What is GERD?
Gastroesophageal Reflux Disease (GERD), more commonly known as heartburn, is caused by acid from the stomach moving into the esophagus, which causes a burning pain in the middle of the chest.
Anatomy
After swallowing, food moves down the esophagus and into the stomach. The lower esophageal sphincter (LES), which is at the connection between the esophagus and stomach, prevents stomach contents from moving back into the esophagus. The lower esophageal sphincter is located below the diaphragm, where pressure from the abdominal organs helps keep the sphincter closed. There are different causes of GERD, but the lower esophageal sphincter is key to preventing reflux. See below for more details about why GERD occurs.
Source: UpToDate Images: Gastroesophageal Reflux (GERD)
Causes of GERD
Decreased pressure of the lower esophageal sphincter- if the lower esophageal sphincter is too loose/ relaxed, stomach contents move more easily into the esophagus. This can be a pre-existing condition but it can also be caused or worsened by lifestyle habits. For example, tobacco and certain foods such as alcohol, chocolate, caffeine, carbonation, mint, citrus/ tomato-based foods, spicy/ fried/ fatty foods, can also decrease the pressure of the sphincter.
Eating too much/ too fast→ overfilling the stomach leads to increased pressure, causing stomach contents to be pushed into the esophagus
Laying flat- when you are standing or sitting upright gravity helps avoid reflux by keeping food in the stomach, but when laying flat, stomach contents can move into the esophagus more easily. This is why symptoms are often more severe at night or first thing in the morning.
Hiatal hernia- when the lower esophageal sphincter is able to move into the chest, it no longer has the external pressure normally present when it’s in it’s correct position, and it more easily allows stomach contents to move into the esophagus. See link for image.
Obesity or pregnancy- increased pressure on the abdomen from excess weight can put pressure on the stomach and allows stomach contents to move into the esophagus for easily.
GERD: Symptoms and Causes [Mayo Clinic: Patient Care & Health Information]
Diagnosis
Symptoms are often adequate to diagnosis GERD.
A swallow study can provide further information. This study is performed in radiology, and involves drinking contrast material and having x-ray images taken to evaluate the esophagus and stomach while you swallow. This study can diagnose esophageal problems, such as poor muscle function leading to swallowing difficulty. In addition, a hiatal hernia can be identified.
An esophagogastroduodenoscopy (EGD), also known as an upper endoscopy (see link) can be used to assess the inner lining of the esophagus, stomach and the first part of the small intestine (duodenum). There are many things that can be identified on an EGD, but specifically related to GERD, damage to the lining of the esophagus and the presence of a hiatal hernia can be identified with an EGD.
Patient education: Upper endoscopy (Beyond the Basics)Â [UpToDate]
Upper Endoscopy [Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)]
Additional testing can be performed based on symptoms, results of initial testing and response to treatment.
Esophageal manometry- a study to evaluate the muscle function of the esophagus (
pH test- a study to evaluate how much acid the esophagus is exposed to, which is one measure of the severity of GERD.
GERD: Diagnosis and Treatment [Mayo Clinic: Patient Care & Health Information]
Treatment
Lifestyle Modifications [Patient Handout: Anti-Reflux Diet and Lifestyle Modifications]
Eat slowly, avoid eating large meals and stop eating before you feel full.
Avoiding alcohol, chocolate, caffeine, carbonation, mint, citrus/ tomato-based foods, spicy/ fried/ fatty foods.
Avoid lying down for at least 2-3 hours after meals. Don't snack after dinner/ before bed.
Elevating the head of the bed by 6-8 inches. This is NOT done by placing multiple pillows under your head- multiple pillows would actually increase pressure in the abdomen (like doing a sit-up or crunch). For more information, see this guide from the Kingsley clinic.
Lose weight.
Stop smoking.
Avoid tight-fitting clothing.
Medication
Over the counter antacids
Prescription medication
Surgery
Depending on how well medication and lifestyle modifications improve your GERD symptoms, and depending on the results of your other studies, such as your swallow study, esophageal manometry and pH testing, surgery may be an option for GERD.
UpToDate Patient Education