Gastroesophageal reflux disease (GERD) is characterized by the backflow (reflux) of acid or stomach contents from the stomach to the esophagus.

The main symptom of GERD is heartburn, a burning pain in the chest. Other symptoms may include stomach pain, regurgitation of foods or throat discomfort. After eating, some degree of reflux and occasional heartburn are common in healthy people. However, patients with GERD experience heartburn frequently and may experience other symptoms as well.

The cause of GERD is not known. However, an anatomical condition called a hiatal hernia (when part of the stomach is above the diaphragm, the muscle that separates the stomach from the chest) is believed to be a factor. Other factors that may contribute to GERD include being overweight, drinking alcohol, smoking cigarettes, eating certain foods that may increase acid production and laying down after eating.

GERD is usually diagnosed during a physical examination that includes a description of symptoms. In some cases, tests may be performed to verify the condition. These tests may include endoscopy and esophageal pH monitoring.

Gastroesophageal reflux disease (GERD) is a condition in which the contents of the stomach flow back (reflux) into the esophagus and damage its lining. GERD occurs when the lower esophageal sphincter (LES), which separates the esophagus and stomach, does not close properly and/or is weak.

The esophagus carries food from the mouth to the stomach. The LES is a group of muscles that serves as a valve between the esophagus and stomach. When food reaches the LES, the LES relaxes and allows it to enter the stomach. After food enters the stomach, the LES contracts to prevent food and other stomach contents from backing up into the esophagus.

When the LES is weak or remains relaxed for too long, contents of the stomach can reflux into the esophagus. The tissue lining the esophagus differs from the stomach lining and is more susceptible to acid. This causes a burning sensation in the chest or throat called heartburn. When stomach acid can be tasted in the back of the mouth, it is called acid indigestion. In some people, reflux affects the vocal cords or causes stomach contents to flow into the lungs (aspiration).

Experiencing some degree of reflux after a meal is normal. In most people, episodes are brief and do not produce symptoms. Occasional episodes of heartburn are also common in healthy people. Having heartburn does not necessarily mean that a patient has GERD. Patients with GERD experience heartburn and other symptoms more frequently than others and may have damage to the esophagus.

Most patients with GERD, especially those who receive treatment for the condition, will not experience complications. However, GERD can cause a variety of complications including:

• Ulcers in the esophagus. Inflammation of the esophagus (esophagitis) can lead to ulcers, which may be accompanied by bleeding.
  
  
• Stricture. Stomach acid can cause the esophagus to scar and narrow. This can result in pills or food getting stuck.
  
  
• Lung and throat problems. Stomach acid can cause inflammation of the vocal cords (laryngitis), resulting in a sore throat or a hoarse voice. Acid in the lungs can result in asthma symptoms or aspiration pneumonia. Chronic acid reflux can result in permanent lung damage, a condition called pulmonary fibrosis or bronchiectasis.
  
  
• Barrett's esophagus. A few people with GERD may develop this precancerous condition in which the cells lining the lower part of the esophagus are changed or replaced with abnormal cells. An even smaller number of patients with GERD develop adenocarcinoma, a type of esophageal cancer.

GERD can affect anyone, including infants and children. In children, it can cause repeated vomiting, coughing and other respiratory problems. It is usually caused by an immature digestive system and most infants outgrow the condition in their first year.

The cause of gastroesophageal reflux disease (GERD) is not known. However, having a hiatal hernia may contribute to GERD. A hiatal hernia occurs when the upper part of the stomach pushes above the diaphragm, the muscle that separates the stomach from the chest.

The diaphragm supports the lower esophageal sphincter (LES), the muscles that act as a valve between the esophagus and the stomach. A hiatal hernia makes it easier for stomach acid to back up into the esophagus.

Other factors that may increase the incidence of GERD include:

• Drinking alcohol. Alcohol stimulates acid production and may contribute to a more relaxed LES.
  
  
• Being overweight or obese. Excess weight can increase pressure on the abdominal muscles and the stomach. Some research shows that even moderate weight gain increases a person’s risk of developing GERD
  
  
• Pregnancy. Both the pressure of increased weight and the hormone progesterone, which relaxes muscles, can contribute to reflux in pregnant women.
  
  
• Smoking cigarettes. Smoking reduces the production of saliva, which helps neutralize stomach acid. Coughing provoked by smoking can start episodes of reflux. In addition, the nicotine in cigarettes helps relax the LES.
  
