Gastroesophageal Reflux Disease (GERD): The Complete Guide to Causes, Symptoms, and Treatment
Gastroesophageal reflux disease (GERD), also known as acid reflux disease and sometimes as reflux esophagitis, is a common condition. About 13 percent globally, and 6 to 30 percent of the US population, is affected by GERD.
Lifestyle measures as well as long-term medical treatment, are usually necessary, and sometimes even surgery may be required. Here’s an overview of how acid reflux disease develops, which symptoms you might experience, and how it is treated.
What is GERD?
Gastroesophageal reflux disease (GERD) is a chronic condition caused by gastric (stomach) acid, food, or other content refluxing into the esophagus (the tube that connects your mouth to your stomach). Reflux is the movement of stomach contents in the wrong direction, reversing out of the stomach back up into the esophagus. To be diagnosed formally with GERD, you must experience symptoms such as heartburn, or physical damage to the esophagus.
The entrance from the esophagus to the stomach is usually closed by a_ sphincter (ring-shaped muscle) known as the lower esophageal sphincter (LES). The LES opens when food from the mouth travels down the esophagus and enters the stomach, and stays closed the rest of the time to prevent the stomach content from flowing back up. For a person with GERD, the LES no longer is able to stay closed, allowing stomach acid and contents to leak back up into the esophagus. In contrast to the stomach, the lining of the esophagus has no natural acid protection and can be damaged by the gastric acid. This can cause symptoms like discomfort or pain, and physical injury to the tissues of the esophagus and complications.
Diagnosing and classifying GERD
Speak to your physician about your GERD symptoms and how they impact your quality of life—this will help them determine the severity.
Infrequent GERD symptoms occur less than twice a week, while frequent symptoms occur more than twice a week.
A physician can perform an upper endoscopy to examine the esophageal inner lining and determine if there are any lesions of signs of inflammation (esophagitis). Not everyone with GERD has esophageal damage.
Why causes GERD?
GERD develops when the body is unable to prevent stomach contents from refluxing back up into the esophagus.
The following factors can lead to the development of GERD:
- Obesity and increased abdominal pressure: Obese people are more likely to have GERD. This may be because obesity can cause the pressure in the abdominal cavity to increase, which acts against the counter pressure of the LES, causing it to weaken, and making reflux more likely. Increased abdominal pressure can also occur during pregnancy.
- Eating habits: Some foods, like spicy or greasy foods, may cause local irritation to the esophagus and stomach lining. Eating meals shortly before going to bed may also promote reflux.
- A flat sleeping position: May aggravate reflux symptoms.
- Nicotine and alcohol: These substances can cause a reduction of the muscular tone of the LES.
- Hiatal hernia: This occurs when a part of the stomach moves up into the chest through the opening in the diaphragm. Gastric acid can accumulate in this part of the stomach, causing weakening and damage to the LES and esophagus.
- Physical activity: Excessive abdominal and core training may provoke reflux.
- Medications: Some painkillers, medicines for heart diseases, psychopharmaceuticals, antibiotics may cause GERD.
- Local inflammatory conditions of the stomach and esophagus.
Not every person who is affected by reflux shows symptoms. Especially mild forms of reflux often do not cause any symptoms and may go unnoticed. Since GERD is defined by troublesome symptoms, people without symptoms do not have GERD.
GERD symptoms can be divided into two groups: typical symptoms and unspecific symptoms. Unspecific symptoms by themselves do not provide clear evidence of reflux disease.
|Coughing, especially during nighttime / in the morning
Hoarseness and sore throat
Respiratory symptoms similar to asthma
Bad breath (halitosis)
Atypical: nausea and chest pain
Sometimes: trouble swallowing
Heartburn, a major symptom of reflux disease, occurs often after eating. In the morning many symptoms might be most pronounced, as lying for a long time makes it easier for gastric acid to flow back into the esophagus. Coughing and hoarseness can be caused by irritation of the larynx by the acid.
A feeling of pressure or tightness in the chest is a rarer symptom of GERD. It mainly occurs when a hiatal hernia, a defect or hole in the diaphragm allowing the stomach to partially slip up into the chest, is the cause of the symptoms. A hiatal hernia can also lead to a shortness of breath and heart palpitations.
GERD diagnosis and testing
GERD can often be diagnosed from someone’s symptoms, medical history, and a physical examination. While it’s not possible to assess esophageal symptoms with a basic physical examination, a physician can check for other symptoms, like respiratory symptoms or teeth damage.
Sometimes a physician may choose to treat a patient based on this information, using lifestyle changes and/or medications. But if symptoms don’t improve or worsen, or if there are other suspicious symptoms, then further testing is needed.
The physician will perform an upper gastrointestinal endoscopy to examine the health of the esophagus, stomach, and duodenum (the first part of the small intestine). This allows the physician to see if there are any signs of inflammation or damages to the inner lining of the upper digestive tract. A biopsy (small piece of tissue) from the esophageal inner lining may be taken for further lab testing.
Other tests, like pH monitoring over 24 to 48 hours, may be used to check the levels of acidity in the esophagus. Different types of pH monitoring tests can be performed to help determine the relationship between reflux events and symptoms.
X-ray examinations of the esophagus don’t provide direct information about reflux, but may be used to visualize the location and shape of the esophagus and stomach.
Esophageal manometry, which gives information about the muscular contractions of the esophagus, may be performed in order to rule out other conditions.
The treatment of reflux disease is based on three main measures: Lifestyle modification, medication, and in some cases, surgical treatment.
Lifestyle modification and diet changes
Simple changes to lifestyle and diet are used to treat mild forms of GERD, through alleviating symptoms and preventing further episodes.
The first step of lifestyle changes focuses on the diet: avoid greasy and spicy foods, alcohol, overeating, and eating close before bedtime.
Quitting smoking can also help relieve the symptoms of reflux disease.
Losing weight can help reduce abdominal pressure and reduce GERD symptoms. Avoid anything that can cause increased abdominal pressure, such as wearing clothing that is too tight.
Sleeping with a slightly elevated head helps also to prevent reflux at night.
Medication for GERD
Reflux disease can be effectively treated with medication. Medication aims to control symptoms, repair possible esophageal lesions, and prevent complications.
Proton pump inhibitors (PPIs) are a commonly prescribed medication for GERD. These drugs inhibit transporters in the lining of the stomach that are involved in the production of stomach acid (so-called proton pumps). By blocking these transporters, the amount of gastric acid produced is reduced, thus decreasing the cause of the symptoms.
When PPIs are not tolerated, H2-receptor blockers or histamine-2 receptor antagonists can be taken. They also reduce gastric acid production but are not as effective as PPIs. Drug tolerance often occurs with H2-receptor blockers.
Antacids and alginate can be used in acute episodes, as they work rapidly. Antacids neutralize the stomach acid; alginate produces a protective layer in the stomach.
As PPIs take time to start working, they can be combined with antacids to bridge the efficacy gap.
Surgical treatment for GERD
Surgical treatment of reflux disease might be an option:
- if symptoms are not controlled with PPIs
- in advanced stages of GERD
- if there are recurrent aspiration (accidentally breathing stomach juices into the airways)
- if medication is not tolerated
Especially when GERD is caused by a hiatal hernia, surgery may be beneficial.
Gastroesophageal reflux disease is a common disease that can significantly reduce a person's quality of life. Since the symptoms of GERD are very characteristic, the disease can be recognized quickly and treatments can be started. Making lifestyle changes and taking preventative measures, along with using medicinal treatments like proton pump inhibitors, can help to reduce or prevent GERD. In severe cases, surgical options can also provide treatment.
Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R; Global Consensus Group. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol. 2006;101(8):1900‐1943. doi:10.1111/j.1572-0241.2006.00630.x
Hungin APS, Molloy-Bland M, Scarpignato C. Revisiting Montreal: New Insights into Symptoms and Their Causes, and Implications for the Future of GERD. Am J Gastroenterol. 2019;114(3):414‐421. doi:10.1038/s41395-018-0287-1
Eusebi LH, Ratnakumaran R, Yuan Y, Solaymani-Dodaran M, Bazzoli F, Ford AC. Global prevalence of, and risk factors for, gastro-oesophageal reflux symptoms: a meta-analysis. Gut. 2018;67(3):430‐440. doi:10.1136/gutjnl-2016-313589
El-Serag HB, Sweet S, Winchester CC, Dent J. Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut. 2014;63(6):871‐880. doi:10.1136/gutjnl-2012-304269
Kahrilas PJ, Shaheen NJ, Vaezi MF, et al. American Gastroenterological Association Medical Position Statement on the management of gastroesophageal reflux disease. Gastroenterology. 2008;135(4):1383‐1391.e13915. doi:10.1053/j.gastro.2008.08.045
Gyawali CP, Fass R. Management of Gastroesophageal Reflux Disease. Gastroenterology. 2018;154(2):302‐318. doi:10.1053/j.gastro.2017.07.049
Koop H, Fuchs KH, Labenz J, et al. S2k-Leitlinie: Gastroösophageale Refluxkrankheit unter Federführung der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS):AWMF Register Nr. 021-013 [S2k guideline: gastroesophageal reflux disease guided by the German Society of Gastroenterology: AWMF register no. 021-013]. Z Gastroenterol. 2014;52(11):1299‐1346. doi:10.1055/s-0034-1385202
Fibbe C, Keller J, Layer P. Gastroösophageale Refluxkrankheit: Was ist wichtig für die Praxis? Dtsch Med Wochenschr. 2005;130(34/35):1970-1973. doi: 10.1055/s-2005-872614
Issing WJ. Gastroösophagealer Reflux - eine Volkskrankheit? _Laryngo-Rhino-Otol. _2003;82(2): 118-122. doi: 10.1055/s-2003-37727
Armstrong D. Gastroesophageal reflux disease. Curr Opin Pharmacol. 2005;5(6),589-595. doi: 10.1016/j.coph.2005.09.001
Schiefke I, Mössner J, Caca K. Refluxösophagitis [Reflux esophagitis]. Internist (Berl). 2005;46(3):315‐327. doi:10.1007/s00108-005-1373-1
Labenz J, Labenz C. Prävalenz und natürlicher Verlauf der gastroösophagealen Refluxkrankheit. Gastroenterologe. 2016; 11:102-109. doi: 10.1007/s11377-016-0045-0
Sami S, Ragunath K. The Los Angeles Classification of Gastroesophageal Reflux Disease. Video Journal and Encyclopedia of GI Endoscopy. 2013;1(1):103-104. doi:10.1016/S2212-0971(13)70046-3