What doctors wish patients knew about GERD

Imagine this: After every meal, you experience discomfort with a persistent burning feeling that lingers after the last bite of food. This is the reality for millions of people suffering from gastroesophageal reflux disease (GERD). Often dismissed as mere heartburn, GERD is a chronic condition that affects the quality of life for many. But it doesn’t have to be that way. Understanding the causes, symptoms and treatment options are key.

The AMA’s What Doctors Wish Patients Knew™ series gives physicians a platform to share what they want patients to understand about today’s health care headlines.

In this installment, Michal “Misho” Hubka, MD, a thoraco-esophageal surgeon at Virginia Mason Franciscan Health in Seattle, took time to discuss what patients need to know about gastroesophageal reflux disease. Virginia Mason Franciscan Health is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.

Gastroesophageal reflux disease (GERD) affects about 20% of the adults in the U.S., but it is treatable.

Additionally, GERD “can be more common in women” than men and it can increase with age, said Dr. Hubka.

“Gastroesophageal reflux disease means that the acid which normally lives in the stomach is flowing backwards or refluxing into the esophagus,” said Dr. Hubka, noting “that can cause symptoms of heartburn, water brush or acidic taste in the mouth, hoarseness, tooth decay and, of course, can lead to more serious problems such as precancerous or even cancerous changes in the esophagus.”

In older adults, reflux can cause aspiration and even lung inflammation because they are not as good at protecting their airway,” he said, noting “when they lay down, if they have reflux and they don’t protect their airway, it can go into their lungs.”

Additionally, “when women get pregnant, the increased intrabdominal pressure pushes up on the stomach and disrupts the antireflux barrier,” Dr. Hubka said.

“The reason why gastroesophageal reflux disease happens is that there is a mechanical breakdown of the natural antireflux barrier, which sits between the esophagus and the stomach,” Dr. Hubka said. “That has to do with the lower esophageal sphincter or by herniation of the top of the stomach into the chest. And that is called a high level or paraesophageal hernia.

“When we see patients with heartburn, sometimes they have already been placed on an antacid therapy or proton pump inhibitor therapy and either the therapy does not work or the patients does not wish to continue on medical therapy, which oftentimes commits them to lifelong medications,” he said, noting “they wish to have a workup and possible anatomic correction of the antireflux barrier to stop reflux.”

For example, “medications which cause impaired emptying of the stomach—they cause relative gastroparesis,” Dr. Hubka said. “And there are medications such as Wegovy, which is on the market for weight loss, that can contribute to reflux.”

That is “because they can contribute to impairment of the stomach emptying,” he said.

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GERD is “oftentimes dismissed and treated medically even with patients who have a paraesophageal hernia who should really have an operation,” said Dr. Hubka. This is “because even though there is an anatomic derangement such as a paraesophageal hernia—which present with reflux—they can have much more serious consequences than just reflux.

“And treating you with medications, the stomach can twist in the chest and cause a surgical emergency,” he added, noting “oftentimes reflux or hiatal and paraesophageal hernias can run in families.”

“The types of conditions that reflux can lead to are precancerous changes or cancerous changes in the esophagus,” Dr. Hubka said. “Patients with GERD symptoms of five to 10 years with a hiatal hernia and reflux at night are at risk of developing precancerous Barrett’s esophagus.

“Reflux symptoms at night, smoking and a first-degree relative with Barrett's esophagus or cancer are also risk factors,” he added.

“When we see these patients, they need to go on a myriad of tests,” Dr. Hubka said. “One of the tests is called an esophagram where a patient swallows liquid barium,” which is a contrast agent that coats your esophagus as it travels down to your stomach.

“There are conditions in which the esophagus or the stomach does not function normally, so patients get reflux. One of those conditions is called gastroparesis, which we sometimes rule out. That’s especially common among patients with diabetes,” he said. “Then there are other conditions such as scleroderma where the esophagus does not work normally. That can be associated with reflux and impact the type of therapy we provide.”

“We look for the barium refluxing back into the esophagus, and we also evaluate the patient for presence of a high end or paraesophageal hernia,” Dr. Hubka added. “We also can then do objective testing with an endoscope to look for any changes in the esophagus as a result of the reflux, such as inflammation—which is called esophagitis—or precancerous changes, which is called Barrett’s esophagus.”

Barrett’s esophagus is particularly important to identify because it “can progress to low-grade dysplasia, high-grade dysplasia or liver cancer,” he said. “At the same time as we do an endoscopy, we also perform objective pH testing where we assess for reflux with a pH study or a Bravo study,” which measure acidity in the esophagus.

“In preparation for any surgical correction, we also get a test called esophageal manometry, which is a test that assesses esophageal function or how vigorously the esophagus squeezes and moves food from the mouth into the stomach,” Dr. Hubka said.

Patients with GERD can experience disruptions in their sleep. That is why “we recommend patients with undertreated reflux to elevate the head of their bed to help gravity with nocturnal or nightly reflux,” Dr. Hubka said.

Additionally, try to eat dinner at least two to three hours before going to bed. This can reduce symptoms of GERD at nighttime.

That is true “especially when it's associated with a hiatal hernia,” said Dr. Hubka. “One very important thing to remember is that when patients have classic symptoms of reflux such as heartburn, regurgitation and if the esophageal lining changes from normal lining to Barrett's esophagus,” those symptoms may disappear.

“So, sometimes people think that the reflux went away because they can't feel it, but they're still having reflux,” he said. “It's just that the esophagus has accommodated that reflux. And that's actually dangerous because the reflux hasn't gone away.”

“There’s this broad spectrum of medications that are antacids and they are either aimed at minimizing production of acid by the stomach—such as proton pump inhibitors—or simple medications such as Tums, which is calcium carbonate that neutralizes the acid,” Dr. Hubka said. “But in all cases, treating acid just by neutralizing acid does not stop the reflux.

“It just changes the relative acidity of the refluxing,” he added. “So, the patients are still refluxing. It’s just what’s refluxing is not as acidic because we’ve neutralized it with medication.”

After tests are completed, if a hernia is identified in a patient with GERD, “it depends on the size and configuration of the hernia as to how we repair it,” said Dr. Hubka. “In very small hernias or patients with reflux without hernia, we have the ability to correct the anatomy endoscopically without any incisions.”

“With larger hernias, we have to do an operation,” he said. “Most commonly, we perform these operations robotically through six small incisions on the patient’s abdomen with an overnight inpatient stay.

“However, with large hernias where the stomach is twisted in the chest, we need to make bigger incisions and then the recovery is a little bit longer,” Dr. Hubka added.

“One of the things that works is weight loss. Sometimes eating less acidic foods can also help,” Dr. Hubka said, adding that “weight loss can help with symptoms of reflux because the relative pressure in the abdomen decreases and the relative pressure in the chest does not change.”

Meanwhile, “smoking and excessive alcohol use can also contribute to reflux, so minimizing those behaviors can help with symptoms of reflux,” he said.

“All patients who are experiencing reflux should consult their primary care physician,” Dr. Hubka said. “If they develop additional symptoms such as difficulty swallowing or regurgitation of food, they should for certain both contact their primary care physician and seek help of a specialist.”