Gastroesophageal Reflux Disease (GERD)


Everyone has a little heartburn now and then. And if it’s pretty mild and only a rare event, there’s probably nothing wrong with just taking an antacid and forgetting about it. But if the heartburn occurs regularly—say, at least once a week or so—or causes symptoms that are more severe, you’re not just dealing with “a little heartburn” anymore. You probably have gastroesophageal reflux disease, or GERD.

And GERD is not a problem you can afford to just brush off.

What Is Gastroesophageal Reflux Disease (GERD)?

GERD is a disorder of the digestive system in which contents of the stomach flow backwards, up into the esophagus (the swallowing tube). The reflux of stomach contents into the esophagus often produces symptoms that can be quite disruptive to your life, and in some cases it can cause more serious complications.

GERD is a common disorder. Up to 20 percent of people living in developed countries are estimated to be affected by GERD. 

If you have GERD, the good news is that it’s likely you’ll be able to control your symptoms if you adopt appropriate lifestyle changes. If these simpler measures do not work, medications can be quite effective. Surgical treatment is only rarely necessary today. 

Symptoms of GERD

The chief symptom of GERD is heartburn, a burning sensation located beneath the breastbone, often radiating up toward the throat.

Regurgitation is a more severe form of heartburn, in which stomach acid reaches the back of the throat, producing a sour, acid taste. These symptoms may sometimes be accompanied by nausea.

Heartburn and regurgitation are usually much worse right after a meal, and are made more severe while lying flat or bending over.

These symptoms can be improved by taking an antacid, and remaining upright.

“Water brash” is a relatively rare symptom of GERD, but it can be upsetting when it happens. Water brash is a release of excessive saliva—literally, foaming at the mouth—that can occur with the regurgitation of stomach acid.

People with chronic or longstanding GERD may experience dysphagia, or difficulty swallowing. Specifically, they may have a hard time simply moving food, or even liquids, from their mouth to their stomach. Dysphagia sometimes may be accompanied by odynophagia, or painful swallowing. Dysphagia or odynophagia usually indicate that a more severe form of GERD may be present; likely, damage has already occurred to the esophagus.

Complications of GERD

Most people with GERD simply have heartburn. However, GERD can cause complications that can lead to some very serious problems. 

The most frequent complications of GERD affect the esophagus. These include:

  • Barrett’s esophagus: In this condition, the cells that normally line the esophagus are replaced by abnormal cells that resemble stomach cells. The significance of this change is twofold. First, the abnormal esophageal cells have a higher risk of developing into esophageal cancer. Second, the abnormal cells are more prone to develop ulceration, stricture, and bleeding.
  • Erosive esophagitis: In erosive esophagitis, the lining of the esophagus becomes inflamed and begins to develop ulcers. Esophageal ulcers can produce severe symptoms—heartburn, regurgitation, dysphagia, and odynophagia—and can also cause esophageal hemorrhage or perforation.
  • Esophageal stricture: With esophageal stricture, a portion of the esophagus becomes narrowed and partially obstructed. This condition often leads to relatively severe dysphagia, in which solid food may become lodged in the esophagus. Esophageal strictures generally are a result of erosive esophagitis that has healed.

In addition to esophageal complications, GERD can lead to other complications involving the head, neck, and airways.

These include:

  • Asthma: Reflux of stomach contents is now recognized to be a common trigger for asthma. In fact, more than half of people with asthma are thought to have GERD. GERD may trigger an asthma attack by causing the airways to be more reactive (that is, to constrict more readily), by increasing vagal tone, and by the aspiration of gastric acid into the airways. Read more about GERD and asthma.
  • Chronic laryngitis: If gastric contents frequently reach the larynx (voice box), chronic inflammation of the larynx, or laryngitis, can occur. This condition may cause hoarseness, frequent throat clearing, or the feeling of a lump in the throat.
  • Laryngeal or tracheal stenosis: Chronic inflammation can eventually produce a narrowing of the airways around the larynx, producing dyspnea, wheezing, cough, and/or bleeding.
  • Dental cavities may occur with chronic reflux of gastric acid into the mouth.
  • Chronic sinusitis may be caused by chronic GERD.

