Gastroesophageal reflux disease

What is it?

According to the NIDDK: gastroesophageal reflux (GER) is the return of stomach contents into the oesophagus, and many people experience it occasionally without symptoms or with heartburn. It becomes a disease (GERD) when it causes frequent troublesome symptoms or complications over time, and it affects about 20% of people in the United States. The NHS (heartburn and acid reflux) defines it as a burning feeling in the chest caused by stomach acid travelling up towards the throat, and when it persists it is called GORD.

Causes

The lower oesophageal sphincter normally prevents stomach acid from rising; the disease occurs when it weakens or relaxes improperly. Factors (NIDDK): being overweight or obese, pregnancy, smoking or second-hand smoke, certain medicines (benzodiazepines, calcium channel blockers, non-steroidal anti-inflammatory drugs, some asthma medicines, tricyclics), and hiatal hernia.

The NHS also lists triggers: coffee, tomatoes, alcohol, chocolate, fatty and spicy foods, stress and anxiety, hormonal changes, and a stomach ulcer or bacterial infection.

Symptoms

According to the NIDDK: heartburn (a painful burning in the middle of the chest), regurgitation of stomach contents into the throat or mouth, chest pain, nausea, difficulty or pain on swallowing, and chronic cough or hoarseness. Not everyone affected has heartburn or regurgitation.

The NHS lists a sour taste, hiccups, hoarseness, bad breath and bloating, and symptoms are worse after eating, lying down or bending over.

How is it diagnosed?

Upper endoscopy (a flexible tube with a camera) to examine the oesophagus, stomach and duodenum and take biopsies, used “to check for complications of GERD or other problems that may be causing symptoms”. Oesophageal pH monitoring is “the most accurate way” to detect stomach acid in the oesophagus and is used to confirm the diagnosis or see whether treatment has worked, with a thin catheter through the nose or a wireless capsule (NIDDK).

Treatment

The treatment categories usually used are listed here; this is not a prescription. The doctor chooses the plan according to each person's condition; do not change any medicine or dose without a specialist.

Lifestyle according to the NIDDK: losing weight if overweight, raising the head 6 to 8 inches during sleep with pillows or wedges, quitting smoking, and adjusting eating habits and diet. The NHS adds smaller, more frequent meals, avoiding eating 3 to 4 hours before bed, and avoiding tight clothing.

Medicines: antacids to relieve mild symptoms, not for permanent daily use without a doctor; H2 blockers reduce acid secretion and are less effective than proton pump inhibitors in healing the oesophagus; proton pump inhibitors (PPIs) “heal the oesophageal lining in most people affected” and are available over the counter or by prescription for long-term use, and their side effects include headache, diarrhoea, stomach upset and increased risk of Clostridioides difficile infection (NIDDK). MedlinePlus points to an association between long-term use of pump inhibitors and a raised risk of osteoporosis.

Surgery and procedures: fundoplication is the most common, by laparoscopic or open surgery, wrapping part of the stomach around the oesophagus to strengthen the sphincter; bariatric surgery (gastric bypass) for those with GERD and obesity; and less commonly used endoscopic procedures (NIDDK). The NHS lists referral for endoscopy or surgery in severe cases.

Complications

Without treatment, GERD may cause (NIDDK): oesophagitis, stricture, Barrett oesophagus and oesophageal adenocarcinoma; and outside the oesophagus: asthma, chronic cough, hoarseness, laryngitis and tooth enamel erosion.

Prevention

Nothing prevents the disease completely, but a healthy weight, quitting smoking, avoiding triggers, raising the head of the bed and avoiding late eating reduce symptoms (NIDDK, NHS).

Common questions