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What is gastroesophageal reflux disease (GERD)?
The esophagus is the tube that connects the mouth to the stomach. In normal digestion, a specialized ring of
muscle at the bottom of the esophagus (called the lower esophageal sphincter) opens to allow food to pass from
the esophagus into the stomach, and then quickly closes to prevent the stomach contents from flowing back into
the esophagus. Gastroesophageal reflux occurs when the lower esophageal sphincter is either weak or relaxes
inappropriately and allows stomach contents to backflow (reflux) into the esophagus.
When the contents from the stomach regularly back up into the esophagus, a chronic condition called gastroesophageal
reflux disease (GERD) occurs. Stomach contents include digestive fluids such as hydrochloric acid.
Acid reflux is responsible for the majority of the symptoms (and/or damage to the esophagus) that characterize GERD.
It is estimated that about one third of the population has GERD - it is a common condition - and studies have
demonstrated that the symptoms of GERD have a negative impact on people's well-being and quality of life.
What are the symptoms of GERD?
Heartburn is the most common symptom of GERD. Heartburn usually feels like a burning pain in the chest, beginning
behind the breastbone and moving upward to the neck and throat. Heartburn can last as long as 2 hours, and is often
worse after eating and when lying down. The pain is caused by stomach acid in the esophagus, which does not have the
same protection from acid that the stomach has.
Some people also describe the sensation of food or liquid coming up into the throat or mouth (regurgitation),
especially when bending over or lying down. They often report a bitter or sour taste in their mouth. While many
people experience occasional heartburn or regurgitation, these symptoms are persistent in people with GERD.
Adults with GERD may also experience atypical symptoms, including persistent sore throat, hoarseness, chronic cough,
difficult or painful swallowing, asthma, unexplained chest pain, and a feeling of a lump in the throat. Some
experience an uncomfortable feeling of fullness after meals.
How can the doctor tell if I have GERD?
In most cases, your doctor can accurately diagnose GERD just using your description of symptoms (dominant symptoms of
heartburn or acid regurgitation). However, testing may be required to make the diagnosis (including ruling out other
possible causes of your symptoms) or to determine the degree of damage. Various tests may include the following:
Upper GI series: After swallowing a special liquid to coat the esophagus, stomach, and upper part of the
small intestine, x-rays are taken. This may be performed during the early stages of testing and the main value
is to rule out other diagnoses such as ulcers.
Upper GI endoscopy: After patient sedation, a long flexible tube with a tiny video camera on the end (endoscope)
is passed through the mouth and down the esophagus so the doctor can visually examine the lining of the esophagus
for inflammation or irritation. If necessary, a biopsy (removing a small sample of tissue) can be taken for further
testing. Not all people with GERD have visible inflammation in the esophagus - most do not. Endoscopy is an important
procedure when GERD has been present for a long time.
24-hour pH monitoring: A very thin tube is passed to the bottom of the esophagus to monitor the acidity level
over 24 hours while the patient goes about normal activities. The test is used to assess the episodes of reflux
compared with symptoms and the type of activity associated with symptoms. This test is usually used in patients
for whom a diagnosis is difficult.
Other tests that may be performed less frequently include the Bernstein test, in which mild acid is dripped through
a tube placed in the mid-esophagus to confirm that symptoms result from acid in the esophagus. With esophageal manometry,
a specialized tube is passed into the esophagus for pressure measurements of esophageal muscle function and function of
the lower esophageal sphincter.
Treatment of GERD - Lifestyle and dietary changes
Doctors often recommend lifestyle and dietary changes for people with GERD. Certain food and beverages to be avoided
include chocolate, coffee, alcohol, fatty foods, peppermint, citrus fruits and juices, tomato products, pepper, mustard,
and vinegar. Avoiding large portions at mealtime and eating smaller more frequent meals may also control symptoms better.
Many overweight people find relief when they lose weight. Stopping smoking is also important for reducing GERD symptoms.
People with GERD are often advised to avoid lying down right after eating and to avoid eating within two to three hours
before bedtime. Elevating the head of the bed four to six inches may also help.
Treatment of GERD - Medications
Two main approaches to treating GERD with medications have evolved over the last 30 years:
Neutralize acid: Over the counter antacid medication such as Maalox®, Tums®, and bismuth (Pepto-Bismol®) are often tried
initially and may adequately subdue symptoms by neutralizing excess stomach acid. Many people find that non-prescription antacids
can provide quick, temporary, or partial relief. Antacids are short acting and do not prevent heartburn. If antacids are needed for
more than 3 weeks, a doctor should be consulted.
Block acid production: There are two classes of medication that suppress acid secretion: histamine H2-receptor antagonists
(H2-RAs) and proton pump inhibitors (PPIs).
H2-RAs work by blocking the effect of histamine, which stimulates certain cells in the stomach to produce acid. The
first H2-RA, cimetidine (Tagamet®), became available in Canada over 25 years ago; it was followed by ranitidine (Zantac®), famotidine
(Pepcid®), and nizatidine (Axid®). H2-RAs are all available as prescription medications and some are available in a lower dose,
'over-the-counter' without a doctor's prescription. H2-RAs are generally very safe.
PPIs are a newer class of medication. They work by blocking an enzyme necessary for acid secretion. The first PPI
introduced into Canada was omeprazole (Losec®). It was followed by lansoprazole (Prevacid®), pantoprazole (Pantoloc®), and more
recently by esomeprazole (Nexium®), and rabeprazole (Pariet®). PPIs are available only with a prescription from your doctor. PPIs
have emerged as the most effective therapy for relieving symptoms and improving quality of life, as well as healing and preventing
damage to the esophagus in people with GERD. PPIs are generally very safe.
The majority of patients can be successfully treated with lifestyle and dietary changes, and medications. A few people may require surgery.
What are the complications of long-term GERD?
Sometimes GERD results in serious complications. Inflammation of the esophagus (esophagitis) can result from too much
stomach acid in the esophagus. Esophagitis can lead to bleeding or ulcers in the esophagus. Chronic scarring may narrow
the esophagus and interfere with a person's ability to swallow. Some people develop a condition known as Barrett's
esophagus, which is severe damage to the cells lining the bottom of the esophagus. Doctors believe Barrett's esophagus may
increase the chance of developing esophageal cancer. Please talk to your doctor if your GERD symptoms change.
Are you taking prescription medication for any of the following stomach problems/symptoms:
Stomach pain or discomfort
Heartburn
Sour taste in mouth/acid regurgitation
Excessive burping/belching
Increased abdominal bloating
Nausea
Early satiety
If you answer yes to any one of the symptoms listed above then take this test to see if your current medication is adequately controlling your stomach symptoms.
The PASS Test
PPI* Acid Symptom Suppression Test
*PPI is short for proton pump inhibitor, a class of medication used to suppress the acid in your stomach. These include Losec®, Nexium®, Pantoloc®, Pariet™, and Prevacid®.
