Gastroesophageal reflux disease (GERD), also called gastro-oesophageal reflux disease (GORD), is a long-term condition that affects the upper part of the digestive system. It happens when stomach contents regularly flow back into the esophagus, causing symptoms or health problems. Common symptoms include damage to teeth, trouble swallowing, chest pain, a burning feeling in the chest (heartburn), pain when swallowing, bringing up food or liquid, chest pain not caused by the heart, and other issues like a long-lasting cough, a hoarse voice, throat irritation from acid, or asthma-like symptoms. If not treated over time, GERD can lead to problems such as inflammation of the esophagus, narrowing of the esophagus, or a condition called Barrett's esophagus.

Risk factors for GERD include being overweight, being pregnant, smoking, having a hiatal hernia, and using certain medicines. Some medicines that may worsen GERD are benzodiazepines, calcium channel blockers, tricyclic antidepressants, nonsteroidal anti-inflammatory drugs (NSAIDs), and some asthma medications. Acid reflux occurs when the lower esophageal sphincter, a muscle at the top of the stomach, does not close properly. If symptoms do not improve with simple treatments, doctors may use tests such as gastroscopy, an upper gastrointestinal X-ray, esophageal pH monitoring, or esophageal manometry to diagnose the condition.

Treatment for GERD can include lifestyle changes, medicines, or surgery if other methods do not work. Lifestyle changes may involve avoiding lying down for three hours after eating, sleeping on the left side, raising the head of the bed, losing weight, and quitting smoking. Foods that may worsen symptoms include coffee, alcohol, chocolate, fatty foods, acidic foods, and spicy foods. Medicines used to treat GERD include antacids, H2 receptor blockers, proton pump inhibitors, and prokinetics.

In the Western world, about 10 to 20% of people have GERD. It is very common in North America, where 18% to 28% of people experience the condition. Occasional acid reflux without serious symptoms is even more common. The classic symptoms of GERD were first described in 1925 by Friedenwald and Feldman, who noted heartburn and its possible link to a hiatal hernia. In 1934, gastroenterologist Asher Winkelstein described reflux and connected the symptoms to stomach acid.

Signs and symptoms

The most common symptoms of GERD in adults are an acidic taste in the mouth, regurgitation, and heartburn. Less common symptoms include pain when swallowing or a sore throat, increased saliva production (also called water brash), nausea, chest pain, coughing, and a feeling of something stuck in the throat (called globus sensation). Acid reflux can cause symptoms similar to an asthma attack, such as trouble breathing, coughing, and wheezing in people who already have asthma.

GERD can sometimes harm the esophagus. These injuries may include:

• Reflux esophagitis – inflammation of the esophagus lining that can lead to sores near where the stomach and esophagus meet
• Esophageal strictures – long-term narrowing of the esophagus caused by repeated inflammation from acid
• Barrett's esophagus – a change in the cells of the lower esophagus, where they become similar to cells found in the intestines
• Esophageal adenocarcinoma – a type of cancer

GERD can also harm the larynx (called LPR). Other possible problems include aspiration pneumonia, where stomach acid enters the lungs.

GERD is harder to detect in infants and children because they cannot explain their feelings, and signs must be observed. Symptoms in children may differ from adult symptoms. Common signs include frequent vomiting, spitting up without effort, coughing, and breathing problems like wheezing. Other signs may include crying that cannot be comforted, refusing to eat, crying for food and then pulling away from the bottle or breast, not gaining enough weight, bad breath, and burping. Children may have one or many symptoms, and no single symptom is the same for all children with GERD.

Of the about 4 million babies born in the United States each year, up to 35% may experience reflux symptoms in their first few months, called "spitting up." Around 90% of infants will stop having reflux symptoms by their first birthday.

Stomach acid entering the mouth can damage tooth enamel, especially on the inside of the teeth. Signs may include a dry mouth, a burning or sour feeling in the mouth, bad breath, and redness on the roof of the mouth. Less common symptoms of GERD include trouble swallowing, increased saliva, a long-lasting cough, a hoarse voice, nausea, and vomiting.

