Gastroesophageal Reflux Disease, or GERD, is a digestive disorder that affects patients of all ages. It occurs when stomach juices back up or “reflux” due to a dysfunction of the valve in the lower esophagus, the lower esophageal sphincter (LES). In healthy patients, food passes from the esophagus to the stomach and the LES closes to prevent acidic food matter from rising back into the esophagus. However, when LES function is compromised, reflux occurs, leading to a wide array of potential symptoms.
Although heartburn is the most common symptom of GERD reported by patients, there are many others, including chest pain, difficulty swallowing (dysphagia), regurgitation, hoarseness, and chronic cough. There are multiple ways to reduce these symptoms and prevent further harm to the esophagus, which can include esophageal cancer.
Here is some expert advice to consider in the management of gastroesophageal reflux disease (GERD).
- understand your disease
- implement lifestyle changes – even small ones help
- know what your medication is and is not doing
- see a reflux expert if your GERD is progressing
- consider the risks of Barrett’s esophagus and find out if you’re at risk
- assume its reflux; it could be many things
- self-medicate for prolonged periods without seeing a doctor
- assume that PPIs have cured your reflux
- ignore esophageal cancer
If left untreated, chronic exposure of esophageal tissues from GERD can pose significant medical complications including:
Esophageal strictures: Scar tissue resulting from damage to its lining can result in a narrowing of the esophagus. This obstruction can cause severe swallowing difficulties.
Esophageal inflammation: This is known as esophagitis and is caused by extensive erosion of esophageal tissue. It may be extremely painful.
Barrett's esophagus: This pre-cancerous condition occurs when cells typically found in the esophagus are replaced, due to longstanding reflux, by cells that are similar to those found in the lining of the stomach. This condition should be closely monitored, as it increases the risk of developing esophageal cancer.
Esophageal cancer: The relationship between GERD and esophageal cancer is one of many reasons to take it quite seriously. Esophageal cancer often exhibits minimal symptoms, until it has advanced to the incurable stage. However, the most common symptom is difficulty swallowing, While the risk of developing esophageal cancer is relatively low compared with other cancers, it is both the fastest growing type of cancer and one of the deadliest, with few patients surviving 5 years following diagnosis.
Understand that GERD should be managed as a daily part of your life. Do not treat it as a nuisance; it’s a real disease. Practical lifestyle changes will help ease many of your symptoms and may reduce the risk of progressive damage to the lower esophageal sphincter. Some basic but important lifestyle changes that improve the quality of your life include:
- Sleep with your head elevated at least six inches to help reduce nighttime GERD. This enables faster clearing of the stomach contents from the esophagus when reflux does occur.
- Weight gain increases the risk of GERD. Losing even 5 to 10 pounds can improve your reflux symptoms.
- Avoid tight fitting clothing around the abdomen; it puts pressure on the abdomen.
- Eat several small meals instead of two or three large ones.
- Wait 2-3 hours after you eat before you lie down, and avoid late-night snacking.
- Avoid reflux trigger foods, such as: chocolate, mint, alcohol, spicy foods, fatty foods, coffee, and acidic foods.
Because GERD medications typically improve or resolve reflux symptoms, but do not reduce the reflux itself, GERD can lead to serious complications down the road even while taking medications for it. It is important to understand your treatment options since response to medications may vary greatly from patient to patient. A combination of lifestyle changes and medication may provide relief for many, while surgery may be the best treatment option for others.
Many doctors who are not experts make a GERD diagnosis based on patients’ symptoms or response to medications (usually Proton Pump Inhibitors, or PPIs.) This method of diagnosing GERD is not reliable and many patients require special testing for a definitive diagnosis to be made, particularly when the response to medications is poor.
GERD is a progressive disease that moves through different stages of severity. Finding a physician who is a GERD specialist is an important step in ensuring adequate care and treatment of your condition. GERD can be divided into 4 stages based on severity of disease:
Stage one: Mild GERD
Patients with stage one GERD have minor damage to their lower esophageal sphincter and experience occasional reflux episodes. These patients typically tolerate occasional heartburn or use occasional over-the-counter acid medications such as Tums, Mylanta, Zantac, Tagamet or even proton pump inhibitors (PPIs). PPIs include Prilosec, Prevacid, Nexium and others. PPIs are also available by prescription and are the most common medications used by physicians to control GERD symptoms. These medications, used intermittently, control symptoms in those with Stage 1 GERD.
Stage Two: Moderate GERD
Moderate GERD is more difficult to control with over-the-counter medications and is accompanied by more discomfort and advancing symptoms compared to Stage 1. Patients have a greater level of damage to the lower esophageal sphincter, yet management of symptoms requires daily use of PPIs. These patients are “PPI dependent” and must take these medications on a continuous basis to control their symptoms. Patients who experience moderate GERD should consult a GERD specialist to ensure proper diagnosis and management of the disease.
