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What is gastroesophageal reflux disease?
Also known as GERD, gastroesophageal reflux disease is a common condition and can be defined as “symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus or beyond, into the oral cavity (including larynx) or lung” [1]. To simplify this definition, gastric contents from the stomach, which are highly acidic, go up into the esophagus or mouth. This condition can be very uncomfortable and even painful due to the burning sensation that gastric contents can cause when regurgitated. There are two different classifications of this condition: NERD, non-erosive reflux disease; and ERD, erosive reflux disease. The difference between these classifications is “based on the presence or absence of esophageal mucosal damage seen on endoscopy” [1]. An endoscopy is a procedure that involves a medical practitioner using a small camera to see into a specific organ.
I’ve personally had this procedure done, and it isn’t too bad, but it does feel a little weird- in case you don’t know what to expect.
Symptoms
Now, three different types of symptoms can be experienced with GERD, including typical symptoms, acid regurgitation, and heartburn; atypical symptoms, epigastric fullness, epigastric pressure, epigastric pain, dyspepsia, nausea, bloating, and belching; and extraesophageal symptoms, chronic cough, bronchospasm, wheezing, hoarseness, sore throat, asthma, laryngitis, dental erosions [1]. “In general, symptoms tend to be more common after meals and are often aggravated by recumbency and relieved by acid-lowering medications” [1].
So, symptoms can be worsened by the simplest action of just leaning back too much, but different medications can help (which we will address). Also, just because someone experiences some of these symptoms does not necessarily mean they have GERD. Atypical symptoms “may be suggestive of GERD but may overlap with other conditions in the differential diagnosis such as peptic ulcer disease, achalasia, gastritis, dyspepsia and gastroparesis” [1]. Furthermore, “extraesophageal symptoms could be secondary to a host of other conditions and should not uniformly be attributed to a diagnosis of GERD, especially when typical symptoms are absent” [1].
Diagnosis
“The diagnosis of GERD is typically made by a combination of clinical symptoms, response to acid suppression, as well as objective testing with upper endoscopy and esophageal pH monitoring” [1]. A combination of typical symptoms and any changes that can be seen through an endoscopy are “highly specific for GERD,” as well as “a well-taken history [...] of heartburn and acid regurgitation” [1]. Although this can provide enough information to make a presumptive diagnosis, “Additional testing may be necessary [...] for those who do not respond to acid suppression, those who have alarm symptoms (e.g., dysphagia, odynophagia, iron deficiency anemia, weight loss, etc.) and those who have suffered from the disease for an extended period due to concern for Barrett’s esophagus” [1]. Dysphagia and odynophagia both have to do with difficulty or pain when swallowing. Barrett’s esophagus is “a condition in which the flat pink lining of the swallowing tube that connects the mouth to the stomach (esophagus) becomes damaged by acid reflux, which causes the lining to thicken and become red” [2]. So, to reiterate, any of these or the other alarm symptoms listed may require more testing to reach an accurate diagnosis.
There are a variety of tests one can be put through for a more accurate diagnosis; these tests include [1]:
A PPI (proton pump inhibitor) trial will indicate classic GERD symptoms with no alarm symptoms
Esophageal pH monitoring will indicate refractory symptoms where GERD diagnosis is in question and is a preoperative evaluation for non-erosive disease
Upper endoscopy will indicate alarm symptoms, PPI unresponsive patients, and if an individual is at high risk for Barrett’s esophagus
Barium esophagram which is an evaluation for dysphagia, but is otherwise not recommended for GERD evaluation
Esophageal manometry which is performed before anti-reflux surgery to rule out esophageal dysmotility, and problems swallowing but is otherwise not recommended for GERD evaluation
Treatment
Now that we’ve addressed what GERD is, its symptoms, and the different diagnostic tests, let’s go over the different treatments for this disease. “GERD is a chronic disease that typically requires long-term management in the form of lifestyle modification, medical therapy, and, for a subset of patients, surgical therapy” [1]. So, individuals will have to keep up with whatever treatment option is best for them and their experience with this disease.
As for overall changes to lifestyle, “lifestyle and diet modification traditionally have included weight loss, head of bed elevation, avoidance of nighttime meals, and elimination of trigger foods such as chocolate, caffeine, and alcohol” [1]. These changes have proven to help in the treatment of GERD symptoms. As for weight and its relation to individuals with GERD, in a 2006 study, “BMI was found to be associated with symptoms of GERD in both normal weight and overweight women and even moderate weight gain among those of normal weight was found to cause or exacerbate symptoms” [1]. So, since weight gain can affect GERD symptoms negatively, healthy weight loss would help to alleviate symptoms. Additionally, making sure to keep one’s head elevated and not go to sleep within three hours after dinner is encouraged for individuals with GERD [1]. “Despite strict compliance, lifestyle changes alone are frequently inadequate at controlling symptoms and medical therapy often becomes necessary” [1].
So, what medical therapy options exist for the treatment of GERD? Acid suppression is the pillar of GERD treatment, and it “can be achieved with several classes of medications including antacids, histamine-receptor antagonists (H2RAs) or PPIs” [1]. Furthermore, “studies show that ERD is more difficult to treat with H2RA compared to PPIs, and patients with ERD tend to have a higher symptom response to PPIs” [1]. So, PPIs are better suited for individuals with erosive reflux disease. “In general, PPIs are felt to be equally effective and patients should be instructed to take these medications 30-60 min before meals; the exception to this is dexlansoprazole which can be taken irrespective of food intake” [1]. It’s important to make sure you pay attention to the requirements for your medications to ensure you are using them most effectively.
The final treatment option is surgical therapy in which “proper patient selection is critical to obtain the best possible surgical outcomes and it is imperative that there be objective documentation of GERD” [1]. Surgical therapy is encouraged for those who are unable to control their GERD symptoms with medical therapy and lifestyle changes. “The short and medium-term outcomes of laparoscopic anti-reflux surgery are quite good in terms of improving the typical symptoms of GERD. However, in the long term, it appears these results may diminish” [1]. Like many surgical treatments, there is a risk of symptoms returning over some time, and there is also a risk of complications. This is why it’s imperative to discuss with your doctor/surgeon and get all the information you need before undergoing any type of surgery to make sure it is the right decision in the long run.
As we have learned, there are multiple treatment options for those living with GERD. If you feel you are experiencing some symptoms of GERD, be sure to ask your doctor to get a diagnosis so you can take the steps you need to live more comfortably.
References:
1. Badillo, R., & Francis, D. (2014, August 6). Diagnosis and Treatment of Gastroesophageal Reflux Disease.
2. Mayo Foundation for Medical Education and Research. (2022, March 5). Barrett's Esophagus. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/barretts-esophagus/symptoms-causes/syc-20352841
Contributors:
Author: Lauryn Agron
Editor: Kayjah Taylor
Health Scientist: Catherine Sarwat
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