Fast facts about GERD

Click on the links below to find answers to some common questions about gastroesophageal reflux disease (GERD).

What is GERD?
GERD is GastroEsophageal Reflux Disease or Gastro-Oesophageal Reflux Disease, depending on whether the US or UK spelling is used. According to the Montreal Definition of GERD, which was developed recently by a group of experts from around the world, it is a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications.

The most common complication of GERD is reflux esophagitis.
What is reflux esophagitis?
Reflux esophagitis is an inflammation of the esophagus caused by the reflux of gastric acid and pepsin into the esophagus. The severity of reflux esophagitis is graded according to the endoscopic appearance of the esophageal mucosa.

In the Los Angeles (LA) Classification system, which has been used in the studies with Nexium®(esomeprazole), the severity of esophagitis is graded by the presence and extent of mucosal breaks. The classification ranges from LA grade A (mild esophagitis) to LA grade D (very severe esophagitis).

What is the main cause of GERD?
Contrary to common belief, lifestyle factors do not play a major role in the development of GERD. In the majority of people with reflux disease, the dominant mechanism of symptom production is through contact of the esophageal mucosa with gastric acid and pepsin.

Normally, the stomach contents are prevented from refluxing into the esophagus by a ring of muscle, the lower esophageal sphincter (LES). This acts as a one-way valve, which allows food to enter the stomach but not to exit the same way. Sometimes the LES is not completely effective and allows the stomach contents back into the esophagus, where gastric acid and pepsin can cause irritation to the esophageal mucosa. Damage to the esophagus caused by gastric acid and pepsin refluxing through the LES is usually minimised through a number of mucosal defence systems. However, when these mechanisms are impaired or overwhelmed, GERD symptoms may result.

What are the most common symptoms of GERD?
Heartburn and acid regurgitation are the characteristic symptoms of GERD. Heartburn can be defined as a burning sensation in the retrosternal area (behind the breastbone), or as a burning feeling rising from the stomach or lower chest up towards the neck.
In some cases, stomach acid may be regurgitated into the mouth, causing an unpleasant sour taste. Other, less common, symptoms include noncardiac chest pain, dysphagia (or difficulty in swallowing) or extra-esophageal symptoms such as chronic cough or hoarseness.

Doesn’t everyone suffer from heartburn from time to time?
Almost everyone experiences heartburn from time to time, especially after a large meal. However, if heartburn is troublesome enough to affect a patient’s well-being (for example, by making it difficult to sleep or painful to take exercise), this may indicate GERD.

In the recent Montreal Definition, GERD is defined as a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications.

Reflux symptoms that are not troublesome should not be diagnosed as GERD.

How common is GERD?
More than one in 10 adults in Europe and North America has heartburn or acid regurgitation at least once a week.

In Asia, daily or weekly heartburn or acid regurgitation affects up to one in 20 adults.
Furthermore, many patients suffer the symptoms of GERD for years. By the time they do consult, most will already have tried lifestyle changes and antacids and found them inadequate. Some will already have taken prescription therapies that have proved unsatisfactory and may feel frustrated that their recurring symptoms will not go away.

Could GERD develop into complications?
Yes. In up to one half of GERD patients consulting in primary care, refluxed gastric juices have caused visible damage to the esophagus, known as reflux esophagitis. Repeated esophageal damage can, in some cases, lead to the development of Barrett’s esophagus, a pre-malignant change thought to lead to esophageal adenocarcinoma. Barrett’s esophagus is found in one in 10 symptomatic GERD patients.

However, it is not possible to identify which patients have esophagitis or Barrett’s esophagus by looking at the severity of symptoms.

How can GERD be diagnosed?
CloseThe typical GERD syndrome can be diagnosed on the basis of persistent and troublesome symptoms, particularly heartburn and acid regurgitation. International experts agree that patients have GERD when they suffer from troublesome reflux symptoms that adversely affect their everyday life.

Reflux symptoms are likely to indicate GERD when they are mild and frequent (several times a week) or moderate or severe and less frequent (for example, once a week).
However, it is the patient who should decide whether their GERD symptoms are troublesome. Any patient who presents with alarm symptoms, such as dysphagia (difficulty in swallowing), vomiting, bleeding and anaemia, abdominal mass or unexplained weight loss, should undergo further investigation.

What impact does GERD have on patients’ lives?
The pain and discomfort caused by GERD disrupt patients’ everyday lives. GERD interferes with:
– physical activity (e.g. manual work, housework, gardening and sport), because symptoms are often worse during physical exertion.
– social occasions (e.g. eating with family and friends), because symptoms are worse during and after meals.

– sleep, because symptoms are often worse when lying down.
– work, because symptoms disturb sleep, causing daytime tiredness.

Patients with persistent GERD symptoms may also be anxious about their possible long-term effects.

Are there any clinical instruments to help in understanding GERD patients’ symptoms?

The GERD Impact Scale (GIS) is a useful tool that can be used after a GERD diagnosis to assess the symptom burden in patients with GERD, and the implications of those symptoms for their lives. The GIS is a validated one-page questionnaire that asks GERD patients about their symptoms and how they affect their everyday lives. In order to obtain a clear understanding of the impact of GERD symptoms, you can ask newly diagnosed patients to complete the questionnaire during their initial consultation. Those with an established GERD diagnosis can complete it in the waiting room or pharmacy when they consult for a repeat prescription and, by comparing the newly completed form with their original one, the physician can assess the effectiveness of the treatment they are being given. It will therefore help to identify patients who need more effective treatment due to uncontrolled symptoms.

Why is effective acid control important in GERD?
Excess acid in the esophagus is potentially damaging. In addition, the activity of pepsin within the gastric juice is pH-dependent, and declines rapidly when the pH is raised above 4.

Below pH 4, increased acid and pepsin activity can cause damage to the esophageal mucosa and trigger symptoms. It is well established that:
– the frequency of reflux symptoms is directly related to the time that the esophageal pH is below 4.
– the proportion of patients with reflux esophagitis healed after 8 weeks of therapy is directly related to the proportion of time during the 24-hour period for which the intragastric pH is maintained above 4.

The critical threshold for acid control in GERD is therefore to maintain the intragastric pH, and hence the pH of the refluxed gastric contents in the esophagus, above 4.

How should GERD be treated?

For effective management of GERD, the key aim of treatment is to maintain the stomach contents above pH 4 for as long as possible, in order to provide freedom from GERD symptoms and esophageal damage.

Proton pump inhibitors (PPIs) have proven to be the most effective medication for maintaining pH control and are recommended in international guidelines on the management of GERD as first-line treatment for patients with GERD.

However, GERD is a chronic condition and the majority of patients will suffer a symptomatic relapse within 2–3 months of cessation of the initial therapy.

Most patients with GERD therefore require long-term management, and international guidelines recommend a ‘step down’ from the initial healing dose of PPI in order to maintain freedom from symptoms and esophagitis.
. Freedom from symptoms during long-term treatment is a good predictor of the absence of esophagitis.

Why is freedom from GERD symptoms so important for the patient?
For the patient, rapid relief of symptoms is very important for their well-being. Furthermore, patients with persistent, recurring symptoms, need an effective solution that can provide enduring relief. Effective prescription treatment for GERD helps patients to lead more normal everyday lives by:
– improving sleep dysfunction