Gastroesophageal reflux disease is a medical condition characterized by reflux of acid and digestive enzymes from the stomach into the esophagus, resulting in discomfort, abnormal tastes, and abnormal smells. 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.
The symptoms of gastroesophageal reflux are caused by acid and digestive enzymes from the stomach entering the esophagus. This results in irritation of the esophageal lining – leading to the burning sensation that gives heartburn its name. 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 with 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 – known as Barrett’s esophagus. Eventually, chronic irritation can lead to adenocarcinoma of the lower esophagus.
Conditions that lead to severe acid reflux generally occur as a result of other medical conditions. Any condition that increases the amount of physical pressure on or in the abdominal cavity can result in gastric reflux. Some of these conditions are very common and temporary, while others are rarer and irreversible. Exposure to certain toxins and substances may also result in reflux. The most common causes of gastric reflux are:
- 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
Gastroesophageal reflux is extremely common in the United States with an estimated 20% to 30% of the population experiencing symptoms in a given year. The majority of individuals with symptoms experience them on a regular basis, one study stated that 22% of adults report experiencing symptoms of reflux in a given year.
Reflux is more common among individuals with the risk factors listed above and can be acutely worsened by the regular use of substances such as alcohol, tobacco, and over the counter pain relievers such as ibuprofen and aspirin.
The signs and symptoms of gastroesophageal reflux often begin intermittently and are relatively mild. This condition is commonly known as “heartburn” as the most common symptom is a sensation of burning within the chest, below the sternum. Most patients have at least one additional symptom, the most common being:
- Regurgitation – a sour taste in mouth
- Abdominal discomfort
- Dyspepsia – bloating, early satiety
- Asthma exacerbations
Red flag symptoms that are concerning for some complications of reflux such as cancer, stomach ulcers, and damage to the esophagus are:
- Advanced age >55
- Difficulty swallowing (dysphagia)
- Pain on swallowing (odynophagia)
- Anorexia & weight loss
- Blood in the stool
The diagnosis of gastroesophageal reflux is based on your history of symptoms. Your doctor will generally ask you about when your symptoms seem to present and any obvious triggers you have noticed. More detailed questions about your medical history and a basic physical examination of the mouth, neck, and abdomen will then be performed. If your symptoms are atypical or there is anything in your history to suggest that a complication of gastroesophageal reflux is present your physician may order some specialized tests and imaging studies.
Your doctor may test you for Helicobacter pylori infection with a stool antigen study. This bacteria can infect the stomach and small intestine resulting in severe peptic ulcer disease and symptoms of reflux. 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 to evaluate the liver, gallbladder, and pancreas for other medical conditions that can present with reflux as a symptom.
Some doctors will obtain an ECG (electrocardiogram) if they are concerned for heart disease. This is more likely if you have conditions such as diabetes, high blood pressure, or high cholesterol that increase your risk for heart disease.
Patients with severe symptoms, symptoms that suggest potential complications, 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 visually 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 lesions and may be able to treat various abnormalities (eg, balloon dilation of a stricture).
Your doctor may also recommend 24-hour ambulatory pH monitoring. Which analyzes the acidity of the esophagus throughout the course of the day and can give insight into what may be triggering your symptoms.
Gastrointestinal reflux disease is initially treated with lifestyle and dietary modifications. This includes avoiding alcohol/tobacco use, excessive caffeine intake, spicy foods, and NSAIDs. A low-impact exercise plan that is focused on walking, bicycle riding, yoga, Pilates, or light weight lifting has been shown to improve reflux symptoms. Weight loss in those that are overweight or obese has also been associated with dramatic reductions in the symptoms of GERD.
Patients are also typically treated with medications that reduce the acidity of the stomach, proton-pump inhibitors (PPIs) are the most common and are commonly available over the counter. The most commonly prescribed are:
- Prilosec (omeprazole)
- Protonix (pantoprazole)
- Prevacid (lansoprazole)
- Dexilant (dexlansoprazole)
PPIs are generally taken daily and are 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. These medications are often prescribed in combination with PPIs in patients with severe symptoms. Those with severe allergies may also benefit from histamine blockers.
Studies show that about 10%-40% of individuals with acid reflux do not respond to standard doses of proton pump inhibitors. In some cases, more frequent dosing will be recommended by your physician.
If the symptoms of reflux do not respond to first-line treatment strategies or if you have red flag symptoms such as bleeding, intolerance of food, or constant pain, you may require referral to a gastroenterology specialist for consideration of further work-up with upper endoscopy or 24-hours ambulatory pH monitoring.