Gastroesophageal reflux disease (GERD) is a chronic condition that results when acid in the stomach moves upward into the esophagus. The esophagus is the tube that moves food and saliva between the throat and the stomach.

At the lower end of the esophagus lies a ring of muscle fibers known as the lower esophageal sphincter. These muscles act like a valve, closing off the esophagus except when food is being swallowed. When the sphincter does not close tightly, acid and other substances can back up into the esophagus in a process called reflux.

Chronic reflux can cause cell changes in the esophagus that have been associated with the esophageal cancer, in particular adenocarcinoma.  Most cases of adenocarcinoma are due to Barrett’s esophagus – a condition that develops in the lining of the lower esophagus. About 30 percent of esophageal cancers can be traced to GERD, according to the American Cancer Society (ACS).

GERD can affect everyone from newborns to adults. Symptoms typically include heartburn, a burning pain in the center of the chest that starts in the upper abdomen and sometimes spreads into the neck. For some adults, reflux symptoms are so minor that they may not be aware of them. However, those with GERD usually feel substantial heartburn after most meals.

The American College of Gastroenterology recommends that people with long-standing symptoms of reflux undergo endoscopy. This is a procedure performed by a physician, usually a gastroenterologist, to examine an individual’s esophagus and stomach. It is completed with an endoscope, which is a thin, lighted tube with a camera.

An endoscopy also can be used to sample suspicious tissue (biopsy) to diagnose precancerous or cancerous changes. Periodic endoscopies may be recommended for patients who have had symptoms of GERD for several years to help monitor for Barrett’s esophagus or other precancerous changes.

Gastroesophageal reflux disease (GERD) is a chronic condition that results when partially digested stomach contents and/or acid move upward into the esophagus. The esophagus is the long, muscular tube that moves saliva and food between the throat and the stomach. Chronic reflux can cause cell changes in the esophagus that are at high risk for becoming malignant (cancerous). About 30 percent of esophageal cancers can be traced to GERD, according to the American Cancer Society (ACS). Some research studies suggest that GERD is a possible risk factor for laryngeal and hypopharyngeal cancer as well.

Normally, the sphincter at the bottom of the esophagus remains closed after a person has eaten. In the stomach, acid begins breaking down the food. The stomach lining is protected from the acid by a layer of mucus. The esophagus, however, does not have such protection.

When the sphincter does not close properly, the liquid stomach contents can move upward into the esophagus, a condition known as reflux. This can stimulate nerve fibers in the esophagus, causing a burning pain in the chest known as heartburn. It is estimated that more than 15 million Americans experience heartburn symptoms daily, according to the American College of Gastroenterology. Frequent heartburn, such as two to three times a week, discomfort in the chest and food regurgitation may be associated with GERD.

Acid and pepsin (an enzyme that starts the digestion of proteins) produced by the stomach are the primary substances that are refluxed. Bile from the duodenum (part of the small intestine attached to the stomach) also may be part of the refluxed liquid.

When this acidic reflux liquid damages the esophagus, it can cause dysplasia, a precancerous change in the tissue. This can lead to Barrett’s esophagus, a condition in which the lining of the esophagus undergoes changes and becomes similar to tissue found in the intestine. Long-term reflux is the most common cause of a form of esophageal cancer known as adenocarcinoma.

In the United States, an estimated 15,000 new cases of esophageal cancer will be diagnosed in 2007, according to the ACS. Nearly 14,000 people will die of the disease in the same year. However, only 10 to 15 percent of patients with GERD will develop Barrett’s esophagus.

Many people experience heartburn and acid indigestion (a sour taste in the mouth) from eating spicy foods, overeating or bending forward. This feeling is usually described as burning sensation or “gas” behind the breastbone. Some people also complain of a bitter taste as far up as the neck and throat. This is not GERD, which is a chronic, persistent and longer-lasting reflux problem. GERD usually occurs when the band of muscle fibers known as the lower esophageal sphincter fails to close off the esophagus from the stomach. This valve failure allows highly acidic stomach contents to back into the esophagus.

