Gastroesophageal reflux disease (GERD), acid reflux and heartburn

 

Acid reflux is a term used to describe the abnormal movement of acid from the stomach upwards and towards the mouth. When gastric acid moves upwards, it enters the gullet (esophagus), an organ that connects the throat to the stomach. This movement causes a feeling of hotness in the chest and is often described as squeezing or burning, hence the term heartburn. Sometimes it can be mistaken for a heart attack. In reality, heartburn is not related to the heart. It is purely an acid related issue.

Acid reflux occurs if we burp or lie down after a large meal. A muscular valve separates the esophagus (gullet) from the stomach. When this valve is relaxed or loose, gastric acid can flow back into the esophagus. Should this problem occur excessively, it will lead to esophageal damage and is then called gastroesophageal reflux disease or simply GERD.

 

The risk factors for GERD are:

  • Obesity
  • Pregnancy
  • Hiatus hernia (migration of the upper part of the stomach above the diaphragm)
  • Abnormally slow transit of food from the stomach into the intestines (due to delayed gastric emptying or an obstruction in the stomach)

 

The symptoms of GERD are triggered under the following circumstances:

  • Eating a meal just before sleeping
  • Eating excessively large meals
  • Smoking cigarettes
  • Consume coffee, tea and fatty foods
  • Squatting down
  • Straining the tummy when lifting heavy objects

Some people experience the symptoms of GERD only at night when they are lying flat. This is known as nocturnal GERD.

 

Common signs and symptoms of gastroesophageal reflux disease are:

  • Heartburn and central chest pain (usually burning in nature)
  • A sour, bitter taste in the throat or mouth (acid reflux)
  • Regurgitation of stomach contents into the mouth
  • Sensation of a lump in the throat that does not clear with swallowing

 

Less common symptoms are:

  • Persistent cough which does not resolve with cough mixtures
  • A throat that is persistently sore
  • A hoarse voice
  • Worsening of asthma or a new onset of asthma in an adult

 

How is gastroesophageal reflux disease evaluated?

A specialist (Gastroenterologist) consultation is required if there is no response to gastric medicines or if the symptoms are recurring. Individuals who have bleeding (vomiting blood), problems with swallowing, unintentional weight loss or a loss of appetite need to see a Gastroenterologist. These signs and symptoms are indicative of a more serious problem.

The evaluation of GERD requires a gastroscopy (OGD or oesophagogastroduodenoscopy). This procedure uses a flexible tube with a camera at its end to examine the esophagus and stomach. A gastroscopy is a quick and safe procedure. It allows your Gastroenterologist to check the esophagus for acid related damage and a hiatus hernia. It also checks for complications such as cancer and ulcers.

 

What are the complications of GERD?

Gastroesophageal reflux disease causes acidic damage to the lower portion of the esophagus. If this is untreated, ulcers may develop. It may lead to a narrowing in the esophagus due to scarring (stricture). When this happens, one experiences difficulty in swallowing food or pain during swallowing.

Prolonged acid exposure encourages the development of pre-cancerous changes in the esophagus. This is a condition called Barrett’s esophagus. Over time, patients with Barrett’s esophagus may develop an esophageal cancer.

 

Treatment of gastroesophageal reflux disease

Diet and lifestyle changes are recommended in all patients who have GERD. This includes eating smaller and more frequent meals, rather than three large meals a day. A reduction in coffee and tea improves the symptoms of reflux. Fatty and oily foods should be avoided as well. In addition, one should avoid lying down soon after a meal or a drink. It is advisable to stay upright for 3 hours after a meal.

If nocturnal symptoms are prevalent, then one should avoid suppers and a heavy dinner. Sleeping with the head of the bed tilted upwards will minimise the chances of acid reflux. The tilt should include the upper body and not only the head. Finally, patients who are overweight should lose some weight.

There are three types of medicines for GERD:

  • Tablets to suppress gastric acid
  • Tablets to relieve bloating and empty the stomach (prokinetic)
  • Medicines to neutralise acid (antacids)

Finally, surgery can be performed in patients who have severe symptoms or experience breathing difficulties due to the regurgitation of acid and food. This operation is a fundoplication. During a fundoplication surgery, the upper part of the stomach that is adjacent to the esophagus is tightened. In doing so, acid reflux is prevented. The aim of such an operation is cure GERD, so that medicines may be stopped. However, in almost 20% of all patients who undergo this operation, reflux symptoms will reoccur after several years and medicines will be needed again.

 

Dr Eric Wee,

Consultant Gastroenterologist and Hepatologist,

Nobel Gastroenterology Centre

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