GERD — It’s Not Spicy Food!

Normally, swallowed food and liquid (bolus) propels from the mouth to the stomach via the esophagus, a muscular tube using coordinated squeezing and relaxing waves called peristalsis. The bolus arrival at the muscular “gate” or lower esophagus sphincter (LES) relaxes the LES, passing the bolus into the stomach where acid begins digestion. The LES then squeezes shut to keep stomach contents out of the esophagus. The LES is assisted by the surrounding muscle of the diaphragm, which is the main muscle for breathing.

In some people, the LES and diaphragm “gate” doesn’t prevent stomach contents from entering the esophagus. While this can happen to anybody, it is usually shortly after meals, brief and asymptomatic. In gastroesophageal reflux (GERD) patients, episodes are more frequent, they last longer and cause symptoms. GERD is not the result of acidic foods burning the esophagus!

GERD affects 10% to 20% of people. Classic symptoms of heartburn (sense of burning behind the chest) and regurgitation (stomach contents re-entering the mouth from the esophagus in small amounts) are not always present. Throat burning, chest pain, nausea and vomiting, upper abdominal pain, belching, hiccups, difficult or painful swallowing, “lump in the throat,” cough or wheezing, or hoarseness — among others — may be the only symptoms.

“Alarm symptoms” may indicate a serious problem. Difficult or painful swallowing, appetite or weight loss, black tarry stools or blood in vomit, frequent vomiting, new symptoms over the age of 60 or chest pain should promptly be reported (for example, chest pain can indicate heart disease). Ongoing, frequent (twice weekly of more) symptoms or inability to stop medication also warrant evaluation.

Repeated episodes in GERD patients can cause complications from an acid-damaged esophagus. Erosive esophagitis is when the esophagus develops ulcers at risk for bleeding. An esophageal stricture is a scarred narrowing of the lower esophagus (like an hourglass) causing difficult swallowing or blockages. Barrett's esophagus is when normal esophagus cells “transform” into a different cell type to protect the esophagus from repeated acid damage. This increases the risks for future esophagus precancer and esophagus cancer, the most dreaded possible GERD complication.

Many factors promote GERD by causing LES relaxation, increased abdominal pressure/delayed stomach emptying and/or reducing diaphragm muscle assistance. These factors include obesity, pregnancy, certain medications, diet and lifestyle factors (smoking, alcohol, chocolate, peppermint, citrus, tomato products, caffeine) and a hiatus hernia. A hiatus hernia is when part of the upper stomach slides up through the diaphragm, changing the position of the LES in the chest. The diaphragm has a natural opening for the esophagus to pass through to reach the stomach (diaphragmatic hiatus). With a hiatal hernia, that opening enlarges, which allows the stomach to pass upward.

An effective medication trial to reduce acid production generally confirms the diagnosis of GERD. However, an endoscopy (tiny camera used to examine the esophagus) or pH testing (measurement of esophagus pH) is often necessary. Unfortunately, lifestyle modification has limited effectiveness, so many people need ongoing medication. Surgical options aimed at restoring an effective LES barrier can be effective. Regardless, treatment is aimed at controlling symptoms, restoring quality of life and preventing dangerous GERD complications.

Mark Flasar, MD, is a gastroenterologist at Anne Arundel Gastroenterology Associates. He completed his internal medicine residency at Duke University and his gastroenterology fellowship at the University of Maryland.