Gastroesophageal reflux happens when the contents of the stomach flow back up into the esophagus. Occasional reflux is common and normal, and usually nothing to worry about. Gastroesophageal reflux disease, or GERD, is the more severe and long-lasting form, in which reflux happens repeatedly and causes bothersome symptoms or leads to complications over time.
Normally, when you swallow, a circular band of muscle at the bottom of the esophagus, called the lower esophageal sphincter (LES), relaxes to let food and liquid into the stomach and then closes again. In GERD, the sphincter weakens or relaxes when it should not, allowing acid to flow back and irritate the lining of the esophagus. Unlike the stomach, the esophagus does not have a protective lining against acid, which is why reflux causes irritation. Clinically, reflux happening around twice a week or more, over several weeks, points towards GERD rather than occasional heartburn.
GERD is very common. About one in five people in the United States is estimated to have it.
GERD symptoms vary, and not everyone with GERD experiences heartburn. The most common include:
- Heartburn — a burning feeling in the chest behind the breastbone, often after eating and frequently worse at night or when lying down
- Regurgitation — food or sour, acidic liquid backing up into the throat or mouth
- Difficulty or pain when swallowing
- Chest or upper-abdominal pain
- A sensation of a lump in the throat
- Nausea
Some people also have symptoms outside the esophagus, particularly at night, such as chronic cough, hoarseness, laryngitis, and new or worsening asthma. Long-standing acid exposure can also wear away tooth enamel.
Causes and Risk Factors
GERD is caused by frequent acid reflux due to a weak or inappropriately relaxing lower esophageal sphincter. Several conditions and habits increase the risk:
- Hiatal hernia — when the upper part of the stomach bulges through the diaphragm, which can trap acid and weaken the sphincter
- Obesity or being overweight, which raises pressure in the abdomen
- Pregnancy, due to increased abdominal pressure and hormonal changes
- Smoking or exposure to secondhand smoke
- Delayed emptying of the stomach
- Connective tissue disorders such as scleroderma
Certain foods and habits can trigger or worsen symptoms, including large meals, eating late at night, lying down soon after eating, fatty or fried foods, alcohol, coffee and caffeine, chocolate, and mint. Some medications can also contribute, such as anti-inflammatory painkillers, certain blood pressure medicines, sedatives, and some asthma drugs.
Diagnosis
GERD is often diagnosed from the pattern of symptoms and a physical examination. When symptoms are typical and there are no warning signs, doctors may start treatment and observe the response. Further testing is pursued if symptoms do not improve, recur frequently, or include difficulty swallowing. Tests may include:
- Upper endoscopy (gastroscopy) — a camera examines the esophagus, stomach and upper intestine, and can take biopsies and check for complications such as Barrett’s esophagus
- Ambulatory acid (pH) monitoring — considered the most accurate way to detect acid reflux, measuring acid in the esophagus over 24 hours or more
- Esophageal manometry — measures the muscle contractions of the esophagus, used especially when there is trouble swallowing or before anti-reflux surgery
- Barium X-ray (upper GI series) — can detect narrowing or other structural problems
Complications
Left untreated, long-standing inflammation of the esophagus can lead to:
- Esophagitis — inflammation that can cause bleeding, ulcers and pain
- Esophageal stricture — scar tissue that narrows the esophagus and causes swallowing difficulty
- Barrett’s esophagus — a change in the lining of the lower esophagus that is precancerous and a risk factor for esophageal cancer
- Esophageal adenocarcinoma — which develops in a small number of people with Barrett’s esophagus
GERD can also affect areas outside the esophagus, contributing to asthma, chronic cough, hoarseness and tooth-enamel erosion.
Treatment and Management
Treatment usually begins with lifestyle changes and medication, with surgery reserved for selected cases.
Lifestyle and Dietary Changes
- Losing weight if overweight, and stopping smoking
- Elevating the head of the bed by around 15 to 20 cm using blocks or a wedge, rather than extra pillows
- Avoiding lying down for about three hours after eating
- Eating smaller meals and eating slowly
- Avoiding known trigger foods and drinks
- Avoiding tight-fitting clothing
Medication
- Antacids — neutralise stomach acid for quick, short-term relief, but do not heal an inflamed esophagus
- H2 blockers (such as famotidine) — reduce acid production and last longer than antacids
- Proton pump inhibitors (PPIs, such as omeprazole, esomeprazole, lansoprazole, pantoprazole) — stronger acid blockers that allow the esophagus to heal, and the first choice for severe GERD or esophageal damage
- Newer acid-blocking medicines are also available for severe reflux when other treatments have not worked
Surgical and Procedural Options
- Fundoplication — the surgeon wraps the top of the stomach around the lower esophageal sphincter to strengthen it, usually done with minimally invasive (laparoscopic) surgery
- Magnetic sphincter augmentation (LINX) — a ring of magnetic beads placed around the junction of the stomach and esophagus keeps it closed to reflux but opens to let food pass
- Weight-loss surgery may be considered when obesity is a major contributing factor
Prognosis
Most people manage GERD successfully with lifestyle changes and medication, and surgery is uncommon. Occasional acid reflux does not affect long-term health, but untreated GERD can damage the esophagus over time. Because severe GERD can still cause damage even when symptoms are not strongly felt, ongoing management and follow-up are important.
When to See a Doctor
Seek emergency care for chest pain, especially if accompanied by shortness of breath or pain in the jaw or arm, as this may signal a heart problem. See a doctor if you have severe or frequent symptoms, or if you use over-the-counter heartburn medicines more than twice a week. Warning signs that need prompt evaluation include:
- Difficulty or painful swallowing
- Persistent vomiting
- Loss of appetite or unexplained weight loss
- Vomiting blood or material that looks like coffee grounds
- Black, tarry or bloody stools
Early diagnosis and consistent management can control symptoms effectively and prevent long-term complications.