What is GERD?

GERD, or gastroesophageal reflux disease, is a digestive disease in which stomach acid or stomach contents come back up into the esophagus.

It is a recurring and often chronic disease process, occurring at least twice a week or more and interfering with daily life. Anyone can develop GERD, but the risk increases with obesity, hiatal hernia (when part of the stomach pushes up through the diaphragm), stress, smoking, and consuming certain foods (such as carbonated beverages, coffee, and chocolate). Other risks include pregnancy, asthma, diabetes, delayed stomach emptying, or connective tissue disorders such as scleroderma.

Causes and Mechanisms

The most common symptom of GERD is regular heartburn (a painful burning sensation in the middle of the chest, sometimes spreading to the throat).

Other common symptoms include:

• Acid reflux (regurgitating food or sour liquid)
• Chest pain
• Difficulty swallowing or painful swallowing
• Nausea/vomiting
• Dry cough
• Hoarseness or sore throat
• Bad breath
• Damage to teeth

GERD is caused by frequent acid reflux. It occurs when the lower esophageal sphincter (a circular band of muscle around the bottom part of the esophagus) becomes weak or relaxes when it shouldn’t. This allows stomach contents to rise up into the esophagus, causing heartburn. The lower esophageal sphincter becomes weak or relaxes due to certain things, including:

• Increased pressure on the abdomen from being overweight or pregnant
• Smoking
• Hiatal hernia
• Certain medications, such as calcium channel blockers, antihistamines, asthma medications, painkillers, sedatives, or antidepressants

The constant backwash of acid can irritate the lining of the esophagus, causing inflammation (esophagitis). This inflammation can wear away the esophageal lining, leading to complications such as:

• Esophageal ulcer, which may bleed, causing pain and difficulty swallowing
• Esophageal narrowing due to the formation of scar tissue, causing difficulty swallowing
• Barrett’s esophagus, a precancerous condition

The diagnosis of GERD may be made based on frequent heartburn and other symptoms, or a gastroenterologist (a doctor who specializes in digestive diseases and disorders) may be recommended.

There are several tests used to diagnose GERD:

Upper GI (gastrointestinal) endoscopy uses an endoscope to look inside the upper GI tract and is done at a hospital or outpatient center. If a biopsy is needed, a small piece of tissue is taken from the lining of the esophagus.

Upper GI series (barium swallow) looks at the shape of the upper GI tract. While drinking barium to coat the inner lining of the upper GI tract, several x-rays are taken as the barium moves through the GI tract, showing problems related to GERD, such as hiatal hernias, esophageal strictures, or ulcers.

Esophageal pH and impedance monitoring is the most accurate procedure to detect acid reflux. A thin tube is passed through the nose or mouth into the esophagus to measure when and how much acid comes up into the esophagus. The other end of the tube attaches to a monitor that records measurements for 24 hrs. during normal eating and sleeping. This type of pH monitoring can also be done with a wireless capsule attached to the wall of the esophagus for 48 hrs, after which it will fall off and pass through the digestive tract within 7-10 days.

Esophageal manometry measures muscle contractions in the esophagus with a soft, thin tube passed through the nose into the esophagus that is connected to a computer. This procedure can be done during an office visit and can show if symptoms are related to a weak sphincter muscle.

Lifestyle changes to reduce GERD symptoms:

• Avoid overeating and avoid foods or drinks that cause reflux, including:

• Greasy, spicy, and fatty foods
• Tomatoes and tomato products
• Chocolate
• Peppermint
• Coffee (caffeine drinks)
• Alcoholic drinks

• Lose weight if needed
• Do not eat 2-3 hours before bedtime, and stay upright for 3 hours after meals
• Sleep on a slight angle by raising the HOB 6-8 inches with wood blocks under the bedposts (just sleeping on extra pillows will not help)
• Wear loose-fitting clothing around the abdomen
• Stop smoking and avoid secondhand smoke

Depending on the severity of symptoms, the doctor may recommend lifestyle changes, medicines, surgery, or a combination.

There are several over-the-counter and prescription medications for treating GERD symptoms.

• Antacids such as Maalox, Mylanta, Rolaids, or Tums are often recommended first to neutralize stomach acid. Overuse can cause side effects such as diarrhea or constipation.
• H2 blockers such as Tagamet, Pepcid, or Zantac, decrease acid production from the stomach for up to 12 hours, providing relief from acid reflux.
• Proton pump inhibitors (PPIs) lower the amount of acid the stomach makes and are better at treating GERD symptoms than H2 blockers as they allow time for the esophageal lining to heal. However, long term use of PPIs increases the risk of bone fracture and vitamin B-12 deficiency. Prescription PPIs include Nexium, Prevacid, Prilosec, and Protonix. Lower strength Prilosec and Prevacid is available OTC.
• Prokinetics help the stomach empty faster and include prescription Urecholine and Reglan. These both have side effects including nausea, diarrhea, fatigue, depression, anxiety, and delayed or abnormal physical movement.

Surgery may be recommended if GERD symptoms don’t improve with lifestyle changes or medications.

Nissen fundoplication is the most common surgery for GERD, often leading to long-term reflux control. The surgery is done laparoscopically under general anesthesia – this involves using a flexible tube with a tiny video camera through 3 to 4 small incisions in the abdomen. The top of the stomach is sewn around the esophagus to add pressure to the lower end of the esophagus and reduce reflux.

Endoscopic procedures are done under general anesthesia using an endoscope (tube with tiny video camera that travels through the digestive tract).

Endoscopic sewing uses small stitches to tighten the sphincter muscle. Radiofrequency ablation creates heat lesions, or sores, that help tighten the sphincter muscle.

The Linx device is a ring of tiny magnetic titanium beads wrapped around the junction of the esophagus and stomach. The magnetic attraction keeps the opening closed enough to prevent acid reflux, but weak enough so food can pass through it.

Nursing tips to instruct the patient with GERD

• Avoid foods that cause GERD symptoms
• Avoid circumstances that increase intra-abdominal pressure – bending, straining, heavy lifting, coughing, and tight clothing
• Avoid substances that reduce sphincter control – tobacco, alcohol, caffeine, fatty foods, and certain drugs
• Sit upright after meals and eat small, frequent meals
• Eat meals at least 2-3 hours before lying down
• Lose weight if needed

It is important to teach the patient what causes reflux and how to avoid it with diet, lifestyle changes, medication, and possibly surgery.