Signs of enamel erosion include a smooth, shiny, or dull surface on the teeth, with no visible ridges (called perikymata), and intact enamel near the gumline. This damage is often noticeable on teeth with fillings, as the filling may appear higher than the surrounding tooth because the enamel dissolves faster than the filling material.

GERD can lead to Barrett's esophagus, a condition where the cells in the lower esophagus change to a type found in the intestines. This change is a risk factor for developing esophageal cancer. The chance of Barrett's esophagus turning into a precancerous condition called dysplasia is estimated to be about 20%. Because of the risk of long-term heartburn leading to Barrett's esophagus, people with chronic heartburn or who take medications for GERD are advised to have an endoscopy (EGD) every five years.

Causes

A small amount of acid reflux is normal even in healthy people, such as when heartburn occurs rarely and is mild. However, gastroesophageal reflux becomes gastroesophageal reflux disease (GERD) when symptoms happen repeatedly. Frequent acid reflux can occur if the lower esophageal sphincter, the muscle between the stomach and esophagus, does not close properly.

Things that can cause GERD:

• Hiatal hernia, which increases the risk of GERD because of how the stomach and esophagus function.
• Obesity: higher body mass index is linked to more severe GERD. A study of 2,000 patients showed that 13% of changes in acid exposure in the esophagus were connected to changes in body mass index.
• GERD can be a symptom of mast cell activation syndrome (MCAS).

Things that may be related to GERD, but are not proven to cause it:

• Obstructive sleep apnea
• Gallstones, which can block the flow of bile into the duodenum, affecting the ability to neutralize stomach acid

In 1999, a review of studies found that 40% of GERD patients had an infection caused by H. pylori bacteria. Removing H. pylori can increase stomach acid production, raising questions about whether GERD patients with this infection are different from those without it. A 2004 study found no major differences in disease severity between these two groups when measured subjectively or objectively.

The cause of GERD includes bile from the stomach entering the esophagus, which leads to the production of harmful molecules, oxidative stress, inflammation, and DNA damage. In tests, Lactobacilli bacteria helped repair this DNA damage, suggesting they might help prevent the development of Barrett's esophagus and esophageal adenocarcinoma in people with GERD.

During surgery in dogs, acid reflux is common and can cause problems such as esophagitis, esophageal strictures, regurgitation, and aspiration pneumonia. Studies show that 40 to 60% of dogs experience this during non-abdominal surgery when given a combination of an opioid and a sedative.

Diagnosis

The diagnosis of GERD is usually made when typical symptoms are present. Reflux can occur in people without symptoms, and a diagnosis requires both symptoms or complications and the presence of stomach contents moving back into the esophagus.

Other tests may include esophagogastroduodenoscopy (EGD), which uses a flexible tube with a camera to examine the esophagus, stomach, and upper part of the small intestine. Barium swallow X-rays are not used to diagnose GERD. Esophageal manometry, which measures muscle movement in the esophagus, is not recommended for diagnosing GERD but may be used before surgery. Ambulatory esophageal pH monitoring, which tracks acid levels in the esophagus over time, may help confirm GERD in people who do not improve after taking proton-pump inhibitors (PPIs). This test is not needed if Barrett’s esophagus is already confirmed. Testing for H. pylori infection is usually not required.

The most reliable method to diagnose GERD is esophageal pH monitoring. This test provides objective evidence of acid reflux and helps monitor how well treatment is working. A short-term trial of PPIs may also be used to diagnose GERD. If symptoms improve after taking PPIs, it supports the diagnosis. This trial may also help predict whether pH monitoring would show abnormal results in people with symptoms that suggest GERD.

Endoscopy, which uses a flexible tube with a camera to examine the stomach, is not always needed if the condition is typical and responds to treatment. It is recommended for people who do not improve with treatment or who have alarm symptoms, such as difficulty swallowing, anemia, blood in the stool (found through tests), wheezing, unexplained weight loss, or changes in voice. Some doctors suggest having an endoscopy once or every 5 to 10 years for people with long-term GERD to check for changes like dysplasia or Barrett’s esophagus.

