Heartburn and gastroesophageal reflux disease (GERD)
Mechanisms and risk factors
GERD results from an imbalance between the protective mechanisms of the esophagus and the forces favoring acid reflux. Several factors contribute to this imbalance:
| Factor | Mechanism | Impact |
|---|---|---|
| Hiatal hernia | Slippage of part of the stomach over the diaphragm, compromising sphincter competence | Major anatomical factor, present in a large proportion of patients with severe GERD |
| Overweight and obesity | Increased abdominal pressure, favoring reflux; abdominal fat deposits compressing the stomach | Risk multiplied by 2 to 3 in cases of abdominal obesity |
| Pregnancy | Mechanical pressure of the uterus on the stomach and hormonal (progesterone) relaxation of the sphincter | GERD very common in the second and third trimesters |
| Power supply | Foods that reduce sphincter tone or stimulate acid secretion | Direct, modulating aggravating factor |
| Smoking | Decreased lower esophageal sphincter tone, reduced saliva production (natural buffer) | Significant worsening of symptoms and esophagitis |
| Medicines | Some drugs relax the sphincter or directly irritate the esophageal mucosa. | Anti-inflammatory drugs (NSAIDs), calcium blockers, nitrates, benzodiazepines, some antibiotics |
| Slow gastric emptying | Stasis of gastric contents increases intragastric pressure and the risk of reflux | Common in diabetics (gastroparesis) and in cases of motility disorders |
Typical symptoms
The manifestations of GERD vary from person to person. A distinction is made between typical esophageal symptoms and atypical manifestations, which may point to other diagnoses if they occur in isolation:
- Pyrosis: burning sensation rising behind the sternum, often after meals or when lying down.
- Acid regurgitation: reflux of acidic or bitter liquid into the throat or mouth, without the effort of vomiting.
- Dysphagia: difficulty swallowing, sensation of food blockage in the sternum area
- Epigastric pain: discomfort or pain in the pit of the stomach, sometimes mistaken for heart pain
- Nausea, especially in the morning or after heavy meals
- Hypersalivation (waterbrash): excessive production of saliva in response to acid in the oesophagus
Atypical symptoms and extra-digestive manifestations
GERD may manifest itself exclusively or mainly as extra-digestive symptoms, often delaying diagnosis:
| Atypical event | Probable mechanism | Frequency |
|---|---|---|
| Chronic nocturnal cough | Micro-aspirations of acid irritating the respiratory tract; vagal reflex triggered by esophageal acid | Very frequent; GERD = one of the 3 main causes of chronic coughing |
| Hoarseness and dysphonia | Acid irritation of the vocal cords (reflux laryngopharyngitis) | Frequent, often morning |
| Aggravated or difficult-to-control asthma | Acid microaspirations or bronchoconstrictive vagal reflex | GERD present in 50 to 80 % asthmatics |
| Non-cardiac chest pain | Esophageal spasm or visceral sensitization by acid | Common; diagnosis of exclusion after cardiac work-up |
| Dental erosions | Chronic exposure of tooth enamel to gastric acid | Sign often discovered by the dentist |
| Chronic otitis or sinusitis | Acid rises to nasopharynx, irritating ENT mucosa | Less frequent; causal link sometimes difficult to establish |
Diagnosis
The diagnosis of GERD is often based on clinical findings alone when typical symptoms are present. Further investigations are indicated in the case of atypical symptoms, alarm signs, treatment failure or to look for complications:
- History and clinical examination: nature, frequency and triggers of symptoms
- Therapeutic trial with proton pump inhibitors (PPIs): favorable response in 2 to 4 weeks indirectly confirms diagnosis
- Upper GI endoscopy (gastroscopy): direct visualization of the esophagus, stomach and duodenum; detection of esophagitis, Barrett's esophagus or hiatal hernia
- 24-hour ambulatory esophageal pH-metry: objective measurement of esophageal acid exposure; reference test to confirm GERD in case of doubt
- Impedance-pH-metry: also detects non-acid reflux, useful for persistent symptoms on PPIs
- High-resolution esophageal manometry: assessment of esophageal motility, indicated before surgery or in cases of dysphagia
- Oeso-gastro-duodenal transit: useful for testing for hiatal hernia or gastric emptying disorders
Foods and habits to avoid
Certain foods and behaviors are known to trigger or aggravate reflux symptoms. Adapting them is the first step in treatment:
| Category | Examples | Effect on GERD |
|---|---|---|
| Fatty foods | Fried foods, deli meats, fatty cheeses, fast food | Slows gastric emptying and reduces sphincter tone |
| Acidic foods | Citrus fruits, tomatoes and by-products, vinegar | Direct irritation of already sensitized esophageal mucosa |
| Soft drinks | Sodas, sparkling water, beer | Gastric distension increases pressure and promotes acid eructation |
| Coffee and strong tea | Coffee, black tea, energy drinks | Stimulation of acid secretion and reduction of sphincter tone |
| Alcohol | Wine, beer, spirits | Relaxation of the lower esophageal sphincter and direct irritation of the mucosa |
| Chocolate and mint | Dark or milk chocolate, mint candies, mint teas | Sphincter relaxation through serotonin release and muscle relaxant effects |
| Late and hearty meals | Dinner less than 2 to 3 hours before bedtime, very large meal | Maximum gastric distension in the supine position, ideal for nocturnal reflux |
Drug treatments
The pharmacological management of GERD is graded according to the severity of symptoms and the presence or absence of complications:
| Drug | Examples | Indications and remarks |
|---|---|---|
| Antacids | Gaviscon, Tums, Maalox, Rolaids | Rapid but brief relief of occasional burns; not suitable for long-term treatment |
| