Gastroesophageal Reflux Disease (GERD) is a condition that arises when stomach acid backflows into the esophagus causing a burning sensation in the chest and the back of the throat. The medical term “REFLUX” just means fluid flowing in an abnormal direction. For instance, venous reflux is the condition of blood being pulled away from the heart, as in varicose veins in the leg, where blood being pulled downward by gravity instead of returning normally to the heart. Esophageal reflux is the condition of gastric acid and other content being forced upward into the esophagus (the wrong direction!)
GERD may result from a weak esophageal sphincter at the junction of the esophagus and the stomach. Normally, the sphincter allows you to swallow food and liquid down the esophagus and into the stomach, but then prevents it from refluxing back, upwards into the esophagus. The sphincter muscle at the bottom of the esophagus may weaken over time and not close tightly, which prevents the digestive juices from being sealed off from the esophagus and allows them to push upward into the throat and mouth. Or, a hiatal hernia can develop within the diaphragm. The hiatus is a normal hole within the diaphragm that the esophagus passes through to reach the abdomen. If the hiatus begins to enlarge, the hole becomes bigger and the stomach ‘herniates’ or moves upward into the chest. This is because the pressure within the stomach is higher than the pressure within the chest, This hernia causes the person to suffer from esophageal reflux because the esophageal sphincter at the gastroesophageal junction can no longer close properly as its shape has been changed and it now resides in the chest, instead of within the abdomen. Normally, all of the stomach, including the junction of the esophagus and stomach, should be located within the abdomen.
50 million people suffer from GERD in the United States, which is the highest rate in the world, followed by Europe and South America. Asia and Australia have much lower rates, with Asia having the lowest. Interestingly, this correlates with the dietary habits of the different regions. North American’s proclivity for animal fats and high-calorie, high-fat foods has created a nation of people with high a number of conditions stemming from digestive issues. Contrast this diet as opposed to the diets of many Asian countries, where fruits, vegetables, seafood, and poultry are the mainstays. Americans also seem to be conditioned to high-calorie desserts after a meal, whereas people in Asian countries prefer something lighter, like fruit.
Not only do Americans eat high-calorie food, but the portion size is often larger. Restaurants and fast food outlets offer larger and larger portions to compete and attract more patrons, who may gorge themselves to finish even when they are satiated.
Symptoms
No one has to tell you when you have heartburn. That burning sensation in the chest is pretty self-evident and often occurs after eating a large meal, often containing a trigger food . The symptom that is the most horrible is known as “pyrosis” or water-brash. This is the horrible, choking sensation that sometimes awakens someone at night as the acid comes all of the way up the esophagus and empties into the back of the mouth in a large volume and causes a drowning sensation. This symptom is often what makes a patient seek a doctor’s help.
Some patients have what is known as “silent reflux”. These patients have esophageal reflux causing damage to the lining of the esophagus, but they do not have typical symptoms of heartburn. Some of the telltale symptoms of silent reflux can be a chronic cough, hoarse voice, of when the person has to clear their throat often. These symptoms occur because the vocal cords and top portion of the trachea (windpipe) are being damaged from the content of the reflux traveling up the esophagus and then into the top of the trachea in the back of the throat.
Treatment
Lifestyle changes and dietary changes are always the first line therapy to control heartburn and GERD symptoms.
Some lifestyle changes can be to elevate the head of your bed on blocks or old books about 4 inches. A wedge pillow is another alternative, but may not be as effective. These maneuvers will allow gravity to assist the stomach in keeping it’s contents within it as you lie down to sleep.
Avoiding tight fitting clothing which tends to increase pressure within the abdomen and stomach, avoiding eating and snacking before bedtime are also typical changes one should try to pursue to control symptoms. Weight loss is also a very important step. Obesity also increase the pressure within the abdomen and therefore the stomach which pushes the stomach contents upward, into the esophagus. Many with GERD has experienced the increase in symptoms when bending forward (such as to tie your shoes) which increases the abdominal pressure. Those with a hiatal hernia may find that this act makes it more difficult to catch their breath.
The next step in treatment is through medications (or, pharmacological treatment). Whether over-the-counter or prescription, drugs play an important role in treatment of GERD. For mild, occasional cases, antacids may be enough to suppress the symptoms. Antacids simply do what their name implies, they actually soak up or neutralize the acid within the stomach. If the condition becomes chronic, it may be necessary to seek more defined medicine treatment. In such cases, a proton pump inhibitor, such as Omeprazole, or H2 receptor blocker, such as Zantac may be employed. The H2 blockers block Histamine, which causes the stomach to secrete acid. These drugs have been around for decades. Besides Zantac, other examples in this class include Tagamet, Pepcid, and Axid. The most recent class of drugs developed for acid control are proton pump inhibitors. These medications actually turn off the tiny pump in the cells of the stomach lining that secrete acid. Examples are Prilosec, Nexium, Protonix, and Zegerid.
Diet
Avoiding foods that cause the worst symptoms is another first step towards avoiding the problem of GERD. These include, but are not limited to, spicy foods, chocolate, and fried foods; also, beverages containing caffeine, namely coffee, tea, and carbonated drinks should be avoided. Foods that predispose to reflux either cause excess acid production within the stomach or have properties which cause relaxation of the esophageal sphincter. These are known as “trigger foods”.
Other examples of trigger foods such as citrus fruits, tomatoes and tomato sauce containing foods such as marinara sauces, pizza, and chili are typical of those foods resulting in excess stomach acid production. Some patients find that their particular trigger foods may be a bit different from others, but the ones listed here are typical.
Fats of any kind also seem to cause more reflux symptoms. Fried foods seem to be the worst, but fats in food in general such as cheese or other dairy products, olive or other oils, may also predispose to reflux.
Alcohol is also a huge problem for those with GERD. Alcohol decreases the strength of the esophageal sphincter and allows the acid to escape the stomach. Therefore, alcohol with evening meals can cause the worst symptoms as the alcohol is still active when the person lies down. Certain types of alcohol seem to be worse for this problem and red wine as opposed to white is known as a particularly bad offender. Colored liquors such as whiskey seem to also be worse than clear alcohols. Beer combines both carbonation as well as alcohol and is therefore also frequently listed by patients as a cause of their GERD symptoms. Carbonated liquids increase pressure within the stomach as the bubbles in the fluid return to CO2 gas.
The best diet for GERD is to eat foods high in fiber, protein, and lean in fat. Nutrition that promotes health and normal body weight is not only best for GERD symptoms, but remains the best advice in general. A normal sized abdomen decreases the pressure on the stomach and will therefore help decrease esophageal reflux.
Eating healthy foods, exercise, and weight loss are the best protectors of the digestive system. Besides the psychological factors, the physical manifestations of weight gain and obesity are too important to overlook in our overall health. Feeling well and looking good are the best incentives for leading a healthy life. For some, just trying to avoid GERD symptoms have caused better overall dietary habits. Avoiding late night meals, eating less fats (especially saturated fats), avoiding the excess calories associated with alcohol, and eating smaller portions has led to better health.
If you have tried the above remedies, including pharmacological treatment with medicine, but still suffer from GERD symptoms, it may be time to consider surgery. But, in my practice, I would rather patients first try lifestyle and dietary changes and then at least consider or trial medications prior to workup for surgery.