What is GERD. It is short for Gastroesophageal reflux disease?
It is reflux of the stomach contents upwards and out of the stomach into the esophagus (the gullet).
Why is this a problem?
The stomach contents are not meant to go back up into the esophagus. There is a valve at the top of the stomach. This valve is designed to allow food to pass down into the stomach. The valve is made to prevent food and stomach juices refluxing back into the esophagus. The stomach lining produces strong acid in order to digest food. The stomach lining is able to cope with the acidic environment, but the esophagus is not. The stomach juices are irritant to the lining of the esophagus. The result is inflammation and pain, which is felt as heartburn.
Above: Picture of lower oesophageal sphincter showing normal situation and a sliding hiatus hernia
Acid Reflux Disease in more detail
Gastroesophageal reflux disease (known as GERD in the USA and Gastro-oesophageal reflux disease - GORD in the UK) is the most common condition affecting the esophagus (oesophagus in the UK). This health problem is extremely common. About 30% of people experience an episode of acid reflux at least once in 6 months. It probably occurs to some degree in all of us. Reflux is only considered a disease if it causes significant symptoms or complications which are bad enough to affect quality of life.
Causes (aetiology).
In most people reflux disease arises from the excessive exposure of the lower esophagus to refluxed acid, usually because of an abnormal frequency of episodes of reflux. In a few people, however, symptoms arise with relatively normal levels of acid exposure, presumably because of sensitization of the esophageal mucosa. In most people reflux takes place because of a problem with the neural control of the valve at the lower end of the esophagus. There are rare conditions such as scleroderma which can lead to reflux disease because of damage to the esophagus.
Above: Picture of lower oesophageal sphincter showing acid reflux up into the lower oesophagus
A hiatus hernia is commonly present in people with reflux disease. The hiatus hernia causes displacement of the valve (sphincter) from the hiatus formed by the diaphragmatic crura ( muscular cross support formed by the muscles of the diaphragm). The hiatus provides important external support to the sphincter (valve) and helps to maintain adequate functioning of the gastroesophageal valve, particularly during straining. A hiatus hernia therefore reduces the efficiency of the valve at the lower end of the esophagus and leads to acid reflux. Most episodes of reflux take place during the day, usually after meals. Night-time reflux is also extremely important. Acid which refluxes into the esophagus is cleared by peristalsis (muscular contractions of the esophagus which move food and liquids downwards) and swallowed saliva. The slow clearance of acid contributes to prolonged acid irritation in about half of those suffering from gerd.
Above: Picture of sliding hiatus hernia
What does heartburn feel like?
Once heartburn is experienced it is never forgotten. It is felt as a pain or discomfort in the central chest – usually in the lower central chest. It can feel like a burning pain but is more often described as a discomfort. Pain can be difficult to describe. Doctors usually ask patients “what did the pain feel like?” In my experience as a doctor, patients can find this question difficult to answer. The description given by a patient can be helpful in making a diagnosis.
What relieves the pain of heartburn?
A description of the pain can be helpful, but It is more useful to ask: “what makes the pain better or worse?” Heartburn, typically, is quickly relieved by a dose of antacid medicine. A doctor presented with a patient suffering from central chest pain will often administer a dose of antacid medicine. If the pain is relieved within seconds, then this confirms the diagnosis of heartburn. This is reassuring for both patient and doctor if a heart attack is suspected. (Disclaimer: If you are experiencing central chest pain you should immediately seek medical advice. Central chest pain may occur during a heart attack).
What brings on heartburn?
Anything that causes the stomach contents to reflux upwards into the esophagus. This may happen at random times and may not be related to any particular activity or event. Heartburn often comes on after a meal, especially if it is a large meal. Heartburn is often precipitated by bending over. Another common and typical precipitating cause is lying down flat in bed.
Which foods or drinks worsen acid reflux?
Typically heartburn is aggravated by acidic foods, large meals and thermally hot liquids and foods. If you choose your foods with care it is possible to cure heartburn completely.
Which foods or drinks help heartburn quickly?
If you have heartburn now the simplest way to relieve the discomfort quickly is to drink a glass of water. Antacid medicine is more effective but may not always be readily available. Milk is often recommended. Milk does provide rapid relief but doctors debate about whether it is advisable on a frequent basis.
What type of diet should be followed if you suffer from heartburn?
Avoid large meals especially late at night Avoid fatty and fried foods Avoid acidic and irritant spicy foods Eat smaller meals, which are not acidic and low in fat. This does not have to mean eating a bland and boring diet. There are plenty of tasty and enjoyable food that do not cause or worsen heartburn.
More about GERD
Symptoms
Heartburn is the typical symptom of acid reflux. Heartburn feels like a burning upper abdominal (epigastric) or lower and central chest (retrosternal) pain, which spreads upwards. Typically heartburn takes place after meals, especially large meals, and is aggravated by bending over, lying down or straining. It is relieved by standing up or drinking something, especially an antacid. In severe episodes, the pain may refer (radiate) to the lower part of the neck, the angles of the jaw, or down one or both arms. In some people, when they are asleep, there is reflux of liquid into the hypopharynx (the part of the throat or pharynx that connects with the esophagus). This may lead to aspiration of acid and stomach contents into the lungs. The person will wake at night coughing on the aspirated material. If this happens frequently or recurrently then pneumonia or rarely pulmonary fibrosis may occur.
Less commonly GERD can cause other symptoms such as: vomiting up blood (haematemesis) or difficulty swallowing (dysphagia). Vomiting up blood is a symptom which may indicate a serious or life threatening problem. Medical advice should be sought immediately. People with haematemesis usually need immediate admission to hospital for urgent medical assessment. Prolonged acid reflux can lead to scarring and narrowing of the lower end of the esophagus. This may result in food or less commonly liquids getting stuck or passing slowly through the distal (lower) esophagus. This is known as dysphagia (difficulty swallowing). Dysphagia always requires further investigation because it may be a symptom of cancer of the esophagus.
Esophagitis
Esophagitis means that the lower esophagus is ulcerated or has multiple small erosions. This occurs because of the chemical damage caused by excessive exposure of the distal (lower) esophageal lining (mucosa) to acid and pepsin (a digestive enzyme produced by the lining of the stomach to digest proteins). Esophagitis occurs in about 40-60% of people with troublesome reflux symptoms. The degree of ulceration varies greatly from tiny patches of erosions to extensive ulceration affecting the entire circumference of the lower esophagus in a small minority. Persistent esophagitis can lead to a stricture (narrowing) or a condition known as Barrett’s esophagitis. In Barrett’s esophagitis the cells lining the lower esophagus develop what is as columnar metaplasia. This occurs as a consequence of repeated healing of the lining of the esophagus. The problem with Barrett’s metaplasia is that it can lead to esophageal cancer. Having columnar metaplasia is thought to increase the risk of esophageal cancer 40-fold.