Introduction

Gastroesophageal reflux disease (GERD) is gastro-oesophageal reflux disease in the UK, where it's shortened to GORD. On both sides of the Atlantic, however, it's extremely common, although many sufferers don't go to their physicians about it. This is because over-the-counter drugs are fairly effective in dealing with the symptoms, as well as being quite cheap. Here is a summary of a recent review in the Journal of Family Practice on GERD today.

Just how common is GERD?

Depending on how the question is asked, it's reported that between 20% and 50% of the population have GERD symptoms in a given year. Part of the reason for this wide range is that most people don't have symptoms every day, or even every week. If the rates are broken down according to the frequency of symptoms, the following picture emerges:

Different Rates of GERD Symptoms

	Daily Symptoms	One or More Symptoms a Month
General Adult Population	9%	21%
Pregnant Women	25%	52%
Men Over 65	8%	54%
Women Over 65	15%	66%

Only 1 patient in 5 who has weekly symptoms goes to the doctor.

What are the symptoms?

The main symptom of GERD is persistent heartburn, often with acid regurgitation and belching. Sometimes, however, GERD produces chest pain, hoarseness or laryngitis, cough, or difficulty swallowing. You don't have to have heartburn to have GERD

What's the cause?

The principal cause of GERD is weakening of the valve-like structure at the lower end of the esophagus, where it enters the stomach. This weakening allows the stomach contents to leak back into the lower part of the esophagus. The acid contents cause inflammation of the lower part of the esophagus (esophagitis), with slowing of the normal emptying action. Sometimes breaks (erosions) occur in the layer of cells lining the lower esophagus, causing what is called erosive esophagitis.

A weakness in the diaphragm allowing a wider hole for the esophagus (called a hiatal hernia) is an obvious factor in the causation of GERD. Obesity, pregnancy, tight clothing, smoking, fatty food, alcohol, caffeine, chocolate, onions, peppermint -- all may be incriminated as triggers for GERD attacks. For some of these, the connection fairly clear; with others, it's obscure.

How is GERD diagnosed?

After listening to a history of your symptoms, a physician can probably diagnose GERD with a fair degree of accuracy. One of the simplest ways to confirm this is for your physician to prescribe a 4-week course of a type of drug called a proton-pump inhibitor, such as omeprazole (Prilosec). If this results in an improvement in your symptoms, it's highly likely that you have GERD.

This approach is acceptable in uncomplicated cases. However, if there are any signs of obstruction (inability to swallow) or bleeding, or in people over 50 (who are at an increased risk of cancer), further investigation is advisable.

There are two sorts of investigation that may be recommended - 24-hour pH monitoring, and endoscopy. In the first, a small rubber tube is passed through the nose (or the mouth) down the esophagus, and kept in place for 24 hours; small fluid samples are withdrawn at intervals to measure the amount of acidity in the lower esophagus. Endoscopy involves sedation, and then insertion of a small tube down the esophagus to allow the physician to inspect its lower end, take photos, and possibly sample the tissue (painlessly) for microscopic examination.

Twenty-four--hour pH monitoring is less unpleasant than endoscopy. However, endoscopy is best for patients with more serious signs -- difficulty in swallowing, weight loss, or bleeding -- to make sure there is nothing more serious going on. Sometimes other tests are recommended, but none of them is better than pH monitoring or endoscopy.

Medical treatment

To begin with, there is much that can be tried to lessen the likelihood of gastric reflux. Raising the head of the bed and avoiding lying down after meals, for instance. Certain foods and alcohol may be associated with GERD symptoms in some people. Trial and error is often the best approach. It's important to lose weight, if you are overweight -- this reduces a mechanical reason for acid reflux.

Over-the-counter antacid drugs have enormous sales, are cheap, relatively safe, and are quite effective in some people. There are several sorts that usually work by chemically neutralizing the acidity in the stomach; one type produces a neutral foam that 'floats' on top of the stomach contents.

A more specific way of dealing with the problem is to block the secretion of stomach acid. Histamine-2 blockers like cimetidine (Tagamet) or rantitidine (Zantac) have been shown in numerous clinical studies to be effective in healing esophagitis and relieving the symptoms of GERD. It's been estimated that for every 5 GERD patients treated with a histamine-2 blocker, one will benefit; i.e. 20% of people get better with one of these drugs.

A newer class of drugs that suppress acid formation, the proton-pump inhibitors, can claim better clinical results. About 50% of GERD patients are improved in the short term, and over 30% in the long-term. Representatives are omeprazole (Prilosec) and lansoprazole (Prevacid).

Both histamine-2 blockers and proton pump inhibitors appear equally safe, and patients may expect to benefit more from proton pump inhibitors. These results are bought at a price -- in general, proton pump inhibitors are, today, roughly ten times as expensive as generic histamine-2 blockers. This difference in price can explain why some physicians feel obliged to prescribe one type of drug rather than another, at least in the first instance.

There are some drugs that increase the motility of the esophagus and stomach (and thus hasten removal of acid from the esophagus); they include metoclopramide, bethanecol, and cisapride. Side effects can be a problem with these drugs, however.

Time for surgery?

If medical therapy fails, surgery to repair the esophagus-stomach valve can offer long-term (10-year) success rates of over 80%. A newer 'keyhole surgery' (laparoscopic) procedure is equally successful in the short-term, but long-term results are not yet available.

The prospects

With today's drugs -- the proton pump inhibitors -- symptoms of GERD can be suppressed in over 75% of patients after 1 year. Rarely, GERD leads to scarring around the valve, causing contraction (an esophageal stricture), which may require treatment by appropriate dietary changes and, possibly, stretching under anesthesia.

Sometimes a condition known as Barrett's esophagus occurs, in which the cells lining the lower part of the esophagus change into cells that resemble those seen in the stomach. Eventually, these cells can become cancerous. The actual risk of Barrett's esophagus developing in a patient with chronic GERD is small (about 3% to 4%), and only about 4% of these cases go on to develop esophageal cancer, so that it's something to be aware of, but not to worry about. The important thing is to keep your physician in the picture about what drugs (and/or herbs) you are taking, and if your GERD symptoms seem to worsen, with weight loss and/or bleeding.