Acid Reflux (GERD): Symptoms, Causes & Treatment Guide

What Is Acid Reflux and GERD?

Acid reflux occurs when the lower esophageal sphincter (LES) relaxes inappropriately or becomes weakened, allowing stomach acid to flow backward into the esophagus. When acid reflux happens frequently (more than twice a week) and causes troublesome symptoms or complications, it is diagnosed as gastroesophageal reflux disease (GERD).

The esophagus is the muscular tube that carries food from your mouth to your stomach. At the bottom of the esophagus, a ring-shaped muscle called the lower esophageal sphincter (LES) acts as a valve, opening to allow food into the stomach and closing to prevent stomach contents from flowing back up. When this valve doesn't function properly, stomach acid can escape into the esophagus, causing the burning sensation known as heartburn.

Understanding the difference between occasional acid reflux and GERD is important for proper treatment. Occasional heartburn affects most people at some point, often after eating a large meal or lying down too soon after eating. This is generally harmless and can be managed with over-the-counter antacids. However, when reflux becomes chronic and interferes with daily life, it requires more comprehensive management.

GERD is one of the most common gastrointestinal disorders worldwide, affecting approximately 20% of the adult population in Western countries. The prevalence has been increasing over recent decades, partly due to rising obesity rates and dietary changes. While GERD can occur at any age, it becomes more common with advancing age as the LES tends to weaken over time.

The Anatomy of Reflux

To understand acid reflux, it helps to know how the digestive system normally works. The stomach produces about 2 liters of gastric juice daily, containing hydrochloric acid with a pH of 1.5-3.5, which is highly corrosive. This acid serves essential functions: killing bacteria in food, activating digestive enzymes, and breaking down proteins. The stomach wall is protected by a thick mucus layer, but the esophageal lining has no such protection.

The lower esophageal sphincter normally remains closed except during swallowing. It creates a high-pressure zone that prevents gastric contents from refluxing. Several factors can disrupt LES function, including certain foods, medications, hormonal changes, and structural abnormalities like hiatal hernia. When the pressure in the stomach exceeds the LES pressure, reflux occurs.

Types of Gastroesophageal Reflux Disease

GERD is classified into different types based on the presence or absence of visible esophageal damage during endoscopy. Non-erosive reflux disease (NERD) accounts for about 60-70% of GERD cases, where patients have typical symptoms but no visible damage to the esophageal lining. Erosive esophagitis involves visible breaks in the esophageal mucosa and is graded by severity using the Los Angeles classification system (grades A through D).

Additionally, some patients have silent reflux or laryngopharyngeal reflux (LPR), where acid reaches the throat and voice box, causing symptoms like chronic cough, hoarseness, and throat clearing without typical heartburn. This form of reflux is often underdiagnosed because patients don't associate their symptoms with acid reflux.

What Are the Symptoms of Acid Reflux?

The primary symptoms of acid reflux include heartburn (burning sensation behind the breastbone), regurgitation of sour or bitter liquid, chest pain, difficulty swallowing, chronic cough, hoarseness, and the sensation of a lump in the throat. Symptoms typically worsen after meals, when lying down, or when bending over.

Acid reflux symptoms vary widely among individuals, both in type and severity. While some people experience classic symptoms like heartburn and regurgitation, others may have atypical presentations that can mimic other conditions. Understanding the full spectrum of GERD symptoms helps with early recognition and appropriate treatment.

Heartburn is the most characteristic symptom, affecting approximately 75% of people with GERD. It typically feels like a burning sensation that starts behind the breastbone (sternum) and may radiate upward toward the throat. Many people describe it as feeling like their chest is on fire. The sensation usually worsens after eating, especially large or fatty meals, and when lying down or bending over. Despite its name, heartburn has nothing to do with the heart, though the pain location can cause confusion with cardiac symptoms.

Regurgitation, the second most common symptom, involves the effortless return of gastric contents to the mouth or throat. Patients often describe tasting sour or bitter fluid, sometimes accompanied by undigested food particles. This symptom is particularly troublesome when it occurs during sleep, potentially causing choking or aspiration. Unlike vomiting, regurgitation occurs without nausea or forceful abdominal contractions.

Esophageal Symptoms

Beyond heartburn and regurgitation, GERD can cause several other esophageal symptoms. Dysphagia (difficulty swallowing) occurs in about 30% of GERD patients and may indicate esophageal narrowing or stricture formation. Patients may feel like food is getting stuck, particularly solid foods. Odynophagia (painful swallowing) suggests more severe esophageal inflammation or ulceration and warrants prompt medical evaluation.

