Frequently Asked Questions
GERD is a chronic condition in which the contents of the stomach flows back (“reflux”) into the esophagus, potentially causing symptoms such as heartburn. The prolonged exposure of the esophageal tissue to the stomach acid can cause injury and harm to the organ.
The esophagus is the connecting tube that conveys ingested material from the mouth down into the stomach. Due to its basic function, it is one of the simpler regions of the gastrointestinal (GI) tract; consisting of a roughly 20 - 25cm long muscular tube that runs from the back of the oral cavity (i.e., pharynx), through the chest cavity, and into the abdomen where it joins with the opening of the stomach. Once the food & drink has made its way down the esophagus, it is emptied into the acidic environment of the stomach where it is then broken down through chemical and mechanical digestion.
Due to the nature of the stomach's work, the thick cellular layer is a suitable barrier to protect it against stomach acid. In contrast, the thinner mucous membrane of the esophagus was not designed to withstand such harsh conditions. To protect the esophagus from the potential back-flow of stomach contents (reflux), a sphincter is located at the junction between the esophagus and stomach, called the gastroesophageal or lower esophageal sphincter (LES). This sphincter, a circular band of thickened muscle, surrounds the lower esophagus and pinches it closed to keep it separated and safe from the harmful stomach acid... as a result the LES is usually closed. It only opens to allow the passage of swallowed food or drink into the stomach, a reflex that is triggered by the act of swallowing.
The diaphragm is a wide, flat muscle that helps the lungs to expand during breathing, it also separates the chest cavity from the abdomen and has a hole (know as the hiatus) for the esophagus to pass through until it reaches the stomach. The LES is situated near the part of the esophagus that passes through the diaphragm, so that contraction of the diaphragm can reinforce the closure of the sphincter. As a result the diaphragm also aids the closure of the LES.
The most common cause is occasional increased pressure within the abdomen or a momentary relaxation of the LES. Either of these situations can force some stomach contents (half digested food or stomach acid) back into the esophagus. It is normal for all to experiences occasional reflux, as this often happens after a large meal, physical activity, or reclining after a meal. Other conditions that contribute to more frequent reflux include pregnancy and obesity (when there is an increased pressure on the body). As long as gastric reflux is occasional (and not a prolonged condition), and promptly cleared from the esophagus, there is little risk of inflicting any damage.
However, is reflux is present on a more permanent basis it can present serious health concerns. If the esophagus is repeatedly exposed to harsh stomach acids it can have very negative and damaging effects on esophageal tissue.
A functional (transient LES relaxation) or mechanical (hypotensive LES) problem of the LES are the most common causes of GERD.
Transient relaxation of the LES can be caused by foods such as strong coffee, alcohol, chocolate, and fatty meals; medications (such as beta-agonists, nitrates, calcium channel blockers, anticholinergic drugs); or hormones (e.g., progestins); and nicotine. Furthermore various allergies, food sensitivities and Helicobacter pylori infections can contribute to the irritation of the esophagus leading to a prevalence of the GERD.
Some medical practitioners suggest that, rather than too much stomach acid, it may be too little that causes GERD, known as the hypochlorhydria theory. It has been argued that just because acid is being refluxed does not necessarily mean that there is too much in the stomach to begin with. It may be believed that inadequate stomach acid reduces LES tone, thereby allowing stomach contents to be refluxed giving rise to GERD symptoms.
Hydrochloric acid (HCl) in the stomach activates enzymes that help break down proteins and stimulates other digestive processes. This theory proposes increasing stomach acidity to alleviate symptoms, as opposed to lowering it, which is the conventional approach. To do this betaine HCl is administered, which delivers additional hydrochloric acid to the stomach. This therapy is sometimes preceded by the Heidelberg test to measure the pH of the stomach. (see webpage on Low Stomach Acid)
Aside from heartburn, there are several other symptoms associated with GERD that reduce quality of life. These include:
- Hypersalivation (increased saliva production),
- Globus (the sensation of a constant lump in the throat),
- Trouble swallowing,
- Bad breath, and
- Dental erosion.
Due to stomach acid interfering with the normal functioning of the esophagus, sleep disturbances and nocturnal choking are also possible. Because of the close proximity of the larynx (the opening of the windpipe) and esophagus, GERD can manifest certain respiratory symptoms (such as chronic hoarseness, coughing, and laryngitis) as well. GERD can be associated with inflammation of lung tissue (pneumonitis), sinusitis, asthma, and middle ear inflection.
Prolonged exposure of the esophagus to gastric reflux can result in dramatic alterations to its function. Serious complications of GERD, affecting the rest of the body include:
- Peptic Stricture. In people with long-term GERD, healing of ulcerations can lead to the deposit of fibrous scar tissue as well as a narrowing of the esophagus. Segments of the esophagus with stricture are usually thickened, stiff, and may be shortened. As the esophagus shortens, it can end up pull the stomach up, away from its normal location, through the esophageal hiatus, resulting in hiatal hernia.
- Barrett’s Esophagus. This condition relates to a change in the cellular makeup of the mucous membrane of the esophagus. A normal esophagus is lined with a layer of flattened cells. In Barrett’s esophagus, these cells are replaced by a layer of thicker, taller cells, which increases the chance of developing Esophageal cancer.
