Living with
Gastroesophageal Reflux Disease (GERD)

What is gastroesophageal reflux disease?

If you have gastroesophageal reflux disease GERD then you experience stomach acid frequently flowing back into your oesophagus (the muscular tube that connects your mouth and stomach, also called the food pipe). This is called acid reflux.
The stomach acid can irritate the lining of your oesophagus and may cause heartburn.

It is common to experience acid reflux occasionally. However, if you experience persistent mild acid reflux that occurs at least twice a week, or moderate to severe acid reflux that occurs at least once a week, you may have GERD.

You can typically manage the symptoms of GERD with lifestyle changes and antacid medications; however, your doctor may suggest stronger medications or surgery to ease severe, persistent symptoms.

How do you know you have GERD?

Common symptoms of GERD include those associated with indigestion, while heartburn is the most common symptom.

These are some of the symptoms you may experience if you have GERD:

• A burning sensation in the upper abdomen and/or the chest (behind the breastbone) that can radiate up your neck. This is known as heartburn and usually occurs after eating meals and is worse when you lie down or bend over.
• Difficulty or discomfort/pain when swallowing
• Chronically sore throat or feeling like you have a lump in your throat
• Regurgitation of food or liquid that can cause an unpleasant, sour or bitter taste in your mouth
• Gingivitis (inflammation of the gums), dental cavities and bad breath
• Bloating and belching
• Nausea or vomiting.

If you experience acid reflux at night, you may commonly experience:

• A chronic cough, sore throat or laryngitis, and hoarseness of voice
• Worsening asthma symptoms or more frequent asthma attacks
• Disrupted sleep.

When to see your doctor:

See your doctor if you experience severe and persistent symptoms of GERD. Hints that you may have GERD and not just indigestion, and should therefore see your doctor, include if the digestive discomfort you feel interferes with your daily functioning and if you have to use antacid medications more than twice a week to relieve symptoms.

If you experience chest pain with shortness of breath, palpitations or sweating, seek immediate medical attention as these may be symptoms that you are having a heart attack.

What causes GERD?

While the exact prevalence of GERD in South Africa is not clear, it is believed that up to 40 % of people who live in developed countries are affected by the condition.

Your oesophagus is the muscular tube that links the mouth and throat (pharynx) with the stomach. GERD is caused by regular acid reflux from the stomach into the oesophagus. This is usually due to a defective lower oesophageal sphincter (LOS).

Digestion begins in the mouth where food is chewed and mixed with saliva to eventually form a bolus which is propelled to the back of the mouth by the tongue. When you swallow, the peristaltic waves of motion of the oesophageal muscle force the bolus down.
The LOS is the circular band of muscle around the bottom of your oesophagus that relaxes when you swallow to allows the bolus and fluid into your stomach. The sphincter then closes again. In the stomach the food mixes with stomach acid and other digestive enzymes. The LOS prevents digested food, stomach acid and digestive enzymes from moving back up into the oesophagus.

Therefore, if the LOS is weak or relaxes for too long or abnormally, stomach acid can flow back up into your oesophagus. Stomach acid and digestive enzymes can irritate and even damage the lining of the oesophagus, causing inflammation, or oesophagitis.

Risk factors that can contribute to GERD development or worsen GERD beyond a defective LOS, include:

• A family history of GERD: If you have a close family member (a parent or sibling) with GERD, you are at increased risk of developing it.
• Overweight or obesity: Being overweight or obese increases the intra-abdominal pressure.
• Pregnancy: Being pregnant increases the pressure in the abdomen in the same way.
• Hiatal hernia: This is a condition where there is bulging of the top of the stomach up through diaphragm into the chest, lowering the pressure on the LOS that helps keep it closed.
• Slow emptying of the stomach or gastroparesis: This increases the time for which the stomach is distended and in which reflux can occur.