Non-cardiac chest pain is another important symptom that can be indistinguishable from heart-related chest pain. GERD is the most common cause of non-cardiac chest pain, accounting for up to 60% of cases. The pain can be squeezing, pressure-like, or burning, and may radiate to the back, neck, jaw, or arms, mimicking a heart attack. Any new or severe chest pain should be evaluated by a healthcare provider to rule out cardiac causes before attributing it to GERD.

Extraesophageal Symptoms

GERD can manifest with symptoms outside the digestive tract, often called extraesophageal or atypical symptoms. These can be particularly challenging to diagnose because patients may not connect them to acid reflux.

Chronic cough associated with GERD is typically dry, worse at night, and may persist for months or years. The cough can result from micro-aspiration of acid into the airways or from a reflex triggered by acid in the lower esophagus. Studies suggest GERD is responsible for 21-41% of chronic cough cases. Asthma symptoms can worsen with reflux, as acid reaching the airways causes bronchospasm. Conversely, asthma medications can worsen reflux by relaxing the LES.

Laryngeal symptoms include hoarseness, frequent throat clearing, sensation of a lump in the throat (globus sensation), and postnasal drip. These symptoms result from acid and pepsin damaging the delicate tissues of the throat and voice box. Dentists may notice dental erosion on the inner surfaces of teeth, particularly the upper molars, caused by repeated acid exposure.

What Causes Acid Reflux and GERD?

Acid reflux is caused by a weakened or dysfunctional lower esophageal sphincter (LES), often combined with factors that increase stomach pressure or acid production. Major causes include hiatal hernia, obesity, pregnancy, certain foods and medications, smoking, and delayed stomach emptying. The condition results from an imbalance between protective factors and aggressive factors in the esophagus.

The development of GERD involves multiple contributing factors that disrupt the normal anti-reflux barrier. Understanding these causes helps identify modifiable risk factors and guides treatment decisions. While some causes like hiatal hernia are structural, many risk factors relate to lifestyle and can be modified.

The lower esophageal sphincter (LES) is the primary barrier against reflux. In GERD, the LES may be abnormally relaxed at baseline, have frequent transient relaxations (called transient lower esophageal sphincter relaxations or TLESRs), or be structurally compromised. TLESRs are the main mechanism of reflux in most patients, occurring when the stomach distends after eating and triggering a neural reflex that briefly opens the LES.

Structural and Anatomical Causes

Hiatal hernia is one of the most important anatomical risk factors for GERD. It occurs when part of the stomach pushes up through the diaphragm into the chest cavity through the hiatus, the opening where the esophagus passes through the diaphragm. This weakens the natural anti-reflux barrier created by the crural diaphragm and displaces the LES from its normal position, making reflux more likely. Hiatal hernia is present in about 60% of patients with severe GERD and increases in frequency with age.

The size of the hiatal hernia correlates with GERD severity. Small hernias may cause minimal symptoms, while large hernias significantly impair LES function and can lead to complications like ulceration within the hernia itself. Hiatal hernia is also associated with increased esophageal acid exposure and delayed acid clearance.

Lifestyle and Dietary Factors

Obesity is a major modifiable risk factor, increasing GERD risk 2-3 times compared to normal weight individuals. Excess abdominal fat increases intra-abdominal pressure, which overcomes LES resistance and promotes reflux. Obesity also increases the frequency of TLESRs and is associated with hiatal hernia development. Studies show that even modest weight gain increases GERD symptoms, while weight loss can provide significant relief.

Certain foods and beverages can trigger or worsen acid reflux:

• Fatty and fried foods delay stomach emptying and relax the LES
• Acidic foods (citrus, tomatoes) directly irritate the esophagus
• Spicy foods can irritate damaged esophageal tissue
• Chocolate contains methylxanthines that relax the LES
• Coffee and caffeine stimulate gastric acid secretion
• Alcohol relaxes the LES and damages esophageal mucosa
• Peppermint and spearmint relax the LES
• Carbonated beverages increase stomach distension and pressure

Eating behaviors also play a role. Large meals distend the stomach and increase pressure on the LES. Eating close to bedtime doesn't allow adequate time for the stomach to empty before lying down, when gravity no longer helps keep acid in the stomach. Eating quickly without proper chewing leads to swallowing more air and increases stomach distension.

