Barrett’s esophagus and esophageal cancer.

_Citations:

_{Canadian Institute for Health Information. 2017. Prescribed drug spending in Canada, 2017: A focus on public drug programs. Ottawa, ON: CIHI.https://secure.cihi.ca/free_products/pdex2017-report-en.pdf [accessed 3 September 2018]}

_{Eusebi LH et al. Global prevalence of, and risk factors for, gastro-oesophageal reflux symptoms: a meta-analysis. Gut. 2018 Mar;67(3):430-40.}

_{Farrell B et al. Deprescribing proton pump inhibitors: Evidence-based clinical practice guideline. Can Fam Physician. 2017 May;63(5):354-64.}

_{Fedorak RN et al. Canadian Digestive Health Foundation Public Impact Series: Gastroesophageal reflux disease in Canada: Incidence, prevalence, and direct and indirect economic impact. Can J Gastroenterol. 2010 Jul;24(7):431-4.}

_{Hunt R et al. World Gastroenterology Organisation Global Guidelines: GERD global perspective on gastroesophageal reflux disease. J Clin Gastroenterol. 2017 Jul;51(6):467-78.}

_{Savarino E et al. The natural history of gastro-esophageal reflux disease: A comprehensive review. Dis Esophagus. 2017 Feb 1;30(2):1-9.}

What is gastroesophageal reflux disease (GERD)?

GERD causes stomach contents (food or liquid) to leak backwards into the esophagus (the tube from the mouth to the stomach). The backwash can irritate the esophagus, causing heartburn and other symptoms.

What are the symptoms?

The common symptoms of GERD include chronic heartburn (burning pain in the chest) and regurgitation. Less common symptoms include chronic cough, sore throat, and a hoarse voice.

Who is at risk?

Those at risk for GERD include males and people with a family history of gastrointestinal symptoms. Obesity can increase the risk of GERD up to six-fold. Hiatal hernia, smoking, pregnancy, scleroderma, and excessive alcohol consumption are also risk factors.

How many people have GERD?

GERD affects 1 in 6 adult Canadians. 

How is GERD diagnosed?

GERD is often diagnosed based upon symptoms and response to anti-reflux medication. Yet, symptoms alone are not enough to diagnose GERD, and testing is required for conclusive diagnosis. Clinical studies reveal that as many as one in three patients taking proton pump inhibitors (PPIs) do not have GERD. If you have a diagnosis of GERD based upon symptoms, take PPIs regularly, and still have reflux symptoms, speak to a GI about a reflux test.

Are there certain medical conditions associated with GERD?

Being overweight is a definite aggravating factor for reflux by increasing intrabdominal pressure.

Patients with long standing diabetes may develop decreased gastric emptying due to nerve injury to the stomach. This can also occur after certain stomach surgeries. Ulcers or cancers that block the stomach from emptying can cause reflux. Certain medications can contribute to reflux. Scleroderma is a rheumatological problem that can lead to reflux secondary to poor esophageal emptying and a decreased lower esophageal sphincter pressure.

Can reflux cause cancer?

15% of patients who have GERD may develop a Barrett’s esophagus which results in a change in the normal esophageal mucosa to a type of lining that is more of an intestinal type. A gastroscopy with esophageal biopsies is the only definitive way to make this diagnosis of a Barrett’s esophagus.. There are no specific symptoms for Barrett’s esophagus and the risk of a cancer developing in the setting of a Barrett’s esophagus is very low.

Do the medications for GERD cure acid reflux?

The medications are very effective to treat reflux. However they do not cure the disease. The medications work to decrease the acid production by the stomach and once you stop the drugs the stomach returns to its normal ability to make acid. The symptoms of heartburn will therefore often recur after the medication is stopped. If altering lifestyle measures do not prevent the symptoms from recurring then individuals may require medication on a long term basis. This may include using it as necessary when symptoms recur. Some individuals need medication on a daily maintenance basis.

Does having GERD for a long time put me at risk of other illnesses?

Some people may experience problems from acid reflux in areas other than the esophagus. These are called extraesophageal symptoms. Sometimes the acid can spill over into the throat region and vocal cords and cause problems with a voice change, hoarseness, sore throat, and lump-like feeling in the throat region.

If the acid spills into the lungs, it can cause problems with cough, asthma, or infections. These symptoms can be the primary problem of reflux and the person may not even complain of associated burning in the chest or throat region. Some people develop a condition known as Barrett’s esophagus, which is severe damage to the cells lining the bottom of the esophagus. Doctors believe Barrett’s esophagus may increase the chance of developing esophageal cancer.

