Gastroesophageal Reflux Disease (GERD) Treatment

What is Gastroesophageal Reflux?

Gastroesophageal reflux is a medical condition characterized by reflux of acidic juices into the esophagus, resulting in symptoms of regurgitation (sour taste in mouth) and reflux (burning in the chest).  This is an extremely common condition in the United States.  Factors such as obesity, alcohol use, tobacco use, certain medications, and various diets and lifestyle decisions increase your risk of developing gastroesophageal reflux.  Long-term disease can lead to a precancerous condition called Barrett’s esophagus.

Other serious complications include esophageal adhesions, constrictions, and cancer.  Some patients may ultimately develop difficulty swallowing and weight loss – which may require feeding tube placement and surgical intervention.  Due to the importance of this condition, it is critical that patients understand its causes, symptoms, and treatment.  By the end of this article, you will have the answers to these essential questions

What causes Gastroesophageal Reflux?

Gastroesophageal reflux is caused by the reflux of acidic juices from the stomach into the esophagus.  This results in irritation of the esophageal lining – leading to chest burning and discomfort.  Acid can also reach the throat resulting in the sensation of a sour taste in the mouth (regurgitation).  Symptoms often occur after meals and may be associated other features of dyspepsia such as bloating and mild abdominal discomfort.

Long-term inflammation in the lower esophagus can lead to cellular changes that are precancerous if the problem is not corrected or reversed – Barrett esophagus.  Eventually, chronic irritation can lead to adenocarcinoma of the lower esophagus.

Conditions that lead to acid reflux generally occur as a result of abnormal anatomic or pathophysiologic processes.  Often times it is caused by increased intraabdominal pressure, which facilitates acid backflow from the stomach to the esophagus.  Some of these can include:

  • Obesity
  • Pregnancy
  • Abdominal ascites
  • Hiatal hernia – herniation of the stomach through the diaphragm into the chest cavity
  • Eosinophilic esophagitis – food may get caught in esophagus
  • Esophageal stenosis
  • Scleroderma – fibrosis of the esophagus and dysmotility
  • Esophageal mass or cancer
  • Motility disorders – achalasia
  • Medications – NSAIDs, corticosteroids, bisphosphonates
  • Alcohol
  • Tobacco

How common is Gastroesophageal Reflux?

Gastroesophageal reflux is exceedingly common in the United States and responsible for frequent primary care visits.  The most common causes include obesity, tobacco, alcohol, and NSAID use.  The condition may require referral to a gastroenterology specialist if not responsive to lifestyle or behavioral modification and first-line treatment – patients may also require a referral if they have red flag symptoms.

In the West, the incidence of gastroesophageal reflux is about 0.5% per year.  The prevalence is approximately 10%-20%.  In Asia, the prevalence is less than 5%.  One study showed that approximately 22% of Americans report heart burn or regurgitation symptoms within the past month.

What are the symptoms and signs of Gastroesophageal Reflux?

Symptoms of gastroesophageal reflux often include:

  • Heart burn – acid burning in the chest
  • Regurgitation – sore taste in mouth
  • Abdominal discomfort
  • Dyspepsia – bloating, early satiety
  • Asthma

Red flag symptoms that are concerning include:

  • Advanced age >55
  • Difficulty swallowing (dysphagia)
  • Pain on swallowing (odynophagia)
  • Anorexia & weight loss
  • Blood in the stool

How is Gastroesophageal Reflux diagnosed?

The diagnosis of gastroesophageal reflux is suggested based on symptoms and physical examination – unclear cases or typical presentations may require confirmatory laboratory and imaging studies.

Your doctor will typically test you for Helicobacter pylori infection with a stool antigen study.  This bacteria can infect the stomach or small intestine resulting in peptic ulcer disease.  If your condition is moderate to severe, your doctor will likely order blood tests that may include a CMP (comprehensive metabolic panel), CBC (complete blood cell count), lipase, and coagulation studies (PT/INR, PTT).  They may also order an abdominal ultrasound evaluating the liver, gallbladder, and pancreas.