- Esophageal Cancer. Esophageal adenocarcinoma (EAC) arises from metaplasia of tissue in the lower part of the esophagus, and is thought to develop as a result of long-term GERD and Barrett’s esophagus.
In patients with symptoms that suggest uncomplicated GERD such as heartburn and, or regurgitation (often occurring after meals which is aggravated by lying down or bending over, with relief obtained from antacids), the recommended course of action is treatment for GERD with a trial of acid-suppression therapy.
It is only recommended to investigate further if the patient does not respond to acid-suppression therapy, and presents symptoms suggestive of complicated GERD (such as dysphagiaa), or if they have suffered from notmal GERD so long that is could be enough to put them at risk for Barrett’s esophagus.
Tests for GERD may include:
- Barium esophagram, which involves viewing the esophagus via x-ray radiography after swallowing a barium contrast solution. This can give insight into esophageal motility as well as detect esophageal strictures, ulcers, or severe esophagitis.
- With upper GI Endoscopy, direct viewing of the esophagus via a flexible esophagoscope is done to identify mucosal breaks, areas of sloughed cells, ulceration, or redness that is distinct from areas of normal mucous membranes.
- Esophageal pH monitoring is the current gold standard for diagnosing GERD. While a person is upright and mobile, esophageal pH is monitored using a flexible catheter with pH sensor. Normal esophageal pH is close to 7.0, while a reflux event is recorded as a sudden drop in pH to below 4.0.
- The Bilitec System uses a fiberoptic sensor to detect the presence of bile in reflux. Bile has been implicated in symptomatic reflux that is difficult to manage by conventional acid-suppression therapy.
- Esophageal Manometry assesses esophageal and LES function by measuring pressure changes in the esophagus induced by swallowing and peristalsis
Acid suppression therapies are the conventional way in which GERD is treated. Acid suppression therapy neutralizes stomach acid or reduces its secretion, minimizing the potential for damage during reflux episodes. Acid suppression therapies include:
- antacids (providing quick relief of reflux symptoms),
- Histamine-2 receptor blockers (preventing secretion of stomach acid by inhibiting the action of histamine), and
- proton pump inhibitors - PPI (inhibits stomach acid by preventing the secretion of protons from acid producing cells of the stomach), with the use of probiotics. One of the roles of stomach acid is to provide defense against ingested pathogens. Therefore, reductions in stomach acid due to PPI usage can lower resistance 2-4 fold to intestinal infections. Probiotics may prove a useful adjunct to PPI therapy. Another major problem with PPI drugs is that they are often taken for much longer periods than recommended, which could compound their potential for causing side effects. PPI’s are approved for use for 14 day intervals, no more than three times yearly, but many patients take these drugs semi-permanently.
- As a last resort there is surgery. The goal of anti-reflux surgery is the reconstruction of the LES mechanism. This is commonly performed by laparoscopic fundoplication, a minimally invasive technique in which a portion of the stomach is wrapped around the base of the esophagus and sutured into place. Additionally, as the stomach contracts, it constricts the lower esophagus (pinching it shut) instead of forcing acid into the esophagus.
Diet and lifestyle interventions are an important adjunct to standard drug therapy to reduce reflux and other GERD symptoms. Education on managing stress, proper diet, physical activity, and understanding the causes and progression of GERD has been shown to promote significant improvement in patient perception of their illness and well-being.
Some diet and lifestyle modifications commonly suggested for GERD patients include:
- Avoid foods and beverages associated with GERD symptoms
- Spicy foods
- Carbonated beverages
- Additional foods such as tomatoes (cooked and raw), milk, cheese, citrus foods, cakes and pastries.
- Quit Smoking.
- Lose weight.
- Monitor meal size and macronutrient composition.
- Avoid eating close to bedtime.
- Elevate the head of the bed while sleeping.
- Limit aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs).
- Raft-Forming Agents: Raft-forming reflux suppressants have been used to treat GERD for more than 30 years. Raft-formers are combinations of a gel-forming fiber (e.g., alginate or pectin) with an antacid buffer (commonly sodium or potassium bicarbonate). When the combination reaches the stomach, chemical reactions cause the release of carbon dioxide bubbles. These bubbles become trapped in the gelled fiber, converting it into a foam that floats on the surface of the stomach contents. Several studies have demonstrated that rafts reduce GERD symptoms by mechanisms independent of acid reduction.
- Melatonin: Melatonin is a hormone most often associated with the sleep cycle, but is found at levels hundreds of times higher in the gut than in the brain.
- Deglycyrrhizinated Licorice (DGL): Licorice extracts have been shown to support the health of the stomach lining and combat H. pylori – bacterium that can cause ulcers.
- Comprehensive multivitamin (i.e. Amipro Phyto-Multi)
- Vitamin B12
- Magnesium: 140 mg daily as magnesium-L-threonate; 320 mg daily as magnesium citrate
The following ingredients may promote healthy cellular division within the esophagus:
- N-acetyl-cysteine (NAC)
- Broccoli extract
- Apple extract