Biopsies taken during gastroscopy may show:
– Swelling and increased cell growth in the esophagus (non-specific inflammation)
– Inflammation from immune cells (non-specific)
– Inflammation from white blood cells, often caused by reflux or Helicobacter pylori infection
– Inflammation from a type of white blood cell called eosinophils, which may indicate a condition called eosinophilic esophagitis (EE) if the number of eosinophils is very high. If fewer than 20 eosinophils are seen in a microscopic view of the lower esophagus and other signs of GERD are present, it is more likely to be GERD than EE.
– Changes in the cells lining the esophagus, such as the presence of cells similar to those in the intestines (Barrett’s esophagus)
– Enlarged structures in the esophagus
– Thinning of the outer layer of the esophagus
– Abnormal cell changes (dysplasia)
– Cancer

Reflex that does not cause visible damage to the esophagus is called "nonerosive reflux disease."

The severity of GERD can be measured using the Johnson-DeMeester scoring system:
– 0: No symptoms
– 1: Mild – occasional symptoms
– 2: Moderate – symptoms require medical visits
– 3: Severe – symptoms interfere with daily life

Before diagnosing GERD, other causes of chest pain, such as heart disease, should be ruled out. Another type of acid reflux, called laryngopharyngeal reflux (LPR) or extraesophageal reflux disease (EERD), can cause symptoms in the throat and lungs but rarely causes heartburn. This is sometimes called "silent reflux." Other conditions that may be confused with GERD include dyspepsia, peptic ulcers, esophageal or gastric cancer, and food allergies.

Treatment

Treatment for GERD can include changes in food choices, lifestyle habits, medicines, and sometimes surgery. The first step is often using a type of medicine called a proton-pump inhibitor, such as omeprazole. In some cases, people may use over-the-counter medicines to manage symptoms. These are often safer and less expensive than prescription medicines. Some guidelines suggest trying a type of medicine called an H2 antagonist before using a proton-pump inhibitor because of cost and safety concerns.

Medical nutrition therapy helps manage GERD symptoms by reducing acid reflux, preventing pain, and lowering stomach acid production. Certain foods, like chocolate, mint, high-fat foods, and alcohol, can relax the lower esophageal sphincter, increasing the risk of acid reflux. Weight loss is recommended for people who are overweight or obese. Other lifestyle changes include avoiding snacks before bedtime, waiting 2 to 3 hours after eating before lying down, elevating the head of the bed with 6-inch blocks, avoiding smoking, and wearing loose clothing. It may also help to avoid spicy foods, citrus juices, tomatoes, and soft drinks. Eating small, frequent meals and drinking liquids between meals is advised. Some evidence suggests reducing sugar intake and increasing fiber intake may help. Moderate exercise can improve symptoms, but intense exercise may make them worse. Breathing exercises may also help relieve symptoms.

Common medicines for GERD include proton-pump inhibitors, H2 receptor blockers, and antacids with or without alginic acid. Acid suppression therapy is often used to treat symptoms, but it may be overused, leading to side effects and higher costs. Proton-pump inhibitors (PPIs), like omeprazole, are the most effective, followed by H2 receptor blockers. If a once-daily PPI is not fully effective, it may be taken twice daily. PPIs should be taken 30 minutes to one hour before a meal. When used long-term, the lowest effective dose should be used. These medicines may also be taken only when symptoms occur. H2 receptor blockers improve symptoms in about 40% of people.

Antacids have weaker evidence of benefit, helping about 10% of people (NNT =13), while antacids combined with alginic acid (like Gaviscon) may help 60% (NNT=4). Metoclopramide, a type of medicine called a prokinetic, is not recommended due to side effects. Mosapride, another prokinetic, has limited benefit. Sucralfate is as effective as H2 receptor blockers but requires multiple daily doses. Baclofen, a medicine that activates the GABA B receptor, is effective but needs frequent dosing and has more side effects.

