Acid Reflux and GERD

How acid reflux happens

The esophagus carries food to the stomach. At its lower end, the lower esophageal sphincter (LES) and the diaphragm together form a valve. Normally it opens to let food through and then closes. Reflux happens when:

• the LES relaxes briefly at the wrong time (transient relaxations, the most common mechanism, often after meals)
• the LES is weak and stays partly open
• a hiatal hernia pulls the top of the stomach above the diaphragm, separating the two parts of the valve
• the stomach empties slowly or is overfilled, raising pressure
• the esophagus clears acid poorly, for example during sleep or with reduced saliva

The esophagus lining has none of the stomach's protective mucus, so acid, pepsin and bile irritate it.

GER vs GERD

For a practical look at what symptoms feel like and quick relief, see our page on acid reflux symptoms. Detail on the chronic disease is also on our GERD page.

Symptoms

• heartburn, the hallmark symptom
• regurgitation of sour fluid or food
• upper abdominal or chest discomfort
• burping, nausea and bloating
• difficulty or pain swallowing in more advanced disease

Extraesophageal symptoms happen when reflux reaches the throat or lungs: chronic cough, hoarseness, throat clearing, sore throat, worsening asthma, and dental erosion.

Causes and risk factors

• Obesity, especially abdominal fat. Risk rises with BMI.
• Hiatal hernia.
• Pregnancy.
• Smoking and heavy alcohol use.
• Diet and eating habits: large meals, fatty food, late-night eating.
• Medicines: NSAIDs and aspirin irritate the lining. Calcium channel blockers, nitrates, anticholinergics, theophylline, benzodiazepines and some antidepressants relax the LES.
• Delayed stomach emptying (gastroparesis), common in diabetes.
• Connective tissue disease, especially scleroderma.
• Older age, with weaker sphincter function.

How acid reflux is diagnosed

Clinical diagnosis

Most people with classic heartburn and regurgitation and no warning signs are diagnosed from their symptoms. A trial of a proton pump inhibitor (PPI) for 8 weeks that clearly helps supports the diagnosis.

Tests

• Upper endoscopy (EGD): a camera on a flexible tube examines the esophagus, stomach and duodenum. It shows esophagitis (graded A to D in the Los Angeles classification), Barrett's esophagus, strictures and hernias, and allows biopsies. It is done for warning signs, symptoms not responding to treatment, or before surgery.
• Ambulatory pH or pH-impedance monitoring: a thin catheter through the nose, or a wireless capsule clipped inside the esophagus, records acid exposure over 24 to 96 hours. It is the best test to confirm GERD when endoscopy is normal.
• Esophageal manometry: measures muscle and sphincter pressures, mainly before anti-reflux surgery to rule out motility disorders such as achalasia.
• Barium swallow: X-ray that shows hernias and strictures.

Treatment

Lifestyle measures

• weight loss if overweight
• raising the head of the bed 6 to 8 inches (15 to 20 cm) for night symptoms
• avoiding meals within 2 to 3 hours of lying down
• stopping smoking
• avoiding personal trigger foods and drinks

Medicines

After healing, doctors aim for the lowest effective dose, or use on demand. Long-term PPI use is generally safe when there is a clear reason. Possible associations, such as lower magnesium and B12 levels and C. difficile infection, are reasons to avoid unnecessary use, not to stop needed treatment. Do not stop a PPI abruptly after long use, because rebound acid can briefly worsen symptoms. Taper with your doctor.

Procedures and surgery

For people who do not want lifelong medicine, have regurgitation despite medicine, or have a large hiatal hernia:

• Laparoscopic fundoplication: the top of the stomach is wrapped around the lower esophagus to strengthen the valve, usually with hernia repair. It controls reflux in most people, but can cause swallowing difficulty, bloating and inability to belch.
• Magnetic sphincter augmentation (LINX): a ring of magnetic beads placed around the sphincter.
• Transoral incisionless fundoplication (TIF): an endoscopic procedure for selected patients.
• Roux-en-Y gastric bypass: preferred for reflux in people with severe obesity.

Complications

• Esophagitis: inflamed, eroded lining, which can bleed.
• Strictures: scar tissue narrows the esophagus and causes food to stick.
• Barrett's esophagus: the lining changes to a stomach-like type. It affects a minority of people with chronic GERD and slightly raises the risk of cancer, so it is monitored with endoscopy.
• Esophageal cancer: adenocarcinoma is rare overall but more likely with long-standing reflux and Barrett's.
• Respiratory problems: chronic cough, laryngitis, asthma flares and, rarely, aspiration pneumonia.
• Dental erosion.

Outlook

GERD is usually a chronic, relapsing condition, but symptoms are controlled in most people. Weight loss can cure reflux in some. Most people with GERD never develop serious complications. Those with long-term symptoms and risk factors such as being male, over 50, white, a smoker or having central obesity may be offered a one-time screening endoscopy for Barrett's esophagus.

Frequently asked questions

What is the difference between acid reflux and GERD?

Acid reflux (GER) is the backflow of stomach acid into the esophagus, which happens occasionally in most people. GERD is the chronic disease: reflux that causes troublesome symptoms at least twice a week or damages the esophagus. GERD usually needs ongoing treatment.

What causes acid reflux?

The main cause is a lower esophageal sphincter that relaxes at the wrong time or is weak. Hiatal hernia, obesity, pregnancy, smoking, large or late meals, fatty foods, alcohol and certain medicines all make this more likely.

Can acid reflux be cured permanently?

Sometimes. Weight loss, stopping smoking and changing eating habits can resolve reflux for some people. For chronic GERD, medicines control symptoms but do not fix the valve. Anti-reflux surgery can provide long-term control, though some people need medicine again years later.

How is acid reflux diagnosed?

Most cases are diagnosed from typical symptoms and improvement with a PPI. Endoscopy is used for warning signs, such as swallowing trouble or weight loss, or when treatment fails. pH monitoring measures acid exposure to confirm GERD when the endoscopy is normal.

Is it safe to take omeprazole long term?

For people with a clear need, such as erosive esophagitis or Barrett's esophagus, long-term PPI use is considered safe and the benefits outweigh risks. Doctors use the lowest dose that works and review the need regularly, because unnecessary long-term use carries small risks.