Gastroesophageal Reflux Disease (GERD)

What happens in GERD

A ring of muscle called the lower esophageal sphincter (LES) normally opens to let food into the stomach and closes to keep acid out. In GERD:

• the LES relaxes at the wrong times (transient relaxations), or is weak
• a hiatal hernia, where part of the stomach slides up through the diaphragm, weakens the barrier
• the esophagus clears acid slowly
• the stomach empties slowly, or pressure on the stomach is increased, for example by abdominal fat or pregnancy

Acid, pepsin and bile irritate the esophagus lining. Some people develop visible inflammation and erosions (erosive esophagitis), while many have symptoms with a normal-looking lining (non-erosive reflux disease).

Occasional reflux is normal. It becomes GERD when it causes troublesome symptoms, usually 2 or more times a week, or complications.

Symptoms

Typical

• Heartburn: burning behind the breastbone rising toward the throat, often 30 to 60 minutes after eating, when bending over or lying down
• Regurgitation: sour or bitter liquid or food coming up into the throat or mouth

Other symptoms

• chest pain that can mimic heart pain
• difficulty swallowing or a feeling of food sticking
• nausea, belching and bloating
• extraesophageal symptoms: chronic cough, hoarseness, frequent throat clearing, a feeling of a lump in the throat, worsening asthma, dental erosion and bad breath
• disturbed sleep from night-time symptoms

Causes and risk factors

• excess weight, especially around the waist
• hiatal hernia
• pregnancy
• smoking
• large meals and eating within 2 to 3 hours of bedtime
• trigger foods and drinks in some people: fatty or fried foods, chocolate, peppermint, coffee, alcohol, citrus, tomatoes, spicy foods, carbonated drinks
• medicines: calcium channel blockers, nitrates, some asthma drugs, sedatives, tricyclic antidepressants and NSAIDs (which irritate the esophagus)
• connective tissue diseases such as scleroderma
• slow stomach emptying (gastroparesis)

Diagnosis

Based on symptoms

Typical heartburn and regurgitation that improve with an 8-week trial of a proton pump inhibitor (PPI) are usually enough to diagnose GERD without tests.

When tests are needed

• Upper endoscopy for alarm symptoms (trouble swallowing, weight loss, bleeding, anemia, vomiting), symptoms not responding to treatment, or to screen for Barrett's esophagus. It shows esophagitis, strictures, hiatal hernia and Barrett's changes.
• Ambulatory pH monitoring (a wireless capsule or a thin tube for 24 to 96 hours) measures acid exposure. It confirms GERD before surgery or when the diagnosis is uncertain.
• Esophageal manometry measures muscle function before surgery and rules out motility disorders.
• Barium swallow for swallowing problems.

Treatment

Lifestyle changes

These have the best evidence:

• Lose weight if overweight. Even modest weight loss improves symptoms.
• Raise the head of your bed by 6 to 8 inches (15 to 20 cm) with blocks or a wedge, if you have night-time symptoms. Extra pillows alone do not work as well.
• Avoid eating for 2 to 3 hours before lying down.
• Sleep on your left side, which reduces reflux.
• Stop smoking.
• Avoid foods and drinks that clearly trigger your symptoms. Blanket avoidance of all trigger foods is not needed.
• Eat smaller meals.

Medicines

• Antacids and alginates (such as calcium carbonate or alginate rafts): quick relief for occasional symptoms.
• H2 blockers (famotidine): reduce acid for several hours, useful for mild or night-time symptoms.
• Proton pump inhibitors (omeprazole, esomeprazole, lansoprazole, pantoprazole, rabeprazole): the most effective medicines. Take them 30 to 60 minutes before breakfast. An 8-week course is typical, then the lowest dose that controls symptoms. Some people can stop or take them as needed.
• Potassium-competitive acid blockers (vonoprazan): a newer option for erosive esophagitis.

Long-term PPIs are safe for most people who need them. Possible risks include some intestinal infections, low magnesium or B12, and possibly fractures. Review the need for ongoing treatment with your doctor, but do not stop suddenly after long use, because rebound acid can temporarily worsen symptoms.

Procedures and surgery

For people with proven GERD who do not respond to, cannot tolerate, or prefer not to take long-term medicines:

• Laparoscopic fundoplication: wrapping the top of the stomach around the lower esophagus, often with hiatal hernia repair
• Magnetic sphincter augmentation (LINX): a ring of magnetic beads around the lower esophagus
• Transoral incisionless fundoplication (TIF): an endoscopic procedure for selected people
• Roux-en-Y gastric bypass for people with obesity and GERD

Complications

• Esophagitis: inflammation, ulcers and bleeding
• Esophageal stricture: scarring that narrows the esophagus, causing food to stick
• Barrett's esophagus: the lining changes to an intestine-like type, which slightly raises the risk of esophageal adenocarcinoma. Screening may be offered to people with chronic GERD and several risk factors, such as being male, white, over 50, obese, a smoker, or with a family history.
• Esophageal cancer: rare, but more common with long-standing, untreated reflux and Barrett's esophagus
• Respiratory problems: chronic cough, asthma flares, laryngitis, aspiration pneumonia
• Dental erosion

GERD in pregnancy

Heartburn affects many pregnant women, especially in the third trimester. Lifestyle measures and antacids are first-line. Many H2 blockers and PPIs are considered compatible with pregnancy when needed, but check with your doctor or pharmacist.

Frequently asked questions

What is the difference between acid reflux and GERD?

Acid reflux is the backflow of stomach contents into the esophagus, which happens occasionally in most people. GERD is when reflux happens frequently, usually twice a week or more, or causes complications such as esophagitis.

What foods should I avoid with GERD?

Common triggers include fatty and fried foods, chocolate, peppermint, coffee, alcohol, citrus, tomato-based foods, spicy foods and carbonated drinks. Triggers vary between people. Keeping a food diary helps you avoid only the foods that affect you.

Can GERD be cured?

GERD is usually a long-term condition, but it can be well controlled. Weight loss and lifestyle changes resolve symptoms in some people. Surgery can provide long-term control for selected patients. Many others manage with the lowest effective dose of medicine.

Can GERD cause chest pain?

Yes. GERD can cause burning or squeezing chest pain that mimics heart pain. Because it is impossible to tell them apart reliably at home, chest pain with breathlessness, sweating or arm or jaw pain should be treated as a possible heart attack.

Is it safe to take a PPI long-term?

For people who need them, long-term PPIs are generally safe. Possible risks include certain infections and low magnesium or B12. Your doctor will aim for the lowest dose that controls symptoms and review whether you still need it regularly.

What is the best sleeping position for GERD?

Sleeping on your left side with the head of the bed raised 6 to 8 inches reduces night-time reflux. Avoid lying down within 2 to 3 hours of eating. Lying on the right side or flat on the back tends to worsen reflux.