Heartburn & Gastroesophageal Reflux Disease (GERD) Explained:

What Is GERD?

The passage of gastric/stomach contents into the esophagus is called gastroesophageal reflux. It is not abnormal for gastroesophageal reflux to occur, and in fact it is a normal part of our physiology. The physiologic process of reflux becomes a disease (GERD) when symptoms occur, occur frequently, or there is associated injury or complications from the acid injury induced by repeated episodes of reflux.

What Are Symptoms of GERD?

There are two types of symptoms that are attributable to GERD: Typical and Atypical symptoms.

Typical symptoms include: heartburn, which is a burning pain behind the sternum or breast bone, and reflux or regurgitation in which one experiences flow of stomach contents upwards into the chest, mouth and or throat. When longstanding, patients may experience dysphagia or trouble swallowing as a result of inflammation (esophagitis) or formation of a stricture (point of narrowing).

Atypical symptoms include chest pain, a sensation of something stuck in the throat (globus), a chronic cough, hoarseness, wheezing, and nausea. These symptoms can be caused by conditions other than GERD therefore are not sufficient to make a diagnosis of GERD in the absence of more typical or classic symptoms.

What Causes GERD?

GERD occurs when stomach contents flow backwards into the esophagus. This backwards flow is usually limited by the function of the lower esophageal sphincter complex which includes the diaphragm muscle and the lower esophageal sphincter (LES) muscle. The LES largely remains closed and opens when you swallow allowing food to move into the stomach. The diaphragm muscle provides added pressure around the LES.

A number of factors may influence the frequency of reflux episodes by increasing the amount of time the sphincter is open including a hiatal hernia, alcohol, caffeine, spicy foods, fatty meals, large meals, chocolate and peppermint. Risk for GERD also increases with increasing body weight. In addition to these factors late night eating or laying down shortly after eating may increase risk for reflux symptoms.

How Do You Treat GERD?

Treatment for GERD depends on the severity of symptoms as well as presence of underlying life-style choices and medical risk factors. Dr. Motola spends considerable time with patient’s identifying their underlying risk factors and tailors treatment to each individual. However, all forms of treatment should include attempts at maximizing life-style interventions. These include:

1. Weight loss
2. Alcohol cessation
3. Caffeine cessation
4. Avoiding known triggers : for some this includes spicy foods, tomato, citrus fruits, vinegar, fatty foods, heavy meals.
5. Raising the head of the bed or using a wedge pillow
6. Eating smaller meals, eating slowly
7. Stress reduction

In addition to life-style changes medications can be used to decrease stomach acid. There are several medications that can be used to reduce stomach acid levels and each differs in mechanism and strength of effect:

1. Tums: Calcium Carbonate neutralizes acid, short acting quickly but lasting ~1 hour.
2. Rolaids: Calcium Carbonate and Magnesium Hydroxide, neutralizes acid, short acting quickly but lasting ~1 hour.
3. Histamine 2(H2) Receptor antagonists: these block histamine receptors on the stomach cells that make stomach acid (Parietal cells). However, these cells have multiple inputs that lead to output of acid by the proton pump . Loss of effect can be seen over 2-6 weeks due to increased production of H2 receptors by parietal cells –
   • Zantac/Ranitidine: doses 75-150 mg daily to twice daily. Taken 1 hr before meals. Effects last 4-10 hrs. (tachyphylaxis) thus there is less effect over time.

• Pepcid/Famotidine: doses 10-20 mg taken once or twice daily 30-60 min before breakfast

4. Proton Pump inhibitors (PPI): these medications block acid production by parietal cells by binding irreversibly to proteins that pump acid into the stomach. These are the most effective and longest lasting, lasting 24 hrs.

• Prilosec, generic is omeprazole
• Nexium, generic isesomeprazole
• Prevacid, generic is lansoprazole
• Protonix, generic is pantoprazole
• Dexilant, dexlansoprazole
• Aciphex , rabeprazole

What Medications Are Over The Counter? Do I Needs Prescriptions?

With the exception of Protonix/Pantoprazole, Dexilant and Aciphex all forms of medications used to treat heartburn can be found over the counter (OTC). The dosages over the counter are on the low end for most medications. Most OTC PPIs are 20 mg and this is a standard low dose treatment option for GERD, with exception of Lansoprazole, which starts at 15 mg. A prescription can be given for a higher dose of PPI (usually 40 mg) and for longer than 14 days. Further, prescription drug coverage can be used. The OTC medications are no different structurally or functionally compared to those that are prescribed.

Do Acid Suppressing Medications Stop Reflux?

No, in fact, these medications just reduce stomach acid levels. They do not stop backward flow of stomach fluid into the esophagus. However, in the process of reducing stomach acid they can allow healing of underlying inflammation and reduce symptoms such as heartburn, chest pain, nausea, and improve swallowing.

Keep in mind that if lifestyle changes are not made there will likely be continued symptoms of reflux.

When Should One See A Gastroenterologist?

Patients should seek medical attention for GERD symptoms when symptoms are frequent (occur more than once a week), are uncontrolled despite life-style changes, medication therapy, or when symptoms are recurrent and/or are associated with certain warning signs:

• Unintentional weight loss
• Difficulty swallowing
• New onset symptoms in someone age ≥60 years
• Evidence for bleeding (blood in stool or vomit)
• Iron deficiency anemia
• Anorexia
• Pain when swallowing
• Recurrent Vomiting
• Family history of GI cancers

What Is The Role Of Upper Endoscopy?

An upper endoscopy is performed to evaluate for causes of persistent symptoms, difficulty swallowing, in the setting of alarm symptoms and to screen for a precancerous conditions called Barrett’s esophagus in those at risk. Barrett’s esophagus is condition used to describe a change in cells of the esophagus from flat esophageal cells to glandular like intestinal cells, a process called metaplasia. Metaplasia can be visible by eye under endoscopy but must be confirmed through biopsies.

Barrett’s esophagus occurs in the setting of chronic reflux and can lead to esophageal cancer, albeit at a low rate of about 0.1% per year. The risk of cancer of the esophagus is low in general but patient’s with Barrett’s esophagus have a higher risk compared to those without Barrett’s esophagus. Risk factors for Barrett’s include having one or more of the following : male sex, caucasian ethnicity, chronic reflux >5 years, smoking, and obesity.

What Is The Role Of Surgery In GERD?

Patients who do not achieve symptom relief with medications and/or life style changes may be candidates for surgical repair of predisposing structural problems such as a hiatal hernia or a malfunctioning lower esophageal sphincter muscle. Prior to consideration for surgery patients are likely to undergo an upper endoscopy and specialized testing to determine if reflux is the true cause of symptoms such as a 24 hr Ph Impedance test and esophageal motility test. Some patients have reflux hypersensitivity or functional heart burn, which are two conditions that require different treatments altogether.