Many of us experience heartburn from time to time. It is an irritating sore feeling in your chest just behind the breastbone, which might also spread towards your throat and back.  It often occurs  after large fatty spicy meals. Sounds like cardiac disease? It actually has nothing to do with your heart. If it annoys you, say at least once a week, your doctor will tell you that you have GERD, namely, gastroesophageal reflux disease. GERD is the flowing back of stomach contents into the esophagus or mouth causing troublesome symptoms or complications.  Statistics  estimates that 20% to 40% of Americans have symptoms of GERD, making it the most prevalent gastrointestinal disorder in the United States.

          The following are the frequently asked questions about GERD.

1. What are the symptoms of GERD?

         Heartburn and acid regurgitation are the typical symptoms of GERD.  Other symptoms of GERD include:non-burning chest pain, difficulty swallowing or a feeling of something sticking in one’s  throat, increased salivation, sore throat,chronic cough,new or worsening asthma or disrupted sleep.

2. I occasionally have heartburn, is it possible that I also have GERD?

         Most people have occasional bouts of heartburn. Doctors call this physiological acid reflux if it doesn’t affect your life. Only when the reflux become excessive and cause frequent symptoms or damage, it is considered pathological, namely, GERD.

3.How can the gastric acid rise up to the esophagus or even throat and make me uncomfortable?

         There are many theories trying to explain this phenomena. The lower part of the esophagus or esophagogastric junction plays a central role in GERD. The muscle at this part forms an elastic valve, which opens to allow food into the stomach and closes to prevent stomach contents from going back up into the esophagus. When the valve doesn’t work competently, the acidic or bile fluids can leak into the esophagus. If it is transient, it is normal, but it persists, the lining of the esophagus might become inflamed and you will feel frequent heartburn.

4.What are the risk factors of GERD?

          Obesity ranks No.1 in the triggering factors, because central obesity impairs the normal function of the  esophagogastric junction as well as increasing  the abdominal pressure. Eating large meals,eating late at night, lying down or bending over after meals, eating certain foods such as fatty or fried foods and drinking certain beverages, such as alcohol or coffee, can also worsen the symptoms.

         So refrain from eating three to four hours before sleep,avoid caffeine, alcohol and nicotine, avoid lying down for long periods of time and make you slimmer.

5. What tests should I take to see if I have GERD?

          If you have frequent heartburn and regurgitation, your doctor will probably diagnose you with GERD without any tests and give you some acid inhibition medications. However, if the symptoms doesn’t go away as expected, your doctor might recommend you such tests as upper endoscopy,reflux testing (wireless pH/pH impedance),esophageal manometry and barium esophagram for further assessment and evaluation.

6. When should I  do an upper endoscopy if I have heartburn?

          GERD can be subdivided into erosive reflux disease or nonerosive reflux disease based on endoscopic findings. Less than 20 percent of people with heartburn will have abnormal endoscopic findings. This doesn’t prevent upper endoscopy from becoming the best test in evaluating GERD. An upper endoscopy can let your doctor examine the lining of your esophagus and stomach, thereby making an accurate diagnosis of hiatal hernia, esophagitis, esophageal stricture and Barrett’s esophagus.

If you have five years or more of reflux symptoms, GERD symptoms from a young age,obesity and a history of smoking, an upper endoscopy is recommended.

7. Some medications and dietary supplements can irritate your esophagus, what are they?

         Bisphosphonates taken orally, such as alendronate (Fosamax), ibandronate (Boniva) and risedronate,iron supplements,antibiotics, such as tetracycline and clindamycin,pain killers, such as ibuprofen and aspirin,potassium supplements, quinidine,tricyclic antidepressants (amitriptyline, doxepin),calcium channel blockers, statins, angiotensin-converting enzyme inhibitors and nitrates,,progesterone,sedatives or tranquilizers, including benzodiazepines such as diazepam and temazepam.

8. What are the medications commonly used for the treatment of heartburn? Are they safe for long term use?

          There are two kinds of medication used in the treatment of GERD: H2-receptor blockers and proton pump inhibitors. H-2-receptor blockers include cimetidine, famotidine and ranitidine. Proton pump inhibitors (PPI)include omeprazole, esomeprazole, rabeprazole, pantoprazole and lansoprazole. As the H2-receptor blockers are not as effective as the PPIs, they are facing being elbowed out of the market.

         The widespread use of PPIs has caused concerns among health professional as well as the patients. Evidence shows that long term PPI medication might cause rebound acid hyper-secretion, vitamin B 12 deficiency, increased risk of enteric infections, increased risk of hip and vertebral fractures. However, there is no need to panic about so called side effects for most patients taking PPIs. PPIs are safe under the guidance  of an experienced gastroenterologist.

9. I am getting tired of taking medications and wish to cure my heartburn with surgery, is it feasible now?

         Two methods are now accepted clinical practice by wrapping upper part of the stomach around the lower esophagus, thereby relieving the back flow of the acid. One is a surgical procedure, called the Nissen fundoplication, the other is done endoscopically, called the transoral incisionless fundoplication. Though the procedure may help in many patients, it does have its drawbacks,such as difficulty in swallowing and bloating. One must weigh the benefits and risks before choosing these procedures.

          One reminder must be kept in mind: the surgery works well only in those who are responsive to medical therapy.

10. I have GERD. What are the chances that I will develop esophageal cancer?

           There are many risk factors for esophageal cancer, including Barrett's esophagus , GERD, male sex, white race, central obesity and tobacco use. Barrett's esophagus  is the only known precursor for esophageal adenocarcinoma. Patients with Barrett's esophagus  have a risk of esophageal adenocarcinoma 30 to 125 folds greater than those who haven’t.  About 10% to 15% of patients having chronic GERD may develop into Barrett’s esophagus,esp, in severe and long standing symptoms. The average age at diagnosis of Barrett’s esophagus is 55 years. If you are a male over 50 years, obese, smoker,  having heartburn, it is recommended that you have an upper endoscopy to check out whether you have Barrett’s esophagus or early sign of an esophageal adenocarcinoma.

References:

1.Guideline on screening for esophageal adenocarcinoma in patients with chronic gastroesophageal reflux disease. CMAJ 2020 July 6;192:E768-77. doi: 10.1503/cmaj.190814.

2.Naik RD,Meyers MH and Vaezi MF.Treatment of Refractory Gastroesophageal Reflux Disease.Gastroenterology & Hepatology Volume 16, Issue 4 April 2020,196-205.

3.Richter JE, and Rubenstein JH.Presentation and Epidemiology of Gastroesophageal Reflux

Disease.Gastroenterology. 2018 January ; 154(2): 267–276. doi:10.1053/j.gastro.2017.07.045.

4.Zhang XT,Anandasabapathy S,Abrams J, et al. Lifestyle Risk Factors, Quality of Life,and Intervention Preferences of Barrett’s Esophagus Patients: A Prospective Cohort Study.Global Advances in Health and Medicine,2021, Volume 10: 1-12.

5.https://www.hopkinsmedicine.org/health/conditions-and-diseases/heartburns-hidden-cancer-risk.

6.https://www.mayoclinic.org/diseases-conditions/gerd/symptoms-causes/syc-20361940.