Causes of GERD

GERD is produced by the reflux of gastric contents into the esophagus. Normally, reflux is prevented by the lower esophageal sphincter (LES), a ring of muscle located at the junction of the esophagus and the stomach. Most of the time the LES is contracted in order to close the opening and to form a barrier between the stomach and esophagus. Normally, the LES transiently relaxes when we swallow, to allow food to pass into the stomach. It also relaxes when we belch, to allow gas to escape from the stomach.

Most often, GERD occurs when the LES transiently relaxes when it is not supposed to, thus allowing a brief interval of time in which the stomach contents can enter the esophagus. It is not clear why so many people develop frequent, transient relaxations of the LES. 

Less commonly, GERD can be produced when the LES becomes chronically flaccid, allowing reflux to occur at almost any time. These people tend to have fairly severe GERD.

LES pressure can be reduced—and reflux encouraged—by gastric distention (a full stomach), by smoking, by numerous medications, by drinking alcohol, by caffeine, and by several kinds of food (especially fatty foods and chocolate). Any of these things tend to trigger GERD in people who are prone to this condition.

Having a hiatal hernia can contribute to GERD. With a hiatal hernia, a portion of the stomach protrudes above the diaphragm, which can disrupt the normal functioning of the LES. However, the relationship between hiatal hernia and GERD is less direct, and much more complex, than previously thought, and surgery to repair a hiatal hernia is now done much less frequently than in the past. Read more about hiatal hernia.

Obesity—especially abdominal obesity—is a strong risk factor for GERD, and obese people with GERD are more likely to develop complications. Obesity increases the pressure on the stomach contents, and tends to disrupt the normal functioning of the LES. As a result, in obese people transient episodes of LES relaxation happen more frequently, and (because the pressure within the abdomen tends to be high), reflux occurs more readily. Read more about obesity and GERD.

GERD is also very frequent in pregnant women. As with obesity, pregnancy increases abdominal pressure. And during pregnancy hormonal changes tend to cause LES relaxation. Both of these factors strongly contribute to GERD during pregnancy. Read more about GERD and pregnancy.

Diagnosing GERD

In most cases the diagnosis of GERD is pretty straightforward. It is, essentially, a clinical diagnosis. That is, the symptoms of GERD are often so classic that doctors usually can make a confident diagnosis on the basis of symptoms alone. 

Diagnostic testing is usually done only when a person with GERD fails to respond to therapy, or if it is suspected that one of the more serious complications of GERD may have occurred. For instance, a person experiencing dysphagia or odynophagia is very likely to have developed an esophageal complication, and needs testing to make a definite diagnosis.

Tests often used in diagnosing GERD are:

EndoscopyThe most common diagnostic test used for GERD is endoscopy, which is used to visualize the lining of the esophagus, and to biopsy any suspicious areas that are found. This test is useful for diagnosing esophagitis, Barrett’s esophagus, and esophageal strictures.

24-hour pH monitoring: Sometimes a person with symptoms that seem classic for GERD will fail to respond to therapy, and their endoscopy exam will show no esophageal disease. In these cases, 24-hour pH monitoring can be useful in documenting whether acid reflux is actually occurring. This test is done by placing a thin tube into the esophagus that is able to measure pH, that is, the amount of acidity in the esophagus at any given moment. The tube stays in place for an entire day, during which the person with suspected GERD keeps a record of any symptoms he or she may experience. By correlating symptoms with the presence or absence of stomach acid in the esophagus, it can be determined whether the symptoms are actually caused by acid reflux.

Esophageal manometry: Esophageal manometry uses a thin tube passed into the esophagus to measure pressure along the length of the esophagus during swallowing. This test is poor at diagnosing GERD, but it can be useful in diagnosing certain swallowing disorders whose symptoms may mimic GERD, such as esophageal spasm or achalasia

Barium swallow X-rays: Taking X-rays of the esophagus while swallowing barium (a contrast solution) is a test that in former years was commonly used to diagnose esophageal conditions, but its usefulness now has been largely supplanted by endoscopy.

  • Read more about diagnosing GERD.

