Gastro-Esophageal Reflux Disease (GERD)

Article by Dr Tan Chi Chiu

Gastro-Esophageal Reflux Disease (GERD)

Dr Tan Chi Chiu

Gastroenterologist
National University of Singapore Faculty of Medicine
University of Nottingham, United Kingdom
Academic Medical Centre in Amsterdam
Advanced Management Program of Harvard Business School in 2003 (elected valedictorian)
Medical Ethics Course, Imperial College London
External Coach Intensive Course, Columbia University's Coaching Certification Program.
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Gastro-Esophageal Reflux Disease or GERD is a common condition in the general population and is seeing an increasing prevalence in Asia. Heartburn is the predominant symptom of GERD. The other common symptom is acid reflux, where stomach fluids reflux into the throat or even the mouth, with a sour or bitter taste. Sometimes the acidic fluid overflows into the larynx and airways causing reflux cough, pharyngitis or even asthmatic symptoms. These syndromes constitute “extra-esophageal reflux disease”. But patients also complain of a variety of other symptoms, such as:

• Belching
• Chronic sore throat
• Difficulty or pain when swallowing
• Waterbrash (sudden flow of fluid into the mouth)
• Hoarseness
• Sour taste in the mouth
• Bad breath
• Inflammation of the gums
• Erosion of tooth enamel (the surface of the teeth)

There is little correlation between the severity of symptoms of GERD and the actual damage caused by acid. Sometimes, there are no symptoms and GERD is only diagnosed when complications (see below) arise. At other times, a patient could have very severe heartburn, but normal endoscopically. When there are no erosions, the patient may be said to have Non Erosive Reflux Disease (NERD).

There is no known single cause of GERD. Reflux disease is more common in patients with a Hiatal Hernia. There is conflicting evidence of the importance of other factors. Weight loss in obese individuals has been shown to improve GERD, but the evidence is less convincing for smoking, alcohol, caffeine, diet and psychological factors.

GERD is usually diagnosed from the typical symptoms although it may also be a cause of non-cardiac chest pain. If the symptoms are appropriate, a trial of GERD medications (mostly proton pump inhibitors) for two weeks may be given to see if there is relief. If the pain recurs, a referral for a Gastroscopy is appropriate. If a definitive diagnosis is to be made before starting treatment, so as to have confidence in the diagnosis and to exclude significant diseases such as peptic ulcers or cancer (which may give overlapping symptoms), a Gastroscopy is recommended. In some refractory cases, further testing, such as by Esophageal pH or Multimodal pH-impedence measurement, may be done to confirm the diagnosis.

The mainstay of treatment in GERD is proton pump inhibitors. In some cases a prokinetic agent may be added. Weight loss in those who are overweight may be helpful. Observing a 3 hour interval between meals and bed time is useful too. If nighttime reflux is intractable, elevating the head of the bed by 10-15 cm may also be helpful. In the most severe and intractable cases unresponsive to maximal medical therapy, surgery to tighten the gastro-esophageal valve may be necessary.

Besides the obvious effect on quality of life, untreated GERD can lead to some serious complications. They include:

Erosive Esophagitis of varying severity.
Peptic Stricture formation leading to dysphagia.
Development of Barrett's esophagus – a precancerous change in the esophageal mucosa.
Esophageal cancer.

In conclusion, GERD is a common disease which may cause disturbing symptoms. It is often mild, but occasional cases may be severe with life threatening consequences. Since it is not possible to assess severity on symptoms alone, Gastroscopy is often done to diagnose GERD and to exclude its complications and other serious diseases that may have similar symptoms. Once diagnosed, treatment is usually by medicines alone and surgery is rarely necessarily.