Barrett’s esophagus is a condition in which the cells in the lining of the esophagus are replaced by a type of tissue normally found in the intestine. This process (intestinal metaplasia) does not always cause symptoms but it does increase the risk of esophageal adenocarcinoma. People with Barrett’s esophagus have 30 to 125 times the risk of developing adenocarcinoma than those who do not have the condition, according to the American Cancer Society (ACS).

However, the majority of patients who have Barrett’s esophagus do not develop esophageal cancer. Researchers estimate that less than 1 percent per year will get cancer of the esophagus.

Although the exact causes of Barrett’s esophagus remain unknown, it is believed to be closely associated with the reflux damage caused by gastroesophageal reflux disease (GERD). Barrett’s esophagus is usually diagnosed in people age 60 or older. It is twice as common in men as women and it is much more likely to occur in white men then men of other races. Barrett’s esophagus is not common in children.

This type of cancer is increasing rapidly among white men in the United States. The increase is thought to be related to the higher rate of obesity and GERD in this population. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) estimates that Barrett’s esophagus affects about 700,000 adults in the United States.

Barrett’s esophagus is diagnosed by endoscopy and biopsy of the esophageal tissue.  Esophageal adenomcarcinoma is frequently diagnosed at a late stage and treatments are not effective. For this reason, this type of cancer is often incurable. There are no set guidelines as to who should be screened for Barrett’s esophagus. However, many physicians recommend that patients over the age of 40 with GERD symptoms for a number of years should have an endoscopy to check for Barrett’s esophagus.

For patients with Barrett’s esophagus, most physicians recommend periodic endoscopic evaluations to monitor the condition. Biopsies of the suspected tissue should be taken during endoscopies to diagnose precancerous or cancerous changes (dysplasia). The recommended interval between the examinations varies depending on a number of factors and the ideal schedule has not been established by healthcare professionals.

Several conditions mimic the symptoms associated with gastroesophageal reflux disease (GERD). A physician must rule out these conditions before making a diagnosis of GERD. Such conditions include:

• Dyspepsia. Pain or discomfort in the upper abdomen that does not include heartburn. Feelings of fullness early in a meal, bloating and nausea are all indicators of dyspepsia. In rare cases, this disorder is caused by stomach cancer.
• Duodenal or gastric (stomach) ulcers. Such ulcers are most often caused by:
  
  
  • Helicobacter pylori infection. A bacterial infection that usually responds well to antibiotic treatment.

  • Nonsteroidal anti-inflammatory drugs (NSAIDs). Overuse of these drugs, such as aspirin or ibuprofen, can cause ulcers to form. Cancer patients often use NSAIDs for pain relief.

• Eosinophilic esophagitis. This is an uncommon allergic, inflammatory disease of the esophagus. It can mimic the symptoms of GERD.
• Heart attack (myocardial infarction). The heartburn associated with GERD can be very difficult to distinguish from symptoms of a heart attack. Pain associated with a heart condition usually gets worse with exertion. This normally does not occur in those with GERD.

Patients who experience any of these symptoms should notify their physician.

Food travels from the mouth to the throat before it enters the esophagus, a muscular tube that runs from below the tongue to the stomach. Muscles in the esophagus push the food down into the stomach when a person swallows, a process known as peristalsis.

The stomach responds to the presence of food by producing hydrochloric acid, which helps to break down the starch, fat and protein in the food. An inner mucous lining protects the stomach from the corrosive effects of this acid. Various enzymes, including pepsin, also contribute to the digestion process.

Once food moves from the esophagus to the stomach, the junction separating these two portions of the body opens and closes from the muscular action of the lower esophageal sphincter. When this valve is closed, it prevents acid and other substances in the stomach from traveling back into the esophagus.

