Gastroesophageal Reflux Disease

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The passage of gastric contents into the esophagus (gastroesophageal reflux) is a normal physiological process.  Most episodes are brief and do not cause any symptoms, esophageal injury, or other complications.  Gastroesophageal reflux becomes a disease (GERD) when it either causes symptoms, which include a burning sensation the throat (heartburn), chest pain, difficulty swallowing, a sensation of a lump in the throat, and/or regurgitation of food or sour liquid, or it causes detectable damage to the esophagus as seen during medical testing.

For patients whose GERD symptoms are mild and occur less than once a week, over-the-counter antacids may be effective and may be taken as needed.  Patients with mild and intermittent symptoms occurring more that twice weekly should seek medical attention. 

The first step in treating GERD is to make diet and lifestyle modifications.  The only two changes proven to help are weight loss and elevating the head of the bed.  Dietary triggers that may play a role in GERD include caffeine, alcohol, spicy foods, food with high fat content, carbonated beverages and peppermint.  Selectively eliminating one of these at a time may provide patients with specific dietary guidance.

When symptoms persist in spite of lifestyle modifications, famotidine, an over-the-counter acid blocker, can be effective.  If symptoms persist for more than 2 weeks in spite of daily famotidine use, a proton pump inhibitor (PPI) such as omeprazole is indicated.  PPI’s must be taken regularly to be effective.  PPI’s are stronger than famotidine and these drugs usually control GERD symptoms.  Famotidine and PPI’s both work by significantly reducing the amount of acid released by the stomach.  Commonly reported PPI side effects include diarrhea, headache, and vitamin B12 and magnesium deficiency, as well as associations with increased risk of fractures.  These side effects may increase if PPI’s are taken for more than 8 weeks.  The use of alcohol with PPI’s may also increase some side effects.

If PPI’s fail to control symptoms within 8 weeks or if alarm symptoms are present, esophagogastroduodenoscopy (EGD) is indicated.  Alarm symptoms include difficulty swallowing, painful swallowing, intestinal tract bleeding, anemia, weight loss and chest pain.

For an EGD, the patient takes nothing by mouth for at least eight hours before the test is performed.  An intravenous line is inserted and the patient is given sedation but continues to breathe on their own.  A gastroenterologist then inserts a flexible tube that includes a camera through the mouth and down through the esophagus and into the stomach.  The doctor can see evidence of inflammation of the esophagus and stomach, unusual growths, ulcers, and active bleeding,  and samples can be taken to confirm a diagnosis.  After a brief recovery, patients return home for rest and are usually back to normal within a few hours.

Findings related to GERD at the time of EGD can include erosive esophagitis (acid irritation and inflammation that can injure the esophagus over time) and Barrett’s esophagitis (a condition in which the flat pink lining of the esophagus becomes damaged by acid reflux).  Unchecked, Barrett’s esophagus can  transform into cancer.  Both conditions are usually treated with high-dose PPI’s.  Patients with these conditions should have regular monitoring by a gastroenterologist.

Management of GERD in special circumstances:

• In pregnant patients, GERD is more likely both because the muscles that push food down the esophagus move more slowly, and, as the uterus grows, it pushes on the stomach and may force stomach acid up into the esophagus.  For patients who are pregnant or  breastfeeding, treatment begins with lifestyle modifications.   When symptoms persist, medical therapy includes  antacids and, if needed, sucralfate (a prescription drug that acts to protect the lining of the esophagus and stomach), rather than PPI’s.

• For patients with asthma, GERD has been identified as a potential trigger for asthma attacks and is often present in cases of severe asthma that are difficult to treat.  The likely cause is that asthma patients may be unknowingly inhaling small amounts of stomach acid, which then triggers spasm and obstruction of air passages in the lungs.  Gastroesophageal reflux in asthma patients should be evaluated and treated.   Respiratory symptoms, including those associated with asthma (eg, cough, wheezing, difficulty breathing and chest tightness), are increased in patients with gastroesophageal reflux.  

Mild and self-limited GERD symptoms can be managed at home.  For persistent, worsening and/or severe symptoms, patients should contact their physician.

For more information, see these links:

https://www.medicalnewstoday.com/articles/14085#what-is-GERD

https://www.webmd.com/heartburn-gerd/guide/heartburn-during-pregnancy#2

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