GERD is The Word

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Gastroesophageal reflux disease, or GERD, is defined by its cardinal symptoms (recurrent and troublesome heartburn and regurgitation) or by its specific complications (esophagitis, peptic strictures [scarring and blockage of the esophagus], and Barrett esophagus). GERD is caused by stomach contents, which include very potent acids and digestive enzymes, reaching the esophagus. The stomach has a mucosal barrier that prevents its contents from digesting the stomach itself, but the esophagus does not have such a barrier. In GERD, gastric juices can reach as high as the pharynx, mouth, larynx, and airways, causing symptoms such as hoarseness, wheezing, cough, and asthma. The prevalence of GERD is increasing, with greater rates in high-income countries where up to 25% of the population may be affected. GERD can result in diminished health-related quality of life, and its prevalence can consume substantial healthcare resources and result in high costs to society. Risk factors for GERD include obesity, smoking, and a genetic predisposition. Conversely, infection with the gastric bacterium Helicobacter pylori, or H pylori, can decrease the risk. Alcohol consumption and dietary factors may precipitate symptoms in persons with GERD, but they are not associated with its development.

GERD involves dysfunction at the esophagogastric junction barrier, including loss of effective lower esophageal sphincter function, which allows acidic stomach contents to reach into the esophagus. The lower esophageal sphincter is a ring of muscle, similar to the rectal sphincter, located where the esophagus meets the stomach at the diaphragm. A properly functioning sphincter keeps stomach contents out of the esophagus. Transient sphincter relaxation is normal, for example to allow belching, but prolonged relaxation can contribute to GERD. A frequent contributor to GERD is a sliding hiatal hernia, where part of the stomach herniates upward through the diaphragm and into the chest cavity. This prevents the esophageal sphincter from functioning properly.

The usual symptoms of GERD are heartburn and acid regurgitation. Chest pain is also a common symptom. Less common symptoms include dysphagia (difficulty swallowing), bleeding, chronic cough, asthma, chronic laryngitis, hoarseness, teeth erosions (from acid), belching, and bloating. Persons with these symptoms plus progressive dysphagia, involuntary weight loss, or bleeding should be immediately referred to a gastroenterologist for endoscopy as these symptoms may represent the development of malignancy. Those with untreated GERD may develop Barrett esophagus, a pre-malignant condition where the cells that line the esophagus, due to chronic acid exposure, undergo a cellular change. Barrett esophagus requires very close monitoring as there is a high possibility of developing cancer of the esophagus.

Lifestyle factors may reduce GERD symptoms, for example weight loss and smoking cessation. Elevation of the head of the bed and avoidance of late meals are also recommended. Alcohol, spicy foods, and chocolate should be avoided, and alkaline water and the Mediterranean diet can be helpful. The mainstay of treatment is the use of protein pump inhibitors, or PPIs, such as omeprazole and pantoprazole. PPIs block the production of stomach acid and raise the pH of the stomach. Emerging research, however, suggests that long-term PPI use should be avoided, as there are indications that long-term use may be associated with kidney diseases, certain infections, osteoporosis, and gastric cancer. Therefore, current recommendations are that once GERD symptoms have abated, PPI dosage should be tapered as low as possible, often just taken as symptoms warrant. As a last resort in treatment-resistant GERD, a surgical procedure called fundoplication may be warranted. This procedure reduces the hiatal hernia and puts the stomach back in the abdomen where it belongs.

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 By Peter Galvin, MD

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