When the valve fails to close properly, the condition is known as reflux. Hydrochloric acid and other substances such as pepsin and bile can travel back up into the esophagus. The esophagus lacks the protective lining of the stomach, so these substances often irritate the tissues and trigger heartburn. This is a burning pain in the center of the chest that starts in the upper abdomen and sometimes spreads into the neck. Reflux can also trigger many other symptoms.

Normally, the lower esophageal sphincter opens to allow foods to travel to the stomach, and to expel ingested air through belching. However, several factors can prevent the lower esophageal sphincter from properly opening and closing. In some people, contractions of the valve are especially weak, causing failure of the valve to properly close. In others, the valve relaxes frequently and unexpectedly, allowing reflux to slip into the esophagus.

Certain medical conditions can also contribute to gastroesophageal reflux disease (GERD). Hiatal hernias are common in patients with GERD, and in people over age 50. This condition involves a small part of the upper stomach pushing up into the diaphragm. Being significantly overweight or obese can also increase the severity due to the pressure it places on the stomach.

Pregnancy often triggers GERD symptoms, because hormones cause the digestive system to slow down. Muscles that usually push food through the esophagus slow down, as increased levels of the hormone progesterone cause muscle relaxation. Also, the expansion of the uterus with the growing fetus can produce upward pressure on the stomach and acid reflux.

In addition, activities such as smoking and alcohol consumption can damage the ability of the lower esophageal sphincter to open and close properly. Certain foods known to cause reflux include:

• Caffeinated foods and beverages (e.g., chocolate, coffee)
• Spicy foods, such as onion and garlic
• Vinegar
• Peppermint
• Sugary foods
• Fried or fatty foods
• Tomatoes and acid-based foods, such as spaghetti sauce, chili and pizza
• Citrus foods and fruit drinks
• Alcoholic and carbonated beverages

Gastroesophageal reflux disease (GERD) is typically marked by heartburn after meals but it can last up to two hours. Reflux often feels like food is coming back up into the throat or mouth. A bitter aftertaste is common after reflux, and excessive saliva may be produced. Symptoms often become worse when a person lies down, because this prevents gravity from keeping stomach contents down. In some people with GERD, no symptoms are present. This is known as “silent reflux.”

General symptoms of GERD include:

• Heartburn
• Belching a sour-tasting liquid
• Food regurgitation
• Dull, heavy discomfort in the chest and/or throat
• Hiccups
• Hoarseness or change in voice
• Sore throat
• Coughing or wheezing

Chronic GERD that is not treated can result in more serious complications and symptoms. Signs that more serious damage may have occurred include:

• Dysphagia (difficulty swallowing)
• Vomiting blood
• Black, tarry stools
• Choking
• Weight losss

In some cases, persistent GERD that is untreated can cause or provoke other health conditions. These include:

