Gastroesophageal Reflux Disease (GERD)

Gastroesophageal reflux disease (GERD), commonly experienced as heartburn, is a common digestive condition in which stomach acid regularly flows back up into the oesophagus, the muscular tube connecting the throat to the stomach. Occasional reflux after a heavy meal is normal and experienced by almost everyone from time to time. GERD refers specifically to reflux that is frequent or severe enough to cause troublesome symptoms or to damage the lining of the oesophagus over time.

GERD sits on a spectrum, and understanding where a particular case falls on that spectrum matters for both treatment and long-term outlook. Many people have reflux symptoms without any visible damage to the oesophagus on examination. Others develop visible inflammation and erosion of the oesophageal lining (erosive esophagitis), graded by severity. In a smaller group of people, long-standing reflux leads to a change in the cells lining the lower oesophagus called Barrett's oesophagus — a condition that carries an increased, though still relatively low, risk of progressing to oesophageal cancer over time. This is why persistent or severe GERD is treated as more than simply an uncomfortable nuisance.

How Reflux Happens

The lower oesophageal sphincter (LES) is a ring of muscle at the junction between the oesophagus and the stomach that acts as a one-way valve — relaxing briefly to let swallowed food pass into the stomach, then closing again to keep stomach contents from flowing back upward. GERD develops when this valve does not close properly or relaxes too often, allowing acidic stomach contents to reflux upward and irritate the oesophageal lining, which, unlike the stomach lining, is not designed to withstand regular acid exposure.

A common cause of this condition is a stomach abnormality called a hiatal hernia, which happens when the upper part of the stomach and LES (lower esophageal sphincter) move above the diaphragm. It can also be triggered by certain foods like spicy and fatty foods as well as conditions like anxiety, asthma and pregnancy.

The Spectrum of GERD

• Non-Erosive Reflux Disease (NERD): Reflux symptoms are present, but the lining of the oesophagus appears normal on endoscopy. The most common presentation of GERD, and generally the most straightforward to manage.
• Erosive Esophagitis: Reflux has caused visible breaks or erosions in the oesophageal lining, graded by severity from A (mild, small breaks) to D (severe, extensive, circumferential breaks), using what is known as the Los Angeles classification. More severe grades (C and D) generally require longer or more intensive treatment and closer follow-up.
• Barrett's Oesophagus: Long-standing reflux causes the normal lining of the lower oesophagus to be replaced by a different type of tissue, more similar to the lining of the intestine. Considered a precancerous change requiring regular endoscopic surveillance, since it carries an increased risk of progressing to oesophageal cancer, even though most people with Barrett's oesophagus never develop cancer.

Why Persistent Reflux Shouldn't Be Ignored

It's easy to think of heartburn as a purely uncomfortable, low-stakes symptom — and for most people, most of the time, that's an accurate picture. But persistent, poorly controlled reflux over years is the main pathway to both erosive esophagitis and Barrett's oesophagus, and Barrett's oesophagus is, in turn, the principal identified risk factor for oesophageal adenocarcinoma, one of the two main types of oesophageal cancer.

This progression is neither fast nor inevitable, it typically takes years of poorly controlled reflux, and only a minority of people with long-standing GERD ever develop Barrett's oesophagus, and only a minority of those go on to develop cancer. But it is a real enough pathway that guidelines recommend endoscopic evaluation for people with long-standing GERD symptoms, particularly those with additional risk factors such as being over 50, male, or having a family history of Barrett's oesophagus or oesophageal cancer — not to alarm, but because identifying Barrett's oesophagus early allows it to be monitored, and in some cases treated, well before it has any chance of progressing further.

The practical takeaway is straightforward: reflux that is frequent, has been present for years, or requires regular over-the-counter medication to control is worth a proper medical assessment, rather than indefinite self-management — both to control symptoms more effectively and to check whether any changes to the oesophageal lining have developed.

Symptoms of GERD

• A burning sensation in the chest (heartburn), often after eating or when lying down
• Regurgitation of food or sour-tasting fluid into the mouth or throat
• Difficulty swallowing (dysphagia)
• A sensation of a lump in the throat
• Sore throat or hoarseness
• Chronic cough
• Nausea
• Dental erosion, from repeated acid exposure

Reflux occurring at night can cause additional problems, since lying flat removes the help of gravity in keeping stomach contents down:

• A persistent cough, particularly at night
• Inflammation of the vocal cords, causing hoarseness
• Wheezing or worsening of underlying asthma
• Disrupted sleep

Causes and Risk Factors for GERD

• Hiatal hernia: Disrupts the normal anatomical support of the lower esophageal sphincter
• Obesity: Increases abdominal pressure, pushing stomach contents upward
• Pregnancy: Combines hormonal relaxation of the LES with increased abdominal pressure
• Smoking: Weakens the LES and reduces saliva production, which normally helps neutralise refluxed acid
• Certain foods and drinks: Fatty or fried foods, spicy food, chocolate, caffeine, and alcohol can all relax the LES or increase acid production
• Eating large meals or eating close to bedtime
• Delayed stomach emptying
• Certain medications, including some used for asthma, blood pressure, and depression
• Connective tissue disorders, such as scleroderma, which can affect oesophageal muscle function

How GERD is Diagnosed

• Clinical Diagnosis and Trial of Treatment: For typical symptoms without alarm features, GERD is often diagnosed based on symptoms alone, with a trial of acid-suppressing medication used both to relieve symptoms and to support the diagnosis if symptoms improve.
• Endosscopy: A thin camera examines the oesophagus and stomach directly, identifying and grading erosive esophagitis, detecting Barrett's oesophagus, and taking biopsies if needed. Recommended for anyone with alarm symptoms, long-standing symptoms, or additional risk factors for Barrett's oesophagus, rather than reserved only for those who fail initial treatment.
• Ambulatory pH Monitoring: A small sensor, placed via a thin catheter or a clip attached during endoscopy, measures acid exposure in the oesophagus over 24 to 48 hours. The most direct way to confirm abnormal acid reflux, particularly useful when the diagnosis is uncertain or before considering surgery.
• Esophageal Manometry: Measures the pressure and coordination of oesophageal muscle contractions and the function of the LES, helping to rule out other swallowing disorders and to plan surgery if being considered.
• Barium Swallow: A chalk-like liquid is swallowed and tracked with X-ray imaging as it passes through the oesophagus and stomach, useful for detecting structural abnormalities such as a hiatal hernia or a stricture (narrowing).

Managing GERD Day to Day

• Eat smaller meals, since a full stomach increases pressure on the LES and stimulates more acid production
• Have dinner several hours before lying down, rather than eating late at night
• Avoid personal trigger foods — common culprits include fatty or fried food, spicy food, chocolate, caffeine, and alcohol, though triggers vary between individuals
• Elevate the head of your bed, or use a wedge pillow, if night-time symptoms are prominent
• Quit smoking, since tobacco directly weakens the LES
• Work toward a healthy weight if overweight, since this is one of the most effective, evidence-backed steps for reducing reflux
• Take prescribed medication consistently and as directed, including timing before meals, since inconsistent use is a common reason for poor symptom control
• Don't rely indefinitely on over-the-counter medication for frequent symptoms without seeking a proper assessment, particularly if you've been managing symptoms this way for years