Gastroesophageal Reflux Disease (GERD)

Dr. Terry Murphy

ED Medical Director

Samaritan Hospital

GERD is a condition in which food or liquid travels backward from the stomach into the esophagus.  Almost always this reflux of stomach acid, enzymes and bile produces irritation and inflammation of the esophagus (esophagitis).  Left untreated, the inflammation can progress to ulceration, bleeding and/or perforation of the esophagus. The inflammation can produce a number of symptoms but far and away the most common symptom is a burning pain in the center of the chest, behind the breast bone (sternum), called “heartburn.”  This pain frequently starts lower in the chest and progresses up in the throat, sometimes radiating through to the back.  Technically the term “heartburn” is a misnomer because the pain comes from the esophagus, not the heart; but because of its location, the popular term has persisted in lay terminology.

Symptoms of GERD, in addition to heartburn, frequently include:

Frequent belching

Regurgitation

Difficulty swallowing liquids or food

Sore throat

Frequent coughing

Vomiting blood

Reflux occurs because the muscle fibers of the lower end of the esophagus (the sphincter) fail to function correctly.  Normally, between swallowing, the sphincter muscles remain contracted, essentially closing the opening between the esophagus and stomach, much like a draw string.  When these muscle fibers fail to keep the end of the esophagus closed; stomach acids, enzymes, bile and food can reflux back into the esophagus.

It isn’t known exactly why these sphincter muscles fail to function properly; but we know several things that contribute, including:

lifestyle issues - alcohol ingestion, cigarette smoking, obesity, eating before meals, eating large meals

dietary habits - eating fatty or spicy foods, acidic foods such as citrus or tomatoes, chocolate, garlic, onions, peppermint, caffeine

medications - calcium channel blockers (e.g. Verapamil or Calan), nitrates (e.g. nitroglycerin) antihistamines or theophylline

pregnancy, diabetes, and a hiatal hernia.

Usually, a physician can suspect GERD based on a thorough history and physical exam. The diagnosis can be confirmed through upper GI endoscopy (a fiberoptic scope with a camera is placed through the mouth into the esophagus and stomach under sedation), upper GI x-rays (barium material is swallowed and fluoroscopic imaging is performed), esophageal manometry (measuring the strength of the lower esophageal muscles), or pH monitoring (the strength of stomach acid present in the esophagus is measured for 24 hours through a tube passed into the esophagus through the nose).

Alternatively, because of the invasive nature of all the diagnostic tests, many physicians will treat patients who they suspect have GERD for several weeks and only perform further diagnostic testing if symptoms do not improve.

Treatment of GERD involves a multi-pronged approach – lifestyle/dietary changes, medications and surgery as a last resort. 

Lifestyle changes should include:

avoiding eating for several hours prior to bedtime and avoiding lying down for several hours after eating

elevating the head of your bed 4-6 inches

eating smaller meals

losing excess weight

drinking alcohol moderately or not at all, and never on an empty stomach

smoking cessation

diminishing or avoiding caffeine, or spicy, mint flavored or acidic foods

avoiding aspirin or nonsterioidal anti-inflammatory medications (ibuprofen, naprosyn)

Medications used to treat GERD include:

antacids which neutralize stomach acid and coat the lower esophagus.  Usually antacids should be taken before eating, at bedtime, and when symptoms occur.  Though calcium containing compounds (e.g. Tums) generally neutralize acid better than magnesium or aluminum containing compounds (Maalox, Mylanta) – most patients prefer to alternate antacid types because calcium medications can cause constipation, while magnesium/aluminum medications can cause diarrhea.

stomach acid blocking medications.  Over the counter medications such as Pepcid, Tagamet and Zantac (H2 blockers) reduce the amount of acid produced by the stomach, are relatively inexpensive, and are available without a prescription.  More potent acid reducing medications (proton pump inhibitors or PPIs) such as Prevacid, Prilosec, Nexium are available by prescription, often work better than H2 blocking medications and can be taken once daily.

promotility medications. These medications (such as Reglan, Clopra, Maxolor) work to empty the contents of the stomach more quickly thereby reducing the amount of stomach contents available to reflux, and may be added to a regimen of antacids and acid reducing medications when GERD  is more difficult to treat.

Surgery to tighten the opening between the esophagus and stomach by wrapping a portion of the stomach around the lower end of the esophagus is highly successful (85%) as a last resort.  Fortunately, this procedure, if necessary, can be done laparoscopically in most people now, greatly reducing pain and recovery time.

Determining the cause of chest pain located in the area of both the heart and the esophagus can be very difficult in the Emergency Department and as incorrectly diagnosing heart pain as GERD can be potentially disastrous; it is usually better to be conservative with hospitalization and further testing, even when initial tests are normal. People with new onset of “heartburn” symptoms should seek emergency evaluation because symptoms presumed to be merely “heartburn” are sometimes heart attack signs.  Once the specific diagnosis of GERD is verified; with lifestyle changes and medications, there is a very high likelihood that symptoms will improve without future complications.

This article is intended to provide useful information, not medical advice. This information cannot, and is not meant to, replace consultation with your physician regarding your individual circumstances.