The standard surgery for severe GERD is called Nissen fundoplication. This procedure wraps the top of the stomach around the lower esophageal sphincter to strengthen it and prevent acid reflux. It is only recommended for people who do not improve with PPIs. Surgery improves quality of life in the short term but long-term benefits compared to medical treatment are unclear. Partial posterior fundoplication is more effective than partial anterior fundoplication, and partial fundoplication has better outcomes than total fundoplication.

Esophagogastric dissociation is an alternative surgery sometimes used for children with neurological issues and GERD. Early studies suggest it may reduce reflux recurrence. In 2012, the FDA approved a device called LINX, which uses magnetic beads placed around the lower esophageal sphincter. It is used for people with severe symptoms not helped by other treatments. Its effectiveness is similar to Nissen fundoplication, but long-term data is limited. It reduces complications like gas bloat syndrome but may cause difficulty swallowing, chest pain, vomiting, or nausea. It should not be used by people allergic to titanium, stainless steel, nickel, or ferrous iron, or those who may need MRI scans.

A newer surgery called TIF transoral incisionless fundoplication may be used for people at high surgical risk or who cannot tolerate PPIs. Benefits may last up to six years.

GERD is common during pregnancy but usually improves after childbirth. Symptoms often worsen as pregnancy progresses. Lifestyle changes like elevating the bed, eating small meals, avoiding fluids with meals, and not eating three hours before bedtime may help. Calcium-based antacids are recommended if changes fail. Antacids with sodium bicarbonate or magnesium trisilicate should be avoided. Sucralfate, cimetidine, and PPIs are considered safe during pregnancy.

Babies may benefit from smaller, more frequent feedings, frequent burping, keeping them upright for 30 minutes after feeding, and elevating their head while lying down. Removing milk and soy from the mother’s diet or using milk-free formula may help. Medicines like PPIs or H2 receptor blockers may be used, but PPIs are not effective in babies, and safety evidence is limited.

Occupational therapists help position infants with GERD during and after feeding. A technique called the log-roll is used when changing clothing or diapers. Placing infants on their back with legs lifted is not recommended, as it can cause acid to flow back. Instead, therapists suggest rolling the infant on their side, keeping the shoulders and hips aligned. Feeding on the side with an upright position is preferred. After feeding, infants should be kept on their stomach or upright for 20 minutes.

Epidemiology

In Western countries, GERD affects about 10% to 20% of people, and 0.4% of people develop the condition for the first time. For example, about 3.4 million to 6.8 million Canadians have GERD. The rate at which GERD occurs in developed nations is closely related to age, with adults between 60 and 70 years old being most commonly affected. In the United States, 20% of people experience GERD symptoms during a typical week, and 7% have symptoms every day. There is no evidence that GERD affects one sex more than the other.

History

An outdated treatment is vagotomy, a surgery that removes parts of the vagus nerve that control the stomach lining. This method is now mostly replaced by medicine. Performing vagotomy alone often made it harder for the pyloric sphincter (a muscle at the stomach's exit) to tighten, which slowed the movement of food from the stomach to the intestines. In the past, doctors combined vagotomy with other surgeries, such as pyloroplasty or gastroenterostomy, to help fix this issue.

Research

Several medical devices have been tested to help treat chronic heartburn.

• The Endocinch device uses stitches to strengthen the lower esophageal sphincter (LES) by creating small folds. However, long-term results were not good, and the device is no longer sold by Bard.
• The Stretta procedure uses electrodes to apply radio-frequency energy to the LES. A 2015 review did not support the claim that Stretta was effective for GERD. A 2012 review found that it improved GERD symptoms.
• The NDO Surgical Plicator creates a fold of tissue near the gastroesophageal junction and secures it with a suture-based implant. The company stopped operating in mid-2008, and the device is no longer available.
• Transoral incisionless fundoplication, which uses a device called Esophyx, may be effective.