Many lifestyle factors can also increase your risk of GERD and aggravates existing GERD, including:

• Smoking: Smoking or exposure to cigarette smoke reduces the clearance of refluxed acid out of the oesophagus back to the stomach.
• Alcohol consumption.
• Eating large meals or eating late at night: This increases the pressure against the LOS and there is loss of gravity at night to help return refluxed acid to the stomach.
• Eating certain or foods or drinking certain beverages that trigger indigestion.
• Certain medications: These include medications include those that impair gastric emptying, including: calcium channel blockers, statins, angiotensin-converting enzyme (ACE) inhibitors and nitrates used for hypertension and heart disease, as well as tricyclic antidepressants, opioids, progesterone, sedatives or tranquilisers, (including benzodiazepine) and some asthma medications.

Living and managing

If you have GERD it is a good idea that you avoid the triggers in your lifestyle that may be causing you to suffer the condition. If you have GERD, you should probably follow the following lifestyle tips:

• Maintain a healthy weight: One way of doing this is trying to keep as active as possible. You don’t have to join a gym do this; instead, just take regular walks, ride a bike or go dance along to the music on the radio.
  Your goal for regular exercise should be 30 minutes of moderate activity (makes you sweat and your heart beat a little faster) most days of the week.
• Eating a healthy diet: Try to eat a healthy, well-balanced diet that is low in fat.
  You may also want to try eating smaller meals and taking more your time over meals, eating more slowly. Do not eat before bedtime or lie down after meals.
  Depending on what food triggers you have, you may want to try avoid eating foods that commonly affect stomach emptying and pressure on the LOS, like chocolate. Spicy or very acidic foods may also worsen your GERD, as may carbonated drinks.
  You can get healthy meal ides from Cooking from the Heart.
• Stop smoking: Talk to your doctor about ways to quit smoking.
• Reducing or avoiding alcohol consumption or how much coffee or other caffeinated beverages you drink.
• Find ways to manage your stress levels and make sure to get enough sleep.

How is GERD diagnosed?

Several tests may be used by your doctor or healthcare provider to diagnose you with GERD. The main tests are:

• X-ray of the upper digestive system: You may have to drink chalky liquid that fills the inside lining of your digestive tract, allowing your doctor to see the shape of your oesophagus, stomach and upper intestine.
  Alternatively, you may be asked to swallow a tablet of barium (known as a ‘barium meal’) that can help show on X-ray if there a narrowing of the oesophagus.
• Endoscopy: Here, your doctor will insert a thin, flexible tube (with a light and camera at the end) down your throat to examine the inside lining of your oesophagus and/or stomach.
• Ambulatory acid (pH) test: A monitor is placed into your oesophagus to measure how much acid is in your oesophagus.
• Oesophageal impedance test/oesophageal manometry: This test measures the movement of substances in the oesophagus by, reading the rhythmic muscle contractions in your oesophagus when you swallow.

What treatment is available for GERD?

Your doctor is likely to recommend that you first try the above lifestyle modifications in combination with over-the-counter medications like antacids that neutralise stomach acid.

Your doctor may also suggest or prescribe stronger forms of the following medications:

• H-2-receptor blockers: These medications reduce stomach acid production, and include cimetidine and famotidine.
• Proton pump inhibitors: These medications are stronger acid blockers than H-2-receptor blockers and help damaged oesophageal tissue heal.
• Baclofen: This medication strengthens the lower oesophageal sphincter. Speak to your doctor about its use as it does have side-effects like fatigue and nausea.

If medication and lifestyle modifications fail to provide you with relief, your doctor may suggest surgery to strengthen the LOS. Of course, diagnosed hiatal hernias will probably also require surgery to correct as well.

What are the complications associated with GERD?

If you have GERD, over time, the refluxed stomach acid can cause chronic inflammation in your oesophagus which can lead to:

• Narrowing of the oesophagus, known as oesophageal stricture: The stomach acids cause damage and scar tissue to form in the lower oesophagus, which narrows the pathway through which food must travel to the stomach, leading to problems with swallowing.
• An open sore in the oesophagus (oesophageal ulcer): Stomach acid can corrode the tissue in the oesophagus, causing an open sore, ulcer, to form. Ulcers can bleed and cause pain and difficulty when swallowing.
• Barrett’s oesophagus: This is a precancerous change to the cells in the lower oesophagus caused by damage from acid. These changes are associated with an increased risk of oesophageal cancer.
• Asthma attacks: The irritation of lining of the throat and constant coughing associated with GERD may cause asthma attacks in those with asthma.