GERD (Gastroesophageal Reflux): Causes and Treatment Approaches

GERD and Heartburn

Acid reflux is the backwash of stomach contents into the throat, esophagus, and, sometimes, into the mouth. This is typically acidic. Once in a while, this is normal, but if it occurs more than twice a week, it is considered GERD (gastroesophageal reflux).

Most people have had an occasional episode of this; some people get it very frequently, and some people have it and do not know they have it (silent GERD) - especially at night when they are lying down. Do you or your loved one(s) ever wake up reaching for a TUMS?; choking, or having to swallow stomach contents?

Occasionally, people experience heartburn as well. This is a transient burning in your chest beneath the breastbone. Because the esophagus and upper stomach are near the heart, people sometimes think this pain is heart (cardiac) pain. This can be tricky. 

You can never really tell what your chest pain is from unless you go into the emergency room to have tests done. But, as a general rule: 

Heartburn tends to be worse after eating and when bending over or lying down (although a heart attack can happen after a meal, too).

• Heartburn can usually be relieved by drugs that reduce acid levels in the stomach.

• Heartburn should not cause "crushing" chest pain or shortness of breath.

• A heart attack may cause vomiting, but does not typically cause bloating or belching, which may occur with heartburn.

A few important pointers about CHEST PAIN. As mentioned, it can be very hard to tell the difference between gastric and cardiac chest pain unless you have had it before. If you are in distress, it is recommended that you call 911. 

GERD can cause a number of problems. That's why it's a pretty big deal. Food and acid regurgitation can cause hiccoughing, burping, halitosis (bad breath), tooth decay, excessive mouth-watering, a hoarse voice, and voice changes. Reflux can also cause a chronic cough and/or asthma-type symptoms because acid content can go into your lungs (often times this is what the specialists look for when there is no other explanation for asthma); and, oddly enough, it can be the cause of recurring sinus infections (when backwash frequently enters the back of the sinuses) and sleep apnea (ask your bed partner if you choke during the night or incessantly swallow). Sometimes, the acid from reflux can cause serious ulcers or bleeding in your esophagus. It is best to try to get it under control - sometimes, you can even heal the problem behind the reflux.

Woman Experiencing Heartburn

Causes of GERD

GERD can be caused by several different things. Many times, it has to do with eating habits and certain types of foods, and YOU can fix them. Here are some of the things that can cause reflux:

Certain Types of Foods that can cause reflux:

•         Chocolate

•         High-fat and/or fried foods

•         Alcohol

•         Raw onions

•         Carbonated beverages

•         High cholesterol foods

•         Acidic drinks such as citrus fruit juices

•         Tea and coffee

•         TOMATO SAUCE - That would be pizza, tomato on pasta

•         High-fat dairy products​

Other Causes of Reflux:

• ​Reflux can also be due to a weak esophageal sphincter. The latter is a muscular band located between the lower end of the esophagus and the stomach that controls the flow of food and prevents it from traveling back up the esophagus.​

• ​Smoking

• Pregnancy

• Alcohol use

• Hiatal hernia (a condition in which part of the stomach moves above the diaphragm, which is the muscle that separates the chest and abdominal cavities)

• Obesity

• Scleroderma

• Lying down within 3 hours after eating

• Certain medications can cause GERD:

          Anticholinergics (for example, sea sickness medicine)

          NSAIDS

          Beta-blockers for high blood pressure or heart disease

          Bronchodilators - certain inhalers for asthma or other lung diseases

          Calcium channel blockers are often taken for high blood pressure

          Dopamine-active drugs for Parkinson's disease

          Progestin (hormones)

          Sedatives for insomnia or anxiety

          Theophylline (for asthma or other lung diseases)

          Tricyclic antidepressants,

Anticholinergics (for example, sea sickness medicine)

Check with your doctor or pharmacist to see if it may be your medications causing the problem.

​General Approaches to Treatment of GERD:

• Elimination Diet: You can try this - it may help - Start decreasing or eliminating some of the things on the list above (see foods that cause reflux), especially before bed (many times if you can figure out the cause, you can figure out the remedy yourself) IN CONJUNCTION WITH LIFESTYLE CHANGES and sometimes in combination with protein pump inhibitors (PPI's - see below)

• Review your medications and compare them with the list above. If you find one that may be causing the GERD, speak to your healthcare provider about a substitute.

• Do not eat too close to bedtime

• Don't eat too much before bed (wait 2-3 hours after lying down) 

• Eat smaller, more frequent meals

• Eat and drink slowly

• Avoid Carbonated beverages

• Quit smoking

• Lose weight if overweight

• Avoid tight clothing

• Use more pillows or elevate the head of your bed on risers

• Reduce stress (stress increases acid in the stomach)

Approaches and Treatment for GERD

Over-the-Counter

Many over-the-counter medications exist now that can be used to try to treat reflux.  Some are fairly expensive, and many are not supposed to be used long-term (although people do this quite a bit). Over the long term, they can cause osteoporosis, kidney disease, predisposition to dementia (questionable), predisposition to cardiovascular disease (questionable), diarrhea, and a greater predisposition to C. diff, pneumonia, and a deficiency in nutrients. Some providers recommend that you alternate between H2 inhibitors and protein pump inhibitors, which will be discussed in the following paragraphs.

• Antacids - Tums, Rolaids, and Gaviscon - These are common examples of over-the-counter antacids that can help with heartburn because they neutralize stomach acid, but they generally do not help very well with chronic GERD. The manufacturer claims that it relieves only occasional bouts of reflux.

  The good things about antacids are that they work within five minutes; the downside is that the effects only last for about 20-30 minutes.

They also have the potential to interact with other medications. Some of the more common of these include various antibiotics (like Zithromax and quinolones, including Cipro) and the thyroid medicine, levothyroxine.

• H2 Agonists Receptor are over-the-counter ranitidine/Zantac, famotidine/Pepcid, and cimetidine/Tagamet. Pepcid Complete acts within 5 minutes, but the others take anywhere from 30-60 minutes. These H2 antagonists typically work well, but the effects only work for 6-12 hours (PPIs last twice as long). Cimetidine is metabolized by the CYP450 CYP1A2, CYP2D6, and CYP3A4 enzyme pathways, so it also has several drug interactions.

• Protein Pump Inhibitors (PPIs) include omeprazole (Prilosec), lansoprazole (Prevacid), esomeprazole (Nexium) and others. They take nearly 2-3 hours to work and may take longer for full benefit. However, these tend to last the longest (up to 24 hours). Everyone seems to have their own preference. If you need something for reflux, use one of these for about a month or two as directed and see if the GERD goes away. Do this in conjunction with lifestyle changes (above). Of course, if the symptoms are severe or ongoing – if you feel a need to continue these medications on a regular basis to control your GERD, consider seeing your healthcare provider. Because the PPIs are metabolized by the CYP 450 CYP2C19 enzymes, they can interact with some other medications. Be sure to read labels!

Note: While many people use these on an ongoing basis, PPIs and H2 blockers should only be used for two weeks at a time. Taking them for too long can cause problems like a rebound increase in stomach acid when use is discontinued, decreased ability to absorb certain vitamins and minerals (stomach acid is necessary for absorption), questionable kidney problems, and others. If a person feels that they need to take them long-term, they should taper off after two weeks and, if still needed, resume again after four weeks. Otherwise, they should speak to their healthcare provider.

Considered Herbal and Other Natural Remedies

• Milk (low-fat) - But this can also make things worse

• Ginger

• Baking Soda (1 tsp in 1 c water)

• Basil

• Coconut

• Mint

• Watermelon

• Chewing Gum

• Honey and Lemon

• Slippery Elm

• Lavender

• ginger

• orange

Fermented foods can also help restore balance to the GI tract. The bacteria in these foods are known as probiotics. Probiotics help to reduce digestive issues by balancing the digestive system as a whole.

Foods that naturally contain probiotics include:

• Yogurt

• Kefir

• Raw sauerkraut

• Raw kimchi

• Raw fermented pickles

• Kombucha, a fermented tea drink

• You can also get probiotics in a capsule form

Some probiotic foods help fight a bacterial strain known as H. pylori, which may be linked to their reflux symptoms. *Note that not all people can take probiotics - i.e., those with immune compromise, including those on chemo. Speak to your healthcare provider if in doubt.

A 2013 study of over 500 people found that some foods appear to reduce the incidence of GERD symptoms.

Foods that may reduce symptoms of GERD include:

• Protein from low-cholesterol sources such as tuna, salmon, cashews, almonds, and lentils

• Certain carbohydrates found in natural fruits, vegetables, and some grains

• Vitamin C, for example, in potatoes, may help reduce symptoms

• Fruits such as berries, apples, melons, peaches, citrus fruits, and tomatoes may help (although sometimes acidic foods make things worse)

• Eggs, despite their cholesterol content, appear to reduce GERD symptoms

• Increased fiber in the diet has been linked to fewer GERD symptoms. Research has shown that as people increase the levels of dietary fiber in their diet, the symptoms of GERD decrease.

​Prescription Medications

• ​​​​Baclofen can help to control symptoms by reducing the relaxation of the lower esophageal sphincter, but adverse effects include fatigue and confusion.

• Dexilant - This is a relatively newer prescription PPI. It has some medication interactions and is contraindicated with certain medical conditions.

If you have difficulty or painful swallowing, unintended weight loss, you are vomiting blood or have black stools, your problem may be more severe than just GERD. See your healthcare provider. If you have recurring episodes of GERD and/or your symptoms are ongoing despite your efforts, see your healthcare provider. Ongoing reflux can cause more serious problems like peptic ulcers, esophagitis (inflammation that can cause a sore throat), hoarseness, difficulty swallowing, GI bleeding, and precancerous Barrett's esophagus. Your healthcare provider may need to do some further testing, such as X-rays, an upper endoscopy, or surgery to repair a hiatal hernia or other problems.

These days, most people's diets are pretty formidable with all the processed foods we eat. If you are relatively young, remind yourselves: "If I knew then what I know now..." and the old expression "garbage in, garbage out."