Gastroesophageal Reflux Disease (GERD) is a chronic condition characterized by the frequent backflow of stomach acid into the esophagus. This condition is common, affecting approximately one in five adults in the United States. Understanding the mechanisms behind this disease is the first step toward managing its symptoms.
How Gastroesophageal Reflux Disease Develops
The digestive system relies on the lower esophageal sphincter (LES), a specialized muscular structure that acts as a one-way valve where the esophagus meets the stomach. Its primary role is to open briefly to allow food into the stomach and then immediately contract to prevent stomach contents from moving back up.
GERD develops when this muscular ring fails to maintain tension or relaxes inappropriately. When the LES loosens, it allows the stomach’s highly acidic digestive juices, partially digested food, and sometimes bile, to flow backward into the esophagus. This backward movement is known as reflux.
The esophagus lacks the protective mucosal lining of the stomach, so the refluxed acid causes irritation and inflammation, medically termed esophagitis. The most common mechanism for this failure is transient lower esophageal sphincter relaxation (TLESR), where the sphincter opens spontaneously. This repeated exposure to stomach acid defines the persistent, chronic nature of GERD, distinguishing it from occasional acid reflux.
Recognizing the Symptoms of GERD
Identifying GERD requires recognizing the frequency and type of symptoms experienced. For a diagnosis, symptoms generally need to occur at least two or more times per week, indicating a pattern of chronic irritation.
The most identifiable symptom is heartburn (pyrosis), a burning sensation felt behind the breastbone that often radiates upward toward the throat. This pain is caused by the acidic contents irritating the esophageal lining. Another common symptom is regurgitation, the backward flow of stomach fluid or food into the throat or mouth, often resulting in a sour or bitter taste.
GERD can also manifest through extra-esophageal, or atypical, symptoms that affect the respiratory tract. These may include a persistent cough, hoarseness, or symptoms resembling laryngitis, as the acid irritates the vocal cords.
Some individuals report non-cardiac chest pain, which can be mistaken for a heart issue, or dysphagia (difficulty or pain when swallowing). Dysphagia may signal severe inflammation or the development of a stricture, which is a narrowing of the esophagus caused by chronic scarring.
Common Causes and Contributing Risk Factors
The underlying causes of GERD involve a combination of anatomical issues and lifestyle habits that compromise LES function or increase stomach pressure. One significant anatomical factor is a hiatal hernia, where the upper part of the stomach pushes up through the diaphragm muscle. This displacement impairs the sphincter’s ability to close tightly, making reflux more likely.
Increased intra-abdominal pressure is another major factor, commonly linked to obesity or pregnancy. Excess weight places constant upward pressure on the stomach, forcing contents against the LES. Lying down immediately after consuming a large meal also allows gravity to assist the reflux process.
Certain lifestyle choices directly contribute to the weakening of the LES. Smoking, for instance, reduces saliva production, a natural acid buffer, and decreases the resting pressure of the sphincter muscle.
Dietary habits also play a role, as several substances can temporarily relax the LES or increase stomach acid production. Common triggers include high-fat foods, chocolate, peppermint, alcohol, and caffeine. Consuming these items close to bedtime increases the likelihood of a reflux episode.
Lifestyle Changes and Medical Treatments
Managing GERD typically begins with targeted lifestyle modifications, which can reduce the frequency and severity of reflux episodes. Achieving a healthy body weight is often the most effective change, as it reduces the intra-abdominal pressure stressing the LES.
Adjusting eating habits provides immediate benefits, such as consuming smaller, more frequent meals. It is recommended to avoid eating or drinking anything, except water, for at least two to three hours before lying down.
For nighttime reflux, physically elevating the head of the bed by six to eight inches uses gravity to prevent acid from flowing upward. This elevation should be achieved by placing blocks under the bedposts, not by using extra pillows, which only bend the neck. Avoiding known dietary triggers like high-fat foods, spicy items, and carbonated beverages also helps manage symptoms.
If lifestyle adjustments alone do not provide relief, over-the-counter (OTC) and prescription medications are available to manage acid levels.
Medications
Antacids, such as calcium carbonate, offer quick, temporary relief by neutralizing the acid already present in the stomach.
For longer-lasting symptom control, H2 receptor blockers (H2 blockers) reduce the amount of acid the stomach lining produces. These medications bind to histamine receptors on stomach cells, decreasing acid secretion.
The most potent class of medications are prescription-strength proton pump inhibitors (PPIs), such as omeprazole or lansoprazole. PPIs work by blocking the final step of acid production in the stomach’s parietal cells. These are reserved for more severe or persistent cases of GERD and are typically taken once daily before the first meal.
In rare, severe cases where medication and lifestyle changes fail, or when complications like severe esophagitis or strictures develop, surgical intervention may be considered. Procedures like Nissen fundoplication involve wrapping the top part of the stomach around the lower esophagus to reinforce the weakened sphincter. This procedure increases the pressure barrier to prevent reflux.