  
• Eating/drinking certain types of foods and beverages. Traditionally, physicians have recommended that patients with GERD avoid certain foods and beverages, including citrus fruits, chocolate, fatty foods, spicy foods, tomato sauce, mint and carbonated and/or caffeinated beverages, which may increase acid production or relax LES muscles. However, recent research questions the necessity of such dietary changes.
  
  
• Eating large meals or lying down soon after eating. Physicians typically recommend that patients eat small meals and avoid lying down for at least three hours after eating. However, there is little evidence to support that reclining after meals can prevent or reduce heartburn associated with GERD, according to recent research.
  
  
• Certain medications – such as sedatives, tranquilizers and calcium channel blockers (medication to treat high blood pressure) – may contribute to reflux. Recent research also indicates that taking a certain type of sleeping pills may also increase the risk of developing nighttime heartburn.
  
  
• Other diseases. GERD occurs more commonly with certain diseases, although the relationship is unclear. Some people with conditions that delay the emptying of the stomach, such as diabetes, experience GERD. People with asthma experience GERD or heartburn frequently, possibly from frequent coughing or the effects of asthma medications. Scleroderma, an autoimmune condition that primarily affects the skin, may also cause esophageal problems that may lead to GERD.

Heartburn (burning sensation in the upper abdomen or chest) is the most common symptom of gastroesophageal reflux disease (GERD). Patients with GERD typically experience heartburn at least two or three times a week. However, people may also have GERD without experiencing heartburn.

Other less common symptoms associated with GERD include:

• Stomach pain
  
• Chest pain that does not burn
  
• Difficulty swallowing (dysphagia), painful swallowing (odynophagia), food getting stuck or sense of lump in the throat
  
• Regurgitation of foods or acid taste in the throat
  
• Chronic laryngitis, hoarseness, sore throat, cough, sinusitis or pneumonia
  
• Asthma that occurs at night
  
• Waking up with a choking sensation

Patients experiencing any of the following symptoms should consult a physician:

• Heartburn that occurs several times a week
  
• Heartburn that returns shortly after the effects of taking an antacid wear off
  
• Heartburn that wakes the person during the night
  
• Symptoms that persist even after taking prescription medication
  
• Regurgitated blood
  
• Black stool
  
• Unexplained weight loss

Research also shows that people with GERD have an increased risk of chronic obstructive pulmonary disease (COPD) flare-ups. COPD is a progressive lung disease characterized by coughing, wheezing and breathing difficulties.

Gastroesophageal reflux disease (GERD) is usually diagnosed during a physical examination. Diagnosis is generally based on the patient's symptoms. A physician may try to rule out more serious conditions that may be causing symptoms. For example, a physician may try to rule out heart disease in a patient experiencing chest pain.

Patients exhibiting symptoms of GERD may be referred to a gastroenterologist (a physician who specializes in conditions and disorders of the gastrointestinal tract).

In cases where the diagnosis is unclear, some tests may be performed. They include:

• Endoscopy.  One of the most common tests used to evaluate the esophagus. A small tube with a light and camera (endoscope) is inserted into the esophagus, stomach and small intestine. This allows a physician to determine whether there is tissue damage. Samples of tissues may be taken (biopsy) to determine the extent of the damage.
  
  
• Barium swallow (upper GI series). A test in which an x-ray is taken after liquid barium is ingested. This can detect abnormalities and sometimes inflammation of the esophagus (esophagitis). However, it may not be useful in diagnosing some cases of GERD.
  
  
• Esophageal pH monitoring. This is the most sensitive test for diagnosing GERD. It involves passing a thin tube through the nose and into the esophagus. The tube is attached to a small monitoring device and is worn for 24 hours. The device records how much stomach acid reaches the esophagus. There is a newer method that allows pH recording without the need for a tube through the nose called the Bravo device. The patient records symptoms experienced during the 24-hour period and the physician compares acid levels with symptoms. This is typically performed when an endoscopy is inconclusive or a patient continues to experience symptoms after receiving treatment.
  
  
• Esophageal manometry. Involves a device similar to the pH monitor that measures muscle contractions to determine whether the lower esophageal sphincter (LES) is functioning properly. This is typically performed when surgery is being considered.

The American College of Gastroenterology devised a test called the Richter Scale/Acid Test to help patients determine whether they may have GERD. Questions include:

1. Does the patient frequently have one or more of the following:
   
   
• An uncomfortable feeling behind the breastbone that seems to be moving upward from the stomach?
  
  
• A burning sensation in the back of the throat?
  
  
• A bitter acid taste in the mouth?
  