Medications That Can Worsen Reflux

Several commonly used medications can contribute to GERD by either relaxing the LES or directly irritating the esophagus:

• Calcium channel blockers (for high blood pressure) relax smooth muscle including the LES
• NSAIDs (ibuprofen, aspirin, naproxen) can damage esophageal mucosa
• Benzodiazepines and some sedatives relax the LES
• Anticholinergics delay stomach emptying
• Theophylline (for asthma) relaxes the LES
• Bisphosphonates (for osteoporosis) can cause severe esophagitis if not taken correctly
• Iron supplements and potassium chloride can irritate the esophagus

Other Contributing Factors

Pregnancy commonly causes or worsens GERD due to hormonal changes and physical factors. Elevated progesterone levels relax the LES, while the growing uterus increases abdominal pressure. Up to 80% of pregnant women experience heartburn, particularly in the third trimester. Symptoms typically resolve after delivery.

Smoking contributes to GERD through multiple mechanisms: it reduces LES pressure, decreases saliva production (which normally helps neutralize acid), damages esophageal mucosa, and delays stomach emptying. Smoking cessation is an important part of GERD management.

Gastroparesis (delayed stomach emptying) can worsen reflux by keeping food and acid in the stomach longer than normal, increasing the opportunity for reflux. Conditions like diabetes, connective tissue disorders, and certain medications can cause gastroparesis.

When Should You See a Doctor for Acid Reflux?

See a doctor if you experience heartburn more than twice weekly, if symptoms persist despite over-the-counter treatment for more than 2 weeks, if you have difficulty swallowing, unexplained weight loss, persistent nausea or vomiting, or if symptoms significantly affect your quality of life. People over 50 with new-onset symptoms should be evaluated promptly.

While occasional heartburn is common and usually manageable with over-the-counter medications, certain symptoms and situations warrant medical evaluation. Early diagnosis and treatment of GERD can prevent complications and improve quality of life. Knowing when to seek care helps ensure you receive appropriate treatment.

You should contact a healthcare provider if you experience any of the following:

• Heartburn occurring more than twice weekly for several weeks
• Symptoms that don't improve after 2 weeks of over-the-counter treatment
• Difficulty swallowing or sensation of food getting stuck
• Painful swallowing
• Unexplained weight loss
• Persistent nausea or vomiting
• Symptoms that wake you from sleep
• Chronic cough or hoarseness without respiratory illness
• New symptoms if you're over 50 years old
• Symptoms significantly impacting your daily activities or quality of life

Alarm symptoms require more urgent evaluation as they may indicate complications or other serious conditions. These include dysphagia (difficulty swallowing), odynophagia (painful swallowing), gastrointestinal bleeding (vomiting blood or black stools), anemia, and significant unintentional weight loss. Patients with these symptoms typically need endoscopy to evaluate for strictures, ulcers, Barrett's esophagus, or malignancy.

What to Expect at Your Doctor Visit

Your doctor will take a detailed medical history, asking about the frequency, severity, and triggers of your symptoms. They'll want to know about your diet, lifestyle habits, medications, and any factors that worsen or relieve symptoms. Be prepared to describe when symptoms occur, how long they last, and what you've tried for relief.

In many cases, GERD can be diagnosed based on symptoms alone, and empiric treatment with acid-suppressing medication may be started without immediate testing. If symptoms respond well to treatment, this supports the diagnosis. However, if symptoms persist, worsen, or alarm symptoms are present, further investigation is needed.

How Is Acid Reflux Diagnosed?

GERD is often diagnosed based on typical symptoms and response to acid-suppressing medications. When diagnostic testing is needed, options include upper endoscopy (EGD) to visualize the esophagus and detect damage, 24-hour pH monitoring to measure acid exposure, and esophageal manometry to assess muscle function. Testing is particularly important when symptoms are atypical, don't respond to treatment, or alarm features are present.

The diagnostic approach to GERD varies based on symptom presentation, severity, and the presence of alarm features. For patients with classic symptoms (heartburn and regurgitation) without alarm features, a trial of proton pump inhibitor (PPI) therapy is often both diagnostic and therapeutic. Symptom improvement with PPI treatment supports the diagnosis of GERD.

Upper Endoscopy (Esophagogastroduodenoscopy)

Upper endoscopy (EGD) is the most common diagnostic procedure for GERD. During this test, a thin, flexible tube with a camera (endoscope) is passed through the mouth to visualize the esophagus, stomach, and duodenum. It allows direct assessment of the esophageal mucosa and can identify complications like esophagitis, strictures, Barrett's esophagus, and exclude cancer.

Endoscopy is recommended for patients with alarm symptoms, those who don't respond to standard therapy, patients with long-standing symptoms (for Barrett's screening), and before considering surgery. During the procedure, tissue samples (biopsies) can be taken for microscopic examination. The procedure is performed under sedation and typically takes 15-20 minutes.

It's important to note that a normal endoscopy doesn't rule out GERD. Up to 60-70% of GERD patients have non-erosive reflux disease (NERD) with no visible damage on endoscopy. These patients still have abnormal acid reflux and benefit from treatment.

Ambulatory pH Monitoring

24-hour pH monitoring measures acid exposure in the esophagus over an extended period, providing objective evidence of pathological reflux. It's the gold standard for diagnosing GERD when endoscopy is normal or symptoms are atypical. The test can be performed using a thin catheter passed through the nose or a wireless capsule attached to the esophageal wall.

The test measures the frequency and duration of acid reflux episodes, correlating them with symptoms. Results are expressed as the percentage of time pH is below 4 (acid exposure time) and as a composite score (DeMeester score). This test is particularly useful for patients with persistent symptoms on PPI therapy, atypical symptoms, or before anti-reflux surgery.

Esophageal Manometry

Esophageal manometry measures the pressure and coordination of esophageal muscle contractions and LES function. While it doesn't diagnose GERD directly, it's essential before anti-reflux surgery to ensure adequate esophageal function and rule out conditions that might be worsened by surgery, such as achalasia or severe esophageal dysmotility.

Other Diagnostic Tests

Barium swallow (upper GI series) involves drinking a chalky liquid and taking X-rays to outline the esophagus and stomach. While it can show hiatal hernias and strictures, it has largely been replaced by endoscopy for GERD evaluation. It may still be useful for assessing complex anatomy.

Impedance monitoring, combined with pH testing, can detect non-acid reflux events, useful for patients with persistent symptoms despite adequate acid suppression. This helps identify whether symptoms are related to weakly acidic or non-acidic reflux.

How Is Acid Reflux Treated?

GERD treatment follows a step-wise approach: lifestyle modifications form the foundation, followed by medications (antacids, H2 blockers, or proton pump inhibitors) based on symptom severity. Proton pump inhibitors (PPIs) are the most effective medications, healing esophagitis in 80-90% of patients. For those who don't respond to medication or prefer not to take long-term drugs, surgical options like fundoplication are available.

The goals of GERD treatment are to relieve symptoms, heal esophageal damage if present, and prevent complications. Treatment is individualized based on symptom severity, presence of esophagitis, and patient preferences. Most patients achieve good symptom control with a combination of lifestyle changes and medication.

Lifestyle Modifications

Lifestyle changes are the foundation of GERD management and should be tried before or alongside medication. While individual responses vary, these modifications can significantly reduce symptoms for many patients:

Dietary changes:

• Identify and avoid personal trigger foods (common triggers: fatty foods, citrus, tomatoes, chocolate, coffee, alcohol, spicy foods, mint)
• Eat smaller, more frequent meals rather than large portions
• Avoid eating within 3 hours of bedtime
• Eat slowly and chew food thoroughly
• Limit carbonated beverages

Sleep and positioning:

• Elevate the head of the bed 6-8 inches (15-20 cm) using bed risers or a wedge pillow
• Sleep on the left side, which positions the stomach below the esophagus
• Avoid lying down immediately after eating

Weight and habits:

• Lose weight if overweight or obese
• Quit smoking
• Avoid tight-fitting clothing around the abdomen
• Reduce stress, which can worsen symptoms

Medications for Acid Reflux

Several classes of medications are available for GERD, ranging from over-the-counter options for mild symptoms to prescription medications for more severe disease.

Antacids (Tums, Maalox, Mylanta, Gaviscon) neutralize stomach acid and provide rapid but short-lived relief. They're best for occasional heartburn and work within minutes. Some contain alginates that form a protective barrier on top of stomach contents. Antacids don't heal esophagitis and are not adequate for regular GERD symptoms.

H2 Receptor Blockers (famotidine, cimetidine) reduce acid production by blocking histamine receptors on stomach acid-producing cells. They provide relief within 30-60 minutes and last 6-12 hours. Available over-the-counter and by prescription, H2 blockers are effective for mild to moderate GERD but less effective than PPIs for healing esophagitis.

Proton Pump Inhibitors (PPIs) are the most effective medications for GERD. They include omeprazole, esomeprazole, lansoprazole, pantoprazole, and rabeprazole. PPIs block the final step of acid production in stomach cells, reducing acid secretion by 90-95%. They heal esophagitis in 80-90% of patients within 8 weeks and are the treatment of choice for moderate to severe GERD, erosive esophagitis, and complications.

PPIs should be taken 30-60 minutes before the first meal of the day for maximum effectiveness. For patients with nighttime symptoms, an evening dose may be added. While PPIs are generally safe, long-term use has been associated with potential risks including vitamin B12 deficiency, magnesium deficiency, increased risk of bone fractures, and certain infections. These risks should be weighed against the benefits for each individual patient.

Surgical Treatment

Surgery may be considered for patients who don't respond adequately to medications, those who prefer not to take long-term medication, or those with complications like large hiatal hernias or severe regurgitation despite medication.

Fundoplication is the most common anti-reflux surgery. The surgeon wraps the upper part of the stomach (fundus) around the lower esophagus to reinforce the LES. This can be performed laparoscopically (minimally invasive) with small incisions. The most common technique is Nissen fundoplication (360-degree wrap), though partial wraps (Toupet, Dor) are sometimes used.

Fundoplication provides excellent long-term symptom control in 85-90% of carefully selected patients. However, it can have side effects including difficulty swallowing, gas-bloat syndrome (inability to belch), and increased flatulence. Patient selection and surgical expertise are crucial for good outcomes.

LINX device is a newer surgical option involving a ring of magnetic beads placed around the LES to augment its function. The magnetic attraction keeps the LES closed but allows it to open for swallowing. Studies show good symptom control with fewer side effects than fundoplication.

What Are the Complications of Untreated GERD?

Chronic untreated GERD can lead to several serious complications including esophagitis (inflammation), esophageal ulcers, strictures (narrowing), Barrett's esophagus (precancerous changes), and slightly increased risk of esophageal adenocarcinoma. These complications are preventable with proper diagnosis and treatment. Most people with well-controlled GERD do not develop complications.

While GERD is generally not dangerous and most patients never develop serious complications, chronic untreated reflux can damage the esophageal lining over time. Understanding potential complications emphasizes the importance of treating persistent symptoms rather than simply tolerating them.

Esophagitis and Ulceration

Erosive esophagitis occurs when repeated acid exposure causes visible inflammation and breaks in the esophageal lining. It affects about 30-40% of GERD patients and is graded by severity (Los Angeles classification A-D). Symptoms may include painful swallowing and worsened heartburn. Esophagitis usually heals within 8 weeks of PPI therapy, but may recur if treatment is stopped.

Esophageal ulcers are deeper erosions that can cause significant pain, bleeding, and scarring. They require longer treatment courses and monitoring for healing.

Esophageal Stricture

Peptic stricture results from scarring and fibrosis caused by chronic esophageal injury. As scar tissue forms, the esophagus narrows, causing progressive difficulty swallowing, initially with solid foods and eventually with liquids. Strictures occur in about 5-10% of GERD patients with esophagitis.

Treatment involves endoscopic dilation (stretching the narrowed area with balloons or dilators) combined with aggressive acid suppression. Multiple dilation sessions may be needed, and patients require long-term PPI therapy to prevent recurrence.

Barrett's Esophagus

Barrett's esophagus is a condition where the normal squamous (flat) cells lining the esophagus are replaced by columnar (intestinal-type) cells, a process called intestinal metaplasia. It develops as an adaptive response to chronic acid and bile exposure and is found in about 10-15% of patients undergoing endoscopy for GERD symptoms.

Barrett's esophagus is significant because it's a precancerous condition with increased risk of developing esophageal adenocarcinoma. However, the absolute risk is relatively low, with fewer than 1% of Barrett's patients developing cancer per year. Risk factors for developing Barrett's include long-standing GERD symptoms, male sex, white race, older age, obesity, smoking, and family history of Barrett's or esophageal cancer.

Patients with Barrett's require regular surveillance endoscopies to detect dysplasia (precancerous changes) early. If dysplasia is found, treatment options include endoscopic therapies like radiofrequency ablation, which can eliminate the abnormal cells and reduce cancer risk.

Esophageal Cancer Risk

Chronic GERD is associated with a modestly increased risk of esophageal adenocarcinoma, particularly in patients with Barrett's esophagus. While this sounds alarming, it's important to put the risk in perspective. The vast majority of GERD patients will never develop cancer. Risk increases with duration and severity of symptoms, presence of Barrett's, and other factors like obesity and smoking.

Effective GERD treatment and surveillance of high-risk patients can help prevent progression to cancer or detect it at an early, treatable stage.