GERD: Symptoms, Testing, Treatment
Gastroesophageal Reflux Disease (GERD): A Comprehensive Overview
Gastroesophageal reflux disease (GERD) is a chronic condition where stomach acid frequently flows back into the oesophagus, leading to symptoms like heartburn, regurgitation, and discomfort. It affects approximately 20% of the adult population in Western countries and can significantly impact quality of life. This article delves into the causes, risk factors, diagnosis, and evidence-based treatments for GERD, including the roles of H. pylori, SIBO, and emerging therapies like breathwork.
Risk Factors and Causes of GERD
Primary Causes
Lower Oesophageal Sphincter (LES) Dysfunction: The LES is a muscular valve that prevents stomach acid from flowing back into the oesophagus. Weakness or relaxation of this sphincter is the primary cause of GERD.
Delayed Gastric Emptying: When stomach contents are not emptied efficiently, increased pressure can push acid into the oesophagus.
Hiatal Hernia: This condition occurs when part of the stomach pushes through the diaphragm, weakening the LES and contributing to reflux.
Risk Factors
- Lifestyle: Obesity, smoking, alcohol consumption, and high-fat diets increase the risk of GERD.
- Medications: NSAIDs, calcium channel blockers, and certain sedatives can exacerbate reflux.
- Pregnancy: Hormonal changes and increased abdominal pressure can lead to GERD in pregnant individuals.
- Dietary Triggers: Spicy foods, citrus, caffeine, chocolate, and carbonated beverages are common aggravators.
- Allergic Rhinitis (source): GERD can also be caused by the release of histamine from mast cells, which might promote the onset of this disease through lower-esophageal sphincter contractions. Eosinophils, a key component of the allergic inflammation, are also discovered in esophageal mucosa of GERD patients. You might like to read our blog in Histamine Intolerance.
SIBO and GERD
Small Intestinal Bacterial Overgrowth (SIBO) has been implicated in GERD through mechanisms like increased gas production, which raises intra-abdominal pressure. This pressure can weaken the LES and promote reflux.
A study (source) found a correlation between SIBO and GERD symptoms, suggesting that addressing SIBO may alleviate reflux in some patients.
H. pylori and GERD
The role of Helicobacter pylori (H. pylori) in GERD is complex and depends on the strain of the bacteria and individual patient factors. H. pylori can reduce stomach acid production by causing atrophic gastritis, which paradoxically may decrease typical GERD symptoms but increase susceptibility to other gastrointestinal issues.
Most studies suggest that H. pylori may protect against development of GERD or may reduce its severity, however, a few studies do suggest that it may aggravate the condition (source).
Eradication of H. pylori is often beneficial in patients with concurrent ulcers or gastritis.
Diagnosis of GERD
Clinical Diagnosis
It is often diagnosed based on symptoms such as:
- Heartburn (burning sensation in the chest)
- Regurgitation (acid or food backing up into the throat)
- Dysphagia (difficulty swallowing)
Diagnostic Tests
- Endoscopy: Visualises the oesophagus for inflammation, ulcers, or Barrett’s oesophagus.
- pH Monitoring: Measures acid exposure in the oesophagus over 24 hours.
- Oesophageal Manometry: Assesses the function of the LES and oesophageal muscles.
Types of GERD
It is not a one-size-fits-all condition. Subtypes include:
- Non-Erosive Reflux Disease (NERD): GERD symptoms without visible oesophageal damage on endoscopy.
- Erosive Esophagitis: Visible damage or inflammation of the oesophageal lining.
- Barrett’s Esophagus: A complication where chronic acid exposure leads to changes in oesophageal cells, increasing the risk of oesophageal cancer.
Treatment Options for GERD
Lifestyle and Nutritional Changes
- Weight Loss: Weight loss, when appropriate, may help reduce intra-abdominal pressure and improve LES function.
- Dietary Modifications:
- Avoid trigger foods like caffeine, alcohol, chocolate, and fatty or spicy foods.
- Consume smaller meals to prevent overfilling the stomach.
- Avoid eating 2-3 hours before bedtime.
- Ultimately the evidence has concluded that “based on the limited evidence available, dietary GERD management should be long-term, individualised, and consider both dietary restrictions and/or additions” (source).