• Barrett’s esophagus. A change in the color and composition of the cells lining the esophagus. As reflux damages the esophagus, abnormal glandular cells replace the squamous cells that usually line the tube. These glandular cells are more resistant to stomach acid.  Over time, the abnormal cells develop and progress to become dysplasia, a precancerous condition. There are various degrees of dysplasia, with high-grade dysplasia being the most abnormal.
• Esophageal cancer. Long-standing, untreated GERD is a major contributor to adenocarcinoma of the esophagus. This type of esophageal cancer develops over time in glandular (secretory) cells in the lower esophagus near the stomach. Glandular cells produce and release fluids such as mucus. Esophageal cancer is more common in Caucasians than in African Americans. The incidence of adenocarcinoma is the fastest growing among esophageal cancers in the United States. Approximately two-thirds of esophageal cancers diagnosed now fall into this category, according to the American Cancer Society. Research studies also suggest that GERD is a possible risk factor for laryngeal and hypopharyngeal cancer.
• Asthma. Reflux into the lower esophagus can stimulate nerve impulses causing the bronchioles in the lungs to narrow and produce an asthma attack.
• Ear, nose and throat problems. Acid reflux may cause sore throat, laryngitis and chronic cough. It also may increase sinusitis and ear infections, particularly in children.
• Diabetes. Diabetes can damage nerves in the esophagus and stomach which may cause food to move improperly through the esophagus. The disease may also cause food to stay in the stomach for a longer period of time which increases the production of acid.
• Esophagitis. Stomach acid that is refluxed may cause the esophagus to become irritated and inflamed. It also may cause stricture, a condition that narrows the esophagus making it more difficult for food to move to the stomach.
• Aspiration pneumonia. Individuals, especially infants and the elderly, can experience choking episodes and aspiration pneumonia if acid is refluxed up to the windpipe (trachea) and lungs. Refluxing of liquid into the lungs is known as “aspiration,” which can lead to inflammation, infection and pneumonia.
• Sleep apnea. This occurs when breathing stops temporarily but repeatedly during sleep. This may affect people of all ages including babies. In severe cases, apnea can be life-threatening. Sleep apnea increases the risk of heart disease and stroke due to oxygen deprivation.
• Dental problems. Severe cases of GERD can cause tooth decay as reflux wears away tooth enamel.

When a patient reports symptoms of gastroesophageal reflux disease (GERD), such as chronic heartburn, the physician will typically take a medical history and perform a physical examination. In many cases, GERD can be diagnosed strictly based on reported symptoms. A medication is then likely to be prescribed. If the drug successfully alleviates symptoms, a GERD diagnosis is confirmed.

There are also several tests that can be performed to detect GERD, including:

• Barium swallow radiograph. Also known as an upper GI series, this x-ray procedure is frequently used to diagnose GERD. The patient receives a small  amount of chalky liquid (barium) to swallow. A radiologist watches a video monitor to observe how the barium travels through the esophagus to the stomach. The patient may be asked to change positions during the test to help the radiologist view the esophagus and gastrointestinal tract. If GERD is present, the barium may be seen entering the esophagus from the stomach. In addition, the barium can help to highlight inflammation of the esophagus (esophagitis) or abnormalities of the upper digestive tract.

• Endoscopy. This is an examination of the esophagus with a camera mounted to a thin tube. This allows the physician to see abnormalities such as ulceration or inflammation of the esophagus. It is typically used to look for tissue changes that may reveal signs of Barrett’s esophagus, a condition that may cause esophageal cancer in some patients. During an endoscopy, the physician can take samples of suspected tissue for biopsy. Biopsy is the definitive test for diagnosing Barrett’s esophagus as well as adenocarcinoma.
• Ambulatory acid (pH) probe test.  A more sensitive test considered to be the most accurate way to diagnose reflux. A thin, flexible tube is inserted into the esophagus. The tip rests just above the lower esophageal sphincter, and it is connected to a device that monitors acid levels in the esophagus. The test is usually done over a 24-hour period. Consistently high acid levels indicate are strong evidence of GERD. This test is normally only performed after an endoscopy.
• Esophageal manometry or esophageal pH test. In this test, a thin tube is place through the nose into the esophagus and stomach. The tube can measure the function and pressure of the esophagus. This test can detect spasms of the esophagus, or the inability of the esophagus to move food down to the stomach (motility problems).
• Bernstein test. An acid solution is placed into the lower esophagus and a positive result will reproduce heartburn symptoms, and therefore indicate GERD.
• Abdominal ultrasound. This test provides pictures of abdominal structures and organs. It can help rule out other sources of symptoms, such as gallbladder problems.

The American College of Gastroenterology recommends that people with long-standing symptoms of reflux have their esophagus and stomach examined with an endoscope. Following this recommendation is especially important for people age 40 and older, according to the organization. If a precancerous condition (dysplasia) is found during an endoscopy, the patient’s physician may recommend more frequent endoscopies to monitor the condition. The physician’s recommendations will depend on several factors, including the degree of dysplasia and the patient’s age and general health.

