GERD; Types, Causes, Symptoms, Diagnosis, Treatment

GERD (Gastroesophageal reflux disease ) also known as acid reflux, is a long-term condition where stomach contents come back up into the esophagus resulting in either symptoms or complications. Symptoms include the taste of acid in the back of the mouth, heartburn, bad breath, chest pain, vomiting, breathing problems, and wearing away of the teeth.Complications include esophagitis, esophageal strictures, and Barrett’s esophagus.

Types of GERD/Acid Reflux

Most people experience occasional acid reflux or GER. However, in some cases the digestive condition is chronic. It’s considered gastroesophageal reflux disease (GERD) if it occurs more than twice a week.

Acid reflux can affect infants and children as well as adults. Children under 12 usually don’t experience heartburn. Instead they have alternative symptoms like:

These alternative symptoms can also appear in adults.

Infant of GERD/Acid Reflux

Adults aren’t the only ones affected by acid reflux. According to the National Digestive Diseases Information Clearinghouse (NDDIC), more than half of all babies experience infant acid reflux during their first three months of life. It’s important for your pediatrician to differentiate between normal reflux and GERD.

Spitting up and even vomiting is normal and may not bother the baby. Other signs of normal reflux include:

  • irritability
  • discomfort
  • arching the back during or immediately after feedings
  • poor feeding
  • coughing

Causes of GERD/Acid Reflux

A comparison of a healthy condition to GERD . GERD is caused by a failure of the lower esophageal sphincter.
  • Lifestyle – Use of alcohol or cigarettes, obesity, poor posture (slouching)
  • Medications – Calcium channel blockers, theophylline nitrates, antihistamines
  • Diet – Fatty and fried foods, chocolate, garlic and onions, drinks with caffeine, acidic foods such as citrus fruits and tomatoes, spicy foods, mint flavorings
  • Eating habits – Eating large meals, eating quickly or soon before bedtime
  • Other medical conditions – Hiatal hernia, pregnancy, diabetes, rapid weight gain
  • Hiatal hernia – which increases the likelihood of GERD due to mechanical and motility factors.
  • Obesity – increasing body mass index is associated with more severe GERD. In a large series of 2,000 patients with symptomatic reflux disease, it has been shown that 13% of changes in esophageal acid exposure is attributable to changes in body mass index.
  • Zollinger-Ellison syndrome – which can be present with increased gastric acidity due to gastrin production.
  • A high blood calcium level  – which can increase gastrin production, leading to increased acidity.
  • Scleroderma and systemic sclerosis –  which can feature esophageal dysmotility.
  • Visceroptosis or Glénard syndrome –  in which the stomach has sunk in the abdomen upsetting the motility and acid secretion of the stomach.
  • Gallstones  – which can impede the flow of bile into the duodenum, which can affect the ability to neutralize gastric acid
  • Obstructive sleep apnea

Symptoms can also be caused by certain medicines, such as

Symptoms of GERD/Acid Reflux

GERD sometimes causes injury of the esophagus. These injuries may include one or more of the following:

  • Sharp or burning chest pain behind the breastbone. This is also known as heartburn. It is the most common symptom of GERD. Heartburn may be worse when you eat, bend over or lie down.
  • Reflux esophagitis – inflammation of esophageal epithelium which can cause ulcers near the junction of the stomach and esophagus
  • Esophageal strictures – the persistent narrowing of the esophagus caused by reflux-induced inflammation
  • Barrett’s esophagus – intestinal metaplasia (changes of the epithelial cells from squamous to intestinal columnar epithelium) of the distal esophagus
  • Esophageal adenocarcinoma – a form of cancer
  • Chest pain
  • Difficulty swallowing
  • Regurgitation of food or sour liquid
  • Sensation of a lump in your throat
  • Chronic cough
  • Laryngitis
  • New or worsening asthma
  • Disrupted sleep
  • A burning sensation in your chest (heartburn), usually after eating, which might be worse at night
  • Tightness in your chest or upper abdomen. The pain may wake you up in the middle of the night.
    Regurgitation, the backflow of stomach fluids into your mouth
  • Nausea
  • A recurring sour or bitter taste in the mouth
  • Difficulty swallowing
  • Sore throat
  • Coughing, wheezing or repeatedly needing to clear your throat
  • Hoarseness, especially in the morning

Some researchers have proposed that recurrent ear infections, and idiopathic pulmonary fibrosismight be tied, in some cases, to GERD; however, a causative role has not been established. GERD does not appear to be linked to chronic sinusitis.

Diagnosis of GERD/Acid Reflux

  • Upper endoscopy – Your doctor inserts a thin, flexible tube equipped with a light and camera (endoscope) down your throat, to examine the inside of your esophagus and stomach. Test results can often be normal when reflux is present, but an endoscopy may detect inflammation of the esophagus (esophagitis) or other complications. An endoscopy can also be used to collect a sample of tissue (biopsy) to be tested for complications such as Barrett’s esophagus.
  • Endoscopy – Endoscopy, the looking down into the stomach with a fibre-optic scope, is not routinely needed if the case is typical and responds to treatment. It is recommended when people either do not respond well to treatment or have alarm symptoms, including dysphagia, anemia, blood in the stool (detected chemically), wheezing, weight loss, or voice changes.Some physicians advocate either once-in-a-lifetime or 5- to 10-yearly endoscopy for people with longstanding GERD, to evaluate the possible presence of dysplasia or Barrett’s esophagus.
  • Ambulatory acid (pH) probe test – A monitor is placed in your esophagus to identify when, and for how long, stomach acid regurgitates there. The monitor connects to a small computer that you wear around your waist or with a strap over your shoulder. The monitor might be a thin, flexible tube (catheter) that’s threaded through your nose into your esophagus, or a clip that’s placed in your esophagus during an endoscopy and that gets passed into your stool after about two days.
  • Esophageal manometry – This test measures the rhythmic muscle contractions in your esophagus when you swallow. Esophageal manometry also measures the coordination and force exerted by the muscles of your esophagus.
  • X-ray of your upper digestive system – X-rays are taken after you drink a chalky liquid that coats and fills the inside lining of your digestive tract. The coating allows your doctor to see a silhouette of your esophagus, stomach and upper intestine.
  • A special X-ray called a barium swallow radiograph  – can help doctors see whether liquid is refluxing into the esophagus. It can also show whether the esophagus is irritated or whether there are other abnormalities in the esophagus or the stomach that can make it easier for someone to reflux. With this test, the person drinks a special solution (barium, a kind of chalky liquid); this liquid then shows up on the X-rays.
  • A gastric emptying scan – can help show whether a person’s stomach is emptying too slowly, which can make reflux more likely to happen. This test is done either by drinking milk that has a tracer in it or eating scrambled eggs that have a tracer mixed in. A special machine that doesn’t use radiation can detect the tracer to see where it goes and how fast it empties the stomach.
  • Eosinophilic inflammation (usually due to reflux) – The presence of intraepithelial eosinophils may suggest a diagnosis of eosinophilic esophagitis (EE) if eosinophils are present in high enough numbers. Less than 20 eosinophils per high-power microscopic field in the distal esophagus, in the presence of other histologic features of GERD, is more consistent with GERD than EE.
  • Barium swallow – An X-ray test that outlines the esophagus.
  • Cardiac evaluation  – To check for heart disease.
  • Esophageal manometry or motility studies – To check the squeezing motion of your esophagus when you are swallowing.
  • Esophageal pH monitoring – Uses electrodes to measure the pH (acid level) in the esophagus. It is usually done over a 24-hour period.
  • Ambulatory acid (pH) test –  (monitors the amount of acid in the esophagus)
  • Esophageal impedance test – (measures the movement of substances in the esophagus)
  • Edema and basal hyperplasia (nonspecific inflammatory changes)
  • Lymphocytic inflammation (nonspecific)
  • Neutrophilic inflammation (usually due to reflux or Helicobacter gastritis)
  • Goblet cell intestinal metaplasia or Barrett’s esophagus
  • Elongation of the papillae
  • Thinning of the squamous cell layer
  • Dysplasia
  • Carcinoma

Treatment of GERD/Acid Reflux

Treatment for most people with GERD includes lifestyle changes as described above and medication. If symptoms persist, surgery or endoscopy treatments are other options.

Medications

There are several medications that can be used to treat GERD. They include:

  • Over-the-counter acid buffers — Buffers neutralize acid. They include Mylanta, Maalox, Tums, Rolaids, and Gaviscon. The liquid forms of these medications work faster But the tablets may be more convenient.Antacids that contain magnesium can cause diarrhea. And antacids that contain aluminum can cause constipation. Your doctor may advise you to alternate antacids to avoid these problems. These medicines work for a short time and they do not heal the inflammation of the esophagus.
  • Over-the-counter proton pump inhibitors — Proton pump inhibitors shut off the stomach’s acid production.Proton pump inhibitors are very effective. They can be especially helpful in patients who do not respond to H2 blockers and antacids. These drugs are more potent acid-blockers than are H2 blockers, but they take longer to begin their effect.
  • Proton pump inhibitors – should not be combined with an H2 blocker. The H2 blocker can prevent the proton pump inhibitor from working.These are prescribed at higher doses than those available in over-the-counter forms.
  • Motility drugs – These medications may help to decrease esophageal reflux. But they are not usually used as the only treatment for GERD. They help the stomach to empty faster, which decreases the amount of time during which reflux can occur.
  • Mucosal protectors – These medications coat, soothe and protect the irritated esophageal lining. One example is sucralfate (Carafate).

Over-the-counter and prescription medicines

You can buy many GERD medicines without a prescription. However, if you have symptoms that will not go away, you should see your doctor.

Antacids – Doctors often first recommend antacids to relieve heartburn and other mild GER and GERD symptoms. Antacids include over-the-counter medicines such as. Antacids can have side effects, including diarrhea and constipation.

H2 blockers – H2 blockers decrease acid production. They provide short-term or on-demand relief for many people with GER and GERD symptoms. They can also help heal the esophagus, although not as well as other medicines. You can buy H2 blockers over-the-counter or your doctor can prescribe one. Types of H2 blockers include

Proton pump inhibitors (PPIs) – PPIs lower the amount of acid your stomach makes. PPIs are better at treating GERD symptoms than H2 blockers. They can heal the esophageal lining in most people with GERD. Doctors often prescribe PPIs for long-term GERD treatment. Such as

Talk with your doctor about taking lower-strength omeprazole or lansoprazole, sold over the counter.

Antibiotics – Antibiotics, including erythromycin , can help your stomach empty faster. Erythromycin has fewer side effects than prokinetics; however, it can cause diarrhea.

Prokinetics – Prokinetics help your stomach empty faster. Prescription prokinetics include

Both of these medicines have side effects, including

Prokinetics can cause problems if you mix them with other medicines, so tell your doctor about all the medicines you’re taking.

Prevention of GERD/Acid Reflux

There are a lot of things you can do to prevent the symptoms of GERD. Some simple lifestyle changes include

  • Elevate the head of your bed at least six inches. If possible, put wooden blocks under the legs at the head of the bed. Or, use a solid foam wedge under the head portion of the mattress. Simply using extra pillows may not help.
  • Avoid foods that cause the esophageal sphincter to relax during their digestion. These include:
    • Coffee
    • Chocolate
    • Fatty foods
    • Whole milk
    • Peppermint
    • Spearmint
  • Limit acidic foods that make the irritation worse when they are regurgitated. These include citrus fruits and tomatoes.
  • Excess pounds put pressure on your abdomen, pushing up your stomach and causing acid to reflux into your esophagus.
  • Smoking decreases the lower esophageal sphincter’s ability to function properly.
  • If you regularly experience heartburn while trying to sleep, place wood or cement blocks under the feet of your bed so that the head end is raised by 6 to 9 inches. If you can’t elevate your bed, you can insert a wedge between your mattress and box spring to elevate your body from the waist up. Raising your head with additional pillows isn’t effective.
  • Wait at least three hours after eating before lying down or going to bed.
  • Put down your fork after every bite and pick it up again once you have chewed and swallowed that bite.
  • Common triggers include fatty or fried foods, tomato sauce, alcohol, chocolate, mint, garlic, onion, and caffeine.
  • Clothes that fit tightly around your waist put pressure on your abdomen and the lower esophageal sphincter.
  • Avoid carbonated beverages. Burps of gas force the esophageal sphincter to open and can promote reflux.
  • Eat smaller, more frequent meals.
  • Do not eat during the three to four hours before you go to bed.
  • Avoid drinking alcohol. It loosens the esophageal sphincter.
  • Avoid drinking alcohol. It loosens the esophageal sphincter.
  • Lose weight if you are obese. Obesity can make it harder for the esophageal sphincter to stay closed.
  • Avoid wearing tight-fitting garments. Increased pressure on the abdomen can open the esophageal sphincter.
  • Use lozenges or gum to keep producing saliva.
  • Do not lie down after eating.

References

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