Stage Three: Severe GERD
Severe GERD is considered a serious medical condition and should be closely monitored by you and your physician. Patients whose GERD has progressed to the third stage cannot achieve symptom relief with any medication. The possibility of medical complications, including serious damage to the lining of the esophagus, should be closely evaluated and addressed by a GERD specialist.
Stage Four: Pre-Cancerous or Esophageal Cancer
Patients who experience this advanced form of GERD have had severe reflux for many years. In these patients, the lining of the esophagus has been damaged at the cellular level and may develop into a pre-cancerous condition called Barrett’s esophagus. Patients with Barrett’s have an increased risk of developing reflux-induced esophageal cancer. This late stage GERD can only be diagnosed with an endoscopy.
Barrett’s esophagus in and of itself has no specific symptoms. However, patients with longstanding GERD are those who are typically identified with this condition. While most people with acid reflux do not develop Barrett’s, there is a high-risk group that exists. In addition to longstanding GERD, additional risk factors include:
- Age over 50
- Hiatal hernia
Barrett’s esophagus is found in 10-15% of GERD patients. Many with Barrett’s do not know it. Due to the potential costs, screening for Barrett’s is a controversial subject; however, with deaths from GERD-induced esophageal cancer drastically climbing, it is an option many are considering. Screening typically requires an endoscopy. Patients who are identified as having Barrett’s esophagus, if put under proper surveillance, have a cure rate of as high as 90% if they go on to develop cancer.
Many other medical disorders have symptoms that mimic those of GERD. Patients thought to have GERD should undergo testing to ensure accurate diagnosis, particularly when their symptoms are not resolved with medications. It is the general medical consensus that PPIs are overused and misused, and it is estimated that about 30% of patients thought to have GERD do not have the condition when properly tested. These people do not need daily, lifelong medications for a condition they do not have.
You should always discuss over-the-counter medications with your physician. Any medication, whether over-the-counter or prescription, has the potential to cause unwanted side effects. For example, taking antacids may alleviate the symptoms of GERD, but not the potential damage being done to the lining of the esophagus. You should not take over the counter PPIs for more than 14 days without reporting this to your physician, even if your symptoms seem to resolve with the medication. Conditions such as heart disease or even esophageal cancer may be missed. Testing may be needed to explain the symptoms and develop a proper treatment plan.
For most patients, the best method of testing for GERD is the Bravo pH capsule. This is performed by placing a small electronic capsule in the lower esophagus, usually at the time of endoscopy. The Bravo capsule detects acid in the esophagus over several days of monitoring. An endoscopy alone is usually insufficient for diagnosing GERD, but the Bravo pH capsule definitively makes the diagnosis, and is the gold standard for detecting GERD.
Proton Pump Inhibitors, or PPIs, are the most popular reflux medication prescribed by doctors. While they have helped many suffering from GERD, they carry significant risks that patients and their physicians should carefully consider.
Once PPIs are started, they are usually required for life. However, the long-term use of PPIs can have serious, potentially adverse effects, including magnesium deficiency, increased risk of hip fractures, pneumonia and a serious colon infection called C. Difficile. Reflux is a chronic and progressive disease and PPIs are used to control symptoms but do not stop the reflux. Reflux continues while on PPIs, even if the symptoms disappear. Patients on PPI treatment should be monitored by a qualified physician to assess disease progression and ensure proper management.
If you have GERD, foods that are known to introduce reflux should be avoided. Snacking late at night or consuming even one reflux trigger, such as alcohol, will cause your symptoms to worsen. The only way to make lifestyle changes effective is to pick those that are practical and then, don’t cheat! By permanently stepping away from GERD triggers, you will be on your way to improving the severity of your symptoms. Lifestyle changes can reduce dependence on powerful PPIs, and possibly allow use of medications with fewer suspected side effects, such as H2 blockers or conventional antacids.
Esophageal cancer is on the rise. The American Cancer Society estimates that some 18,000 new cases of esophageal cancer, nearly all of which are caused by chronic reflux, will be reported in 2013, leading some to call it an epidemic. If Barrett’s esophagus is detected and even if cancer appears, it can be treated with a high cure rate. But if not, reflux-induced esophageal cancer kills 85-90% of its victims. Any sign of swallowing difficulty should be investigated, and demographic groups with a high risk of developing Barrett’s should at least consider an endoscopy.
For anyone diagnosed with GERD, or for individuals who experience periodic heartburn, it’s important to understand that GERD is a permanent condition whose symptoms will typically progress over time. Some studies estimate that up to a third of the U.S. population experiences GERD-related symptoms. GERD is more than just a nuisance; it is a significant disease. Patients need to understand the potential complications, consequences, and treatment options. Management in collaboration with an experienced physician will play a critical role in slowing GERD’s progression, avoiding complications, and providing relief.