Treatment of gastroesophageal reflux disease (GERD) is primarily focused on reducing reflux of stomach acid and juices into the esophagus. Treatment is aimed at relieving symptoms and preventing damage to the esophagus, which can increase the risk of esophageal cancer in some patients. Medications usually are sufficient to produce relief, but patients may need to try various drugs or drug combinations before treatment is successful. Patients with severe GERD may have to take medications for the rest of their lives to control their symptoms and prevent possible complications.

Medications provide relief for the majority of patients with GERD. However, it can take weeks before a patient experiences a drug’s beneficial effects. Patients should never take any medication without first consulting their physician. Medications known to alleviate symptoms of GERD include:

• Antacids. Taken after meals and at bedtime, these neutralize stomach acid. However, their effect is brief, usually limited to an hour. Antacids should not be taken for over three weeks, because of side effects including diarrhea, a build up of magnesium and impairing the ability to metabolize calcium.
• Acid reducers. These reduce the overall amount of acid in the stomach. H2 blockers and Proton pump inhibitors are acid reducers.
• Histamine H2 receptor blockers. These drugs block the receptor for histamine, a chemical in the body that can stimulate acid-producing cells. They are particularly effective when taken a half-hour before meals. Some products contain antacids and H2 blockers, providing immediate relief that may last longer.
• Coating agents. Drugs that will coat the mucous membranes and provide an acid barrier.
• Promotility and prokinetic agents. These drugs stimulate the muscles of the gastrointestinal tract, including the esophagus, stomach, small intestine and colon, to help speed movement of food. They also can help close and strengthen the lower esophageal sphincter and increase the rate at which the stomach empties. Studies have found that promotility agents have more negative side effects than other drugs (e.g. H2 blockers, pump inhibitors). They are usually prescribed only when other medications do not work to reduce GERD symptoms. One drug (cisapride) was removed from the market to due serious heart-related side effects. However,it is still available from the manufacturer through a limited-access program for selective patients.
• Proton pump inhibitors. These medications reduce stomach acid production. This type of drug may take one to four days to work. They are typically prescribed for patients who have heartburn several times a week
• Foam barriers. These tablets contain both an antacid and a foaming agent. The foaming agent sits atop the liquid in the stomach, creating a barrier to reflux activity.

For most patients, GERD may be treated with over-the-counter or prescription medications and lifestyle changes. Surgery is a last resort for patients with GERD that do not have additional complications, such as precancerous abnormalities. Procedures that may be used to reduce the symptoms of GERD include:

• Fundoplication. Also known as anti-reflux surgery, it involves wrapping the upper curve of the stomach around the esophagus and sewing into place. This helps strengthen the lower esophageal sphincter. Partial fundoplication involves wrapping the stomach only pathway around the esophagus.
  
  The surgery is performed with a laparoscope, which involves inserting special instruments through small incisions less than an inch long. While the surgery can effectively relieve the symptoms of GERD, the risk of cancer will remain in patients who have experienced dysplasia in their esophagus.
• Gastropexy. Surgery that attaches stomach to the diaphragm if there is a hiatus hernia so the stomach cannot move through the opening of the diaphragm into the chest. This is performed less frequently than fundoplication.
• Stretta radio frequency procedure. A relatively new treatment, it delivers radio frequency energy through an endoscope to tighten the lower esophageal sphincter.
• EndoCinch procedure. Involves a series of sutures that adjust the lower esophageal sphincter so it more effectively blocks reflux.
• Enteryx injections. A solution called Enteryx is injected into the lower esophageal sphincter during endoscopy. This forms a spongy mass that reinforces the lower esophageal sphincter.