Some doctors will obtain an EKG (electrocardiogram) if they are concerned for heart disease.

Patients with red flag features or symptoms that do not respond to first-line medical therapy after 1-2 months of therapy should generally undergo an upper endoscopy.  During this procedure, you gastroenterologist enters the esophagus with a scope and examines the lining of the esophagus, stomach, and proximal small intestine.  They are evaluating for ulcers, masses, and strictures.  They can take biopsies of suspicious legions and may be able to treat various abnormalities endoscopically (eg, balloon dilation of a stricture).

Your doctor may also recommend 24-hour ambulatory pH monitoring.

How is Gastroesophageal Reflux treated?

Gastrointestinal reflux disease is initially treated by lifestyle and dietary modifications.  This includes avoiding alcohol/tobacco use, significant caffeine intake, spicy foods, and NSAIDs.  Weight loss is also an important aspect of management.

Patient are also typically treated with proton-pump inhibitors (PPIs) such as:

These medications work by reducing acid secretion in the stomach.  They are generally used for at least 1 month in patients with acid reflux.

Histamine blockers such as Zantac (ranitidine) and Pepcid (famotidine) are sometimes used as a substitute to proton pump inhibitors.  These medications also work by reducing acid levels but may not be as effective as PPIs.

Studies show that about 10%-40% of individuals with acid reflux do not respond to standard doses of proton pump inhibitors.  In some cases, therapy needs to be escalated to twice daily dosing.

If patients are not responsive to first-line treatment strategies or have red flag symptoms, they often require referral to a gastroenterology specialist for consideration of further work-up such as upper endoscopy and 24-hours ambulatory pH monitoring.

Gastroesophageal Reflux Patient Summary:

  • Gastroesophageal reflux is a medical condition characterized by reflux of acidic juices into the esophagus, resulting in symptoms of regurgitation (sour taste in mouth) and reflux (burning in the chest).
  • The following causes that can aggravate gastroesophageal reflux include: obesity, pregnancy, abdominal ascites, hiatal hernia, eosinophilic esophagitis, esophageal stenosis, scleroderma, esophageal mass or cancer, motility disorders (achalasia), medications (NSAIDs, corticosteroids, bisphosphonates), alcohol, and tobacco.
  • Symptoms of gastroesophageal reflux often include: heart burn, regurgitation, abdominal discomfort, dyspepsia, early satiety, and asthma.
  • Red flag symptoms that are concerning include: advanced age >55, difficulty swallowing (dysphagia), pain on swallowing (odynophagia), anorexia & weight loss, and blood in the stool.
  • Your doctor will typically test you for Helicobacter pylori infection with a stool antigen study. They may also order an abdominal ultrasound.
  • Your doctor may also recommend 24-hour ambulatory pH monitoring.
  • Gastrointestinal reflux disease is initially treated by lifestyle and dietary modifications. This includes avoiding alcohol/tobacco use, significant caffeine intake, spicy foods, and NSAIDs.  Weight loss is also an important aspect of management.
  • Patient are also typically treated with proton-pump inhibitors (PPIs) such as: Prilosec (omeprazole), Protonix (pantoprazole), Prevacid (lansoprazole), and Dexilent (dexlansoprazole).
  • Histamine blockers such as Zantac (ranitidine) and Pepcid (famotidine) are sometimes used as a substitute to proton pump inhibitors.
  • Patients with red flag features or symptoms that do not respond to first-line medical therapy after 1-2 months of therapy should generally undergo an upper endoscopy.

Severe cases of gastroesophageal reflux may require surgical intervention.

References:

  1. Hainer BL, Matheson E, Wilkes RT. Diagnosis, treatment, and prevention of gout. Am Fam Physician. 2014 Dec 15;90(12):831-6.
  2. Neogi T. Clinical practice. Gout. N Engl J Med. 2011 Feb 3;364(5):443-52.

The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.