GERD — Causes, Symptoms, Diagnosis and Treatment

Burning in the chest after a heavy meal is one of the most common complaints I hear in clinic. Most of the time it is harmless, but when it keeps coming back, it may be gastroesophageal reflux disease, or GERD.

What is GERD?

GERD is a chronic condition in which stomach contents flow back into the esophagus and cause symptoms or complications. Occasional acid reflux is normal. It becomes GERD when it happens often, usually heartburn at least twice a week, or when it damages the esophageal lining.

The main problem is a weak or inappropriately relaxing lower esophageal sphincter (LES), the muscular valve between the esophagus and stomach.

Causes and triggers

Several factors make the LES less effective or increase pressure on the stomach:

• Hiatal hernia
• Obesity, especially abdominal fat
• Pregnancy
• Smoking and alcohol
• Large, fatty or spicy meals, coffee, chocolate and carbonated drinks
• Lying down soon after eating
• Medications such as NSAIDs, nitrates and calcium channel blockers

Symptoms and alarm features

The classic symptoms are heartburn and regurgitation of sour fluid. GERD can also appear as chest pain, chronic cough, hoarseness, a sensation of a lump in the throat, or dental erosion. Chest pain should never be assumed to be reflux until a cardiac cause has been considered.

These are the red flags that change my approach:

• Difficulty or pain when swallowing
• Unintentional weight loss
• Vomiting blood, black stools or iron-deficiency anemia
• Persistent vomiting
• New symptoms in an older adult, or a family history of upper GI cancer

How is GERD diagnosed?

In a patient with typical symptoms and no alarm features, GERD is diagnosed clinically. A trial of a proton pump inhibitor (PPI) for 4–8 weeks is both treatment and a diagnostic test.

An upper GI endoscopy is recommended for alarm features, symptoms that do not respond to PPIs, or long-standing reflux in higher-risk patients. It can show erosive esophagitis, strictures, and Barrett's esophagus, where the normal lining is replaced by intestinal-type cells and the risk of esophageal adenocarcinoma rises. In unclear cases, ambulatory pH monitoring and esophageal manometry help confirm the diagnosis.

Lifestyle changes

These are the foundation of treatment, and I ask every patient to start here:

• Lose weight if overweight; this often helps the most
• Stop smoking and cut back on alcohol
• Avoid eating within 2–3 hours of bedtime
• Raise the head of the bed by about 6–8 inches
• Eat smaller meals and avoid your personal trigger foods

Medical treatment

Antacids give quick relief for occasional symptoms. H2 blockers such as famotidine are useful for milder or night-time symptoms. PPIs such as omeprazole or pantoprazole are the most effective option and are best taken 30–60 minutes before the first meal of the day. I aim for the lowest dose that controls symptoms.

Long-term PPI use has been linked to low magnesium, vitamin B12 deficiency and a slightly higher infection risk, so it should be reviewed regularly. For patients with a clear indication, though, the benefits generally outweigh these risks. Newer acid blockers such as vonoprazan are also becoming available.

Surgical treatment

Surgery is considered for patients with confirmed GERD who have persistent symptoms despite optimal medical therapy, who cannot tolerate lifelong medication, or who have a large hiatal hernia. Laparoscopic Nissen fundoplication is the standard procedure. A magnetic sphincter augmentation device is an alternative, and in patients with obesity, gastric bypass can be a good option.