I am pregnant and am suffering from GERD. Is something wrong?

It is very common during pregnancy for reflux to be a problem. The fetus increases the abdominal pressure and the hormones of pregnancy may decrease the lower esophageal sphincter pressure. Also If the stomach doesn’t empty because of a motility problem or a blockage then there is a greater risk for acid to reflux into the esophagus.

I have GERD. Are there complications that I should be aware of before considering surgery?

Complications can occur from surgery with 5-10% of patients. These include making the wrap too tight and developing problems swallowing one’s food, accidental injury to the spleen requiring removal of the spleen, post-operative hernia formation developing diarrhea, inability to burp and loosening of the wrap over time with recurrent reflux needing medication.

I have GERD. When should I consider having surgery?

There are some special circumstances where surgery may be of value for those having troublesome retrosternal burning and extraesophageal symptoms of cough, asthma, voice change and pulmonary infections despite of a trial with at least a double dose of a proton pump inhibitor. It is important to confirm that there is increased acid present in the esophagus with a pH test. Some people who regurgitate fluid that is very troublesome may benefit from surgery. There are some people who respond to the drugs but have side effects from the drugs, find them too expensive or simply don’t like taking medications. This group would benefit from surgery.

People who continue to have symptoms even with a twice a day dose of a proton pump inhibitor and the 24 hour ph test is normal should look to be tested for other problems as this is not in keeping with acid reflux.

I have heard about bacteria that can cause problems. Do these contribute to reflux?

The bacterium is called Helicobacter pylori (H. pylori). This is a common bacterium that infects the stomach and may cause about 10% of people with the bacterium to develop an ulcer. As a rule, one does not look for H. pylori in the setting of reflux.

Is there anything that can be done through the scope to treat reflux?

There have been some endoscopic techniques that have been developed that can increase the lower esophageal sphincter pressure but presently they are more experimental and do not have a role in the treatment of reflux.

What does it mean if I don’t get better with GERD medications?

The medications we use to treat acid reflux are very effective. There is a very small percentage of people who continue to experience acid reflux even with the medications. However there is a group of patients who have symptoms suggestive of reflux and yet there is no increased acid present. These patients may be refluxing bile that is produced by the liver and pancreatic secretions from the pancreas.  Medical treatment of this group may also be challenging and a foam barrier and prokinetic drugs may be helpful. Sometimes more than one drug may be necessary to threat this problem. Some people may also experience hypersensitivity of the esophagus to normal amounts of acid or contractions of the esophageal wall. This is called visceral hypersensitivitiy. Stress may be a contributing factor to esophageal visceral hypersensitivity. A certain class of antidepressants called tricyclic antidepressants which alter the way the brain perceives painful stimuli may be of value in these situations.

Are treatment options available?

GERD can be treated with lifestyle changes, such as weight loss, healthier, smaller meals, and not eating Just before bed time. Prescription and over-the-counter medicines, like proton pump inhibitors, can lower the amount of acid released in your stomach. For patients who do not respond to lifestyle changes and medication, anti-reflux procedures may also be an option.

What happens if GERD goes untreated?

In addition to its negative impact on health-related quality of life, GERD may lead to serious diseases including Barrett’s esophagus. Over a quarter of GERD patients may progress to Barrett’s esophagus in their lifetime. If untreated, Barrett’s esophagus may progress to esophageal cancer. Esophageal cancer may not be curable depending on the stage at diagnosis. It has a low five-year survival rate of 14%.

What is a hiatus hernia? Could this be causing my heartburn?

Normally the esophagus is located above the diaphragm and the stomach is below the diaphragm. The lower esophageal sphincter lies at the level of the diaphragm in between the esophagus and stomach. The diaphragm is a muscle that separates the chest from the abdomen. A hiatus hernia occurs when a portion of the stomach adjacent to the esophagus pushes up thru the diaphragm and rests above the diaphragm in the chest region.

A hiatus hernia is a common occurrence and often causes no problems. Many individuals have reflux and do not have a hiatus hernia. In some individuals it may contribute to reflux. The diaphragm squeezes on the sphincter when it is normally located at the level of the diaphragm and helps to increase the pressure in this region.

When the sphincter is situated above the diaphragm in the setting of a hiatus hernia the diaphragm can no longer assist the effect of the lower esophageal sphincter pressure. Also sometimes acid can be trapped in the hiatus hernia and be a reservoir for acid to more readily reflux into the esophagus.