  
2. Does the patient often experience these symptoms after meals?
   
   
3. Does the patient experience heartburn or acid indigestion two or more times per week?
   
   
4. Does the patient find that antacids provide only temporary relief?
   
   
5. Does the patient experience symptoms even after taking prescription medication?

Patients who answer yes to two or more of the questions may have GERD and should consult a physician.

There is no cure for gastroesophageal reflux disease (GERD). Therefore, the focus of treatment is to ease symptoms and prevent damage to the esophagus and other organs.

Physicians typically recommend that patients prevent or treat mild GERD by making lifestyle changes, including:

• Avoid foods that cause reflux, such as spicy foods and fatty foods.
  
  
• Avoid eating meals too close to bedtime. Lying down makes the condition worse. Meals should be consumed at least three hours before bedtime.
  
  
• Raise the head of the bed 6 to 8 inches (15.2 to 20.3 centimeters). Elevating the head and shoulders over the stomach allows gravity to keep acid from refluxing. Propping the head up with pillows will not help reflux and may increase pressure on the stomach or esophagus.
  
  
• Avoid wearing tight clothing. This can put pressure on the stomach and worsen GERD.
  
  
• Promote salivation by chewing gum or using lozenges. This helps clear acid that has entered the esophagus.
  
  
• Eat smaller meals. This helps prevent the stomach from becoming too full, which causes reflux.
  
  
• Quit smoking.
  
  
• Avoid alcohol.
  
  
• Lose weight. Being overweight may worsen the condition.

Patients with more severe symptoms or symptoms that do not respond to lifestyle changes may be treated with medications, including:

• Antacids. They are available without a prescription and work by neutralizing stomach acid. However, antacids do not heal damage to the esophagus caused by stomach acid.
  
  
• Foaming agents. They are available without a prescription and work by covering the contents of the stomach with foam to prevent reflux. Like antacids, they do not heal damage from stomach acid.
  
  
• H2 blockers. Medications that reduce the acid levels in the stomach by blocking the chemical used to make acid. They are available over the counter and by prescription.
  
  
• Proton pump inhibitors. Medications that reduce the amount of acid in the stomach by inhibiting its production. They are more effective than H2 blockers and can relieve symptoms in almost any patient with GERD. They are available over the counter and by prescription.
  
  
• Prokinetics. Medications that strengthen the lower esophageal sphincter (LES) muscle, which helps food to pass through the digestive system more quickly. They do not affect the level of stomach acid produced.

Most cases of GERD respond well to lifestyle changes and medications. However, in cases that do not respond to other types of treatment, surgery may be performed. The standard surgical procedure performed on patients with GERD is called Nissen fundoplication. This involves wrapping the upper part of the stomach around the LES to strengthen it and prevent acid reflux. The procedure can be performed laparoscopically. A few tiny incisions are made in the abdomen and a laparoscope is inserted. The laparoscope is a thin tube with a video camera and it can be fitted with surgical instruments.

Other surgical procedures performed less frequently include Toupet fundoplication, Hill repair and Belsey Mark IV operation. These involve restructuring the LES to improve its strength and ability to prevent reflux.

In 2000, the U.S. Food and Drug Administration (FDA) approved two procedures to treat GERD with an endoscope (a thin flexible tube that is placed into the mouth and through the esophagus). The first procedure involves using a tool that resembles a miniature sewing machine. Stitches are placed in the stomach near the LES to prevent reflux.

The second procedure uses controlled radiofrequency energy to heat and burn tissues within the esophagus. It works by creating scar tissue and altering the nerves that respond to refluxed acid.

Both procedures can cause a sore throat or chest pain. Also, the long-term effectiveness of the procedures has not been evaluated.

In addition, research suggests that gastric bypass surgery may be more effective than medication alone in treating obesity and reducing related GERD symptoms.

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions regarding gastroesophageal reflux disease (GERD):

1. I sometimes get heartburn. Does that mean I have GERD?
   
   
2. Why do you suspect I may have GERD?
   
   
3. How common is GERD?
   
   
4. What caused my GERD?
   
   
5. I do not get heartburn but I experience other symptoms, such as difficulty swallowing. Is it possible that I have GERD?
   
   
6. What is the best way to treat my case of GERD?
   
   
7. What happens if I do not seek treatment for GERD?
   
   
8. What is the best way for me to prevent or lessen my symptoms of GERD?
   
   
9. Will I ever be cured of GERD?
   
   
10. How many patients with GERD have you treated?