Treatment of GERD

Several potential treatments are available for GERD, including: 

  • Lifestyle changes: Anyone with GERD should take every opportunity to make the changes in lifestyle or habits that are likely to be making the problem worse. Lifestyle changes that have been definitely shown to help reduce symptoms of GERD include weight loss, and elevating the head of the bed. In addition, while specific dietary modification is not universally helpful, anyone with GERD should be alert to foods that clearly trigger symptoms, and avoid those foods. Many people will notice particular problems after eating foods or beverages that contain caffeine or chocolate, or fatty or fried foods, for instance. It is particularly important to avoid smoking and excess alcohol (more than a drink per day), both of which can disrupt the normal functioning of the LES. Refraining from eating for three hours or so before bedtime can greatly reduce nocturnal symptoms of reflux. Avoiding clothing that is tight around the waist can be helpful, as well.
  • Antacids: Antacids do not help to prevent GERD, but they can be taken to help relieve symptoms during an episode of GERD. Commonly used antacids include GavisconMaaloxMylantaRolaids, and Tums.
  • Histamine-2 receptor antagonists (H2RAs): The H2RA drugs help to limit the production of stomach acid, so that stomach contents cause fewer symptoms when they reflux into the esophagus. The H2RAs begin working about two hours after taking a dose, and their effectiveness persists for up to 10 hours—so these drugs are not particularly useful in treating an acute episode of GERD. The H2RAs are more useful when they are taken regularly for a 2-4 week course of therapy. Commonly used H2RA drugs are nizatidine (Axid), famotidine (Pepcid), cimetidine (Tagamet), and ranitidine (Zantac). These drugs are all roughly equally effective. 
  • Proton pump inhibitors (PPIs): PPIs work by inhibiting the “pump” in gastric cells that produces stomach acid. They are the most potent acid inhibitors, and are more effective than H2RAs at eliminating symptoms and healing esophagitis. However, they are more expensive than H2RA drugs, and tend to cause more adverse effects—so most doctors will try an H2RA drug first. The PPIs include rabeprazole (AcipHex), pantoprazole (Prevacid), esomeprazole (Nexium), or omeprazole (Prilosec). Similar to the H2RA drugs, the PPIs are not particularly helpful in relieving acute symptoms of GERD. Rather, they are useful when taken regularly during a planned course of therapy, to try to eliminate GERD altogether. These drugs are all similar to one another in terms of effectiveness. Read more about PPIs for GERD.

Typical Treatment Regimens for GERD

In general, if a person with GERD has only mild symptoms, the doctor will recommend appropriate lifestyle modifications, and most likely prescribe a two- to four-week course of an H2RA drug twice a day. If symptoms persist after the planned course of therapy, the H2RA drug will be stopped, and an eight-week course of a PPI drug will be given instead. During this time, an antacid can be taken as needed for acute symptoms.

If the initial symptoms are judged to be moderate or severe, or if endoscopy has demonstrated the presence of esophagitis or other complications of GERD, doctors usually skip the H2RA drug and go right to an eight-week course of a once-daily PPI drug. 

People whose GERD has caused severe esophagitis or Barrett’s esophagus usually need to continue PPI therapy chronically, to prevent more dire complications such as esophageal perforation or cancer.

If symptoms continue after eight weeks of PPI therapy, more testing may be done to make sure that GERD is the correct diagnosis. This testing may include an endoscopy (if it was not done initially), pH monitoring, and/or manometry. If GERD still appears to be the right diagnosis, then an eight-week course of a PPI drug twice a day is often the next step, sometimes with a different PPI drug than was used initially. In addition, the doctor will very likely stress once again all the lifestyle modifications that ought to be made.

In people whose severe symptoms persist after an 8-week course of twice-daily PPI therapy, surgical treatment may need to be considered. Surgery is aimed at increasing the integrity of the LES in order to reduce the opportunity for reflux. Today, this can often be accomplished with a minimally-invasive procedure.

A Word From Verywell

GERD is a common gastrointestinal disorder that is usually reasonably mild, but it can cause serious complications. If you have symptoms of GERD, you should work with your doctor to make sure you have the correct diagnosis, and to make sure you receive a treatment regimen that will get rid of your problem before it becomes more serious. Fortunately, with appropriate lifestyle modifications and with the kinds of medications that are available today, the large majority of people with GERD can be successfully treated before their annoying problem becomes a dangerous one.


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