If a patient with Barrett’s esophagus has precancer or cancer, surgery is usually recommended as treatment. Because it is a major procedure, it is typically performed only on patients in strong health with a good chance of being cured.  The type of surgery may vary depending on the extent of the damage. However, it usually involves removing most of the esophagus. The stomach is then pulled up to the chest and it is attached to what remains of the esophagus. Many patients with esophageal cancer are older with additional medical problems and surgery is not considered a viable option. Research is continuing on alternative ways to treat the condition.  

Many patients who suffer from GERD find it to be a lifelong disorder requiring drug treatment or in some cases, surgery. However, patients can make many lifestyle modifications that can reduce and possible eliminate symptoms. General prevention measures include:

• Eat small, frequent meals. Eat no later than four to six hours before bedtime or lying down.
• Avoid tobacco and alcohol. Not only do these conditions trigger GERD, but they are also major risk factors for esophageal cancer.
• Take a walk after eating meals.
• Lose weight. Excessive weight increases pressure on the stomach, which can trigger reflux.
• Elevate the upper body during sleep by raising the head of bed 6 inches to 8 inches. This may be best accomplished by placing blocks of wood under the upper portion of the bed or by using an under-mattress foam wedge.
• Wear loose-fitting clothes. Do not wear tight belts or clothes that squeeze the midsection.
• Good posture, both sitting upright and standing straight, will help to prevent reflux by helping food and acid pass into the stomach.
• Drink plenty of water when taking medications or nutritional supplements that may cause heartburn.
• Keep a list of food that triggers GERD. Avoid foods and ingredients known to trigger symptoms, including:
  
  
  • Fatty or spicy foods
  • Chocolate
  • Caffeine
  • Peppermint and spearmint
  • Carbonated drinks and fruit juices
  • Citrus or acidic foods
• Discuss use of the following medications with a physician. These drugs can worsen the symptoms of GERD. Physicians may suggest alternatives that can be used instead of these drugs. However, patients should not start or discontinue the use of medications without first consulting a physician.
  
  
  • Anticholinergics. Bronchodilators often used to treat asthma.
  • Beta2 agonists. A type of bronchodilator used to relieve a sudden asthma attack.
  • Estrogen and progesterone. Used for hormone replacement therapy.
  • Calcium channel blockers. Used to treat heart conditions.
  • Sedatives and tranquilizers, including diazepam and barbiturates.
    
    
  • Quinidine. Used to treat abnormal heart rhythms.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Theophylline. Used to treat asthma.
  • Dietary supplements. Some supplements may increase the inflammation of the esophagus in people with GERD. Consult a physician before taking supplements. These include: potassium, iron and vitamin C supplements.

Research continues to study the relationship between GERD and cancer, particularly cancers of the esophagus, larynx, hypopharynx and stomach. Areas that are being studied include:

• Improved methods for identifying people with Barrett’s esophagus
  
  
• Determining possible causes of dysplasia (e.g., enzymes that may lead to cancer).
  
  
• Testing new screening methods, such as a less invasive scope known as the “skinny scope.”
  
  
• Evaluating types of surgical procedures for esophageal cancer.
  
  
• Determining better prediction methods for those at risk for cancer from GERD.
  
  
• Improving ways to prevent cancer from developing.
  
  
• Evaluating drugs for treatment and prevention of the disease.

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

1. How do I know my symptoms are from GERD?
2. Which tests will I receive to diagnose the condition?
3. How and where will the test be performed?
4. Will you take a biopsy during the endoscopy?
5. If so, when and from whom will I receive the results?
6. What medications will you prescribe for my symptoms?
7. How soon can I expect to feel relief?
8. How long will I need to stay on these medications?
9. What other steps can I take to reduce my GERD?
10. Is it likely to get worse as I get older?
11. If I have Barrett’s esophagus, how likely will it develop into cancer?
12. How will this condition be monitored?
13. How often will I need to have an endoscopy?
14. What symptoms will indicate that my condition is more serious?
15. What is my prognosis with esophageal cancer?