- Increasing fibre intake may also be helpful. A fibre-enriched diet led to a significant increase of minimal lower oesophageal sphincter resting pressure, a decrease of number of gastroesophageal refluxes, and a decrease of heartburn frequency per week in NERD (source).
- Elevating the Head of the Bed: Reduces nighttime reflux.
- Exercise: Intense exercise belongs to factors that are known to exacerbate symptoms. Episodes of reflux seem to be associated with the length and the intensity of the physical activity undertaken. Adjustments of the exercise load and avoiding meals and drinks about the time of physical effort may ease the symptoms (source).
Medications
- Proton Pump Inhibitors (PPIs): Reduce stomach acid production (e.g., omeprazole, esomeprazole).
- H2 Receptor Antagonists: Block histamine-induced acid secretion (e.g., ranitidine, famotidine).
- Antacids: Provide quick relief by neutralising stomach acid.
Surgical Interventions
- Fundoplication: Reinforces the LES by wrapping part of the stomach around it.
- LINX Device: A magnetic ring placed around the LES to improve its function.
Supplements for GERD
Several supplements have been studied for their potential to alleviate GERD symptoms:
- Psyllium: The results of one study (source) showed that treatment of functional constipation by Psyllium seed in patients with GERD leads to improvement of GERD and its recurrences in comparison with omeprazole.
- DGL (Deglycyrrhizinated Licorice): Protects the oesophageal lining and may reduce acid exposure.
- Melatonin: Shown in studies to strengthen the LES and reduce GERD symptoms (source).
- Slippery Elm: Slippery elm has long been used in traditional medicine to soothe gastrointestinal discomfort, including symptoms of gastroesophageal reflux disease (GERD). Its mucilage content coats the esophagus and stomach lining, forming a protective barrier that may reduce irritation caused by stomach acid. Anecdotal evidence suggest it may alleviate GERD symptoms such as heartburn and acid reflux. However, high-quality clinical trials are limited, and more research is needed to confirm its efficacy.
- Probiotics: Probiotic may help address gut dysbiosis, as well as symptoms of GERD (source). While more research is needed to draw firm conclusions this systematic review showed that in one study Bifidobacteria lactis HN019 found in Everyday Max, and in another study Lactobacillus Rhamnosus GG and Saccharomyces Boulardii, were helpful in improving symptoms.
- Zinc-Carnosine: Supports mucosal healing in the oesophagus and stomach.
The Role of Breathwork in GERD Management
Emerging research has highlighted the benefits of diaphragmatic breathing for GERD (source). This technique has been shown to improve pressure generated by the lower oesophageal sphincter (LES).
Technique: Sitting or lying comfortable, practice slow, deep breaths. Breathe deep, through your nose if possible, in to the belly allowing your belly to rise and fall. Aim for 5-10 minutes, 2-3 times daily.
Integrative and Holistic Approaches
Stress reduction should be an important part of GERD symptom management (source).
Stress Reduction: Chronic stress can exacerbate GERD symptoms by impairing digestion and increasing acid production (source). Mindfulness, yoga, and meditation are effective strategies. In fact one study (source) demonstrated that the cultivation of mindfulness led to a reduction in the psychological distress and possibly improved visceral hypersensitivity (a condition that causes the internal organs to be more sensitive to normal bodily sensations). The decreased visceral sensitivity can be related to a decrease in the GERD symptom severity and an improvement in quality of life.
Acupuncture: Some studies suggest acupuncture may reduce symptoms by regulating eosophageal motility and reducing stress (source).
Physiotherapy: May be helpful. Reduced back muscle strength, scoliosis and kyphosis, or cervical vertebropathy, are closely related to GERD (source).
Conclusion
GERD is a multifactorial condition requiring a comprehensive approach to diagnosis and treatment. Addressing underlying causes such as SIBO, H. pylori, and lifestyle factors is essential. Evidence-based therapies—including nutritional modifications, targeted supplements, and breathwork—can significantly alleviate symptoms and improve quality of life. For individuals with severe or refractory reflux, medical and surgical interventions may be necessary.
By understanding the diverse causes and treatments, patients and clinicians can work together to develop personalised and effective management plans.