Gastroesophageal Reflux Disease or GERD

What is Gastroesophageal Reflux?

When you normally swallow, food and drink travel down your esophagus and into your stomach, after passing through the lower esophageal sphincter (LES), which is the normal anatomic valve between the esophagus and stomach. The LES relaxes to allow food and liquid to pass into the stomach. The normal LES then tightens again to minimize reflux of fluid and food into the esophagus from the stomach. When the valve or LES is incompetent, GERD develops. Stomach juices reflux from your stomach into the esophagus. Complications can occur including scarring of the esophagus (strictures) and Barrett’s esophagus (see link), dysplasia and esophageal adenocarcinoma.

When you develop GERD, your esophageal sphincter relaxes between swallows, allowing stomach acid to flow into your esophagus. Your stomach creates hydrochloric acid to digest the food you eat. The lining of your stomach produces mucous to protect it against corrosion, but your esophagus does not. When reflux occurs, digestive acid from your stomach irritates the lining of your esophagus.

Treatment of GERD requires an interdisciplinary approach that draws on various medical specialties. At BMC, physicians in our Center for Minimally Invasive Esophageal Therapies provide comprehensive, quality care including medical oncology, radiation oncology, thoracic surgery, gastroenterology, pathology, pulmonary medicine and radiology.

What are the Symptoms?

Although not everybody who develops GERD experiences heartburn, it is the most common symptom. Heartburn is a burning pain in the center of your chest. It often begins in your upper abdomen and then spreads upward to your neck. It can last up to two hours and is usually worse after you eat.

Other GERD symptoms include:

  • Regurgitation
  • A bitter taste in your mouth
  • A persistent cough
  • Hoarseness especially in the morning
  • Wheezing
  • Shortness of breath

What Causes Gastroesophageal Reflux?

The cause of GERD is unknown. There are several factors that can increase your risk for developing GERD, including:

  • Lifestyle factors, such as cigarette smoking, alcohol use, obesity
  • Medications, such as calcium channel blockers, theophylline, nitrates and antihistamines
  • A diet high in fatty and fried foods, chocolate, garlic and onions, caffeinated drinks, acidic foods, such as citrus fruits and spicy foods
  • Eating large meals or eating just before bedtime
  • Having a hiatal hernia, which displaces the LES and moves it into the chest
  • Being pregnant
  • Having diabetes
  • Rapidly gaining weight

How is Gastroesophageal Reflux (GERD) Diagnosed?

There are several procedures your physician may use to diagnose whether you have GERD:

Bravo pH Test

The Bravo pH test is the first catheter-free way to measure the amount of pH in your esophagus and is generally used to diagnose GERD. An endoscope is briefly passed through your mouth and into your esophagus to place a small gelcap that detects pH levels; the gelcap stays in place for 24 to 48 hours as you go about your daily activities. If there is a low pH in the esophagus, you may have GERD.

Computed Tomography (CT) Scan

CT scans use x-ray equipment and computer processing to produce 2-dimensional images of the body. The patient lies on a table and passes through a machine that looks like a large, squared-off donut. Doctors order CT scans when they want to see a two-dimensional image of the body to look for tumors and examine lymph nodes and bone abnormalities. If contrast dye is used to improve the computer image, the patient may need to avoid eating or drinking for 4 to 6 hours before the test. Patients should tell their provider before the test if they have any allergies or kidney problems.

Esophageal Manometry

This test measures the pressure inside the lower esophageal sphincter (LES). A thin tube is inserted through your mouth or nose and into your stomach. Once it is in place, the physician will gently pull the tube back into the esophagus and ask you to swallow. As you do so, the pressure and coordination of your muscle contractions will be measured. If the pressure is low or the LES is not relaxing properly, achalasia may be present. If the pressure is low or the LES is not contracting properly, it may indicate GERD (reflux disease).

Esophagogastroduodenoscopy (EGD) 

Before esophagogastroduodenoscopy (EGD), you will be given a sedative. Your physician will thread a narrow, flexible tube called an endoscope—which has a tiny light and camera at the tip—through your mouth, esophagus and into your stomach and sometimes small intestine. He or she can then see any abnormalities and take tissue samples for laboratory analysis if desired.

Esophagram

An esophagram, or contrast esophagram (also called a barium swallow), is a series of x-rays of your esophagus. For an esophagram, you will be asked to drink a barium sulfate liquid while x-rays are taken of the swallowing process. As the liquid moves from the mouth down to the esophagus, the physician can assess any narrowing, enlargement or abnormalities. You will most likely be asked not to eat or drink for 8 to 10 hours prior to the test.

Gastric Emptying

If you have symptoms that suggest slow or rapid emptying from your stomach into your small intestine, your physician may order a gastric emptying study. You will eat a meal that contains solid food and a liquid, as well as a small amount of radioactive material. As you digest, a scanner will be placed over your stomach. The scanner can detect how quickly the radioactive particles move through your stomach into your intestines, and treatment decisions can be made. The radioactive material is not absorbed into your body and is eliminated through the bowel. Tell your doctor if you are pregnant or breastfeeding.

Pulmonary Function Test (PFT)

To understand how well your lungs are working, your physician may order a series of pulmonary function tests. With each breath you take in and breathe out, information is recorded about how much air your lungs take in, how the air moves through your lungs and how well your lungs deliver oxygen to your bloodstream.

How is Gastroesophageal Reflux Disease (GERD) Treated?

The goal of GERD treatment is to reduce reflux, relieve symptoms and prevent damage to your esophagus. Depending on the severity of your symptoms, your doctor may first recommend changing your lifestyle, such as not eating within three hours of bedtime, avoiding fatty or fried foods, quitting smoking and/or losing weight. Your doctor may also recommend over-the-counter or prescription medications to control acid production. If non-surgical methods do not take care of your GERD, your doctor may recommend surgery and minimally invasive procedures

Your primary care provider or pediatrician will often refer you to an ENT (ear, nose, and throat) specialist, or otolaryngologist, for evaluation, diagnosis, and treatment if you are having related symptoms.

GERD and LPR are usually suspected based on symptoms, and can be further evaluated with tests such as an endoscopic examination (a tube with a camera inserted through the nose), biopsy, special X-ray exams, a 24-hour test that checks the flow and acidity of liquid from your stomach into your esophagus, esophageal motility testing (manometry) that measures muscle contractions in your esophagus when you swallow, and emptying of the stomach studies. Some of these tests can be performed in an office.

Options for treatment include lifestyle and dietary modifications (see below), medications, and rarely surgery. Medications that can be prescribed include antacids, ulcer medications, proton pump inhibitors, and foam barrier medications. To be effective, these medications are usually prescribed for at least one month, and may be tapered off later after symptoms are controlled. For some patients, it can take two to three months of taking medication(s) to see effects.

Children and adults who do not improve with medical treatment may require surgical intervention. Surgical treatment includes “fundoplication,” a procedure that tightens the lower esophageal muscle gateway (lower esophageal sphincter, or LES). Newer techniques allow this to be done in an endoscopic or minimally invasive manner. Another surgical option uses magnetic beads to tighten the LES.

What Changes Can I Make to Prevent GERD and LPR?

For adults, you can take certain steps to reduce or prevent occurrences of GERD and LPR, including:

  • Lose weight.
  • Cut down or stop smoking tobacco products.
  • Limit or avoid alcohol.
  • Wear clothing that is looser around the waist.
  • Eat three to four small meals a day, instead of two to three large ones, and eat slowly.
  • Avoid eating and drinking within two to three hours of bedtime.
  • Limit problem foods, such as caffeine, carbonated drinks, chocolate, peppermint, tomatoes, citrus fruits, fatty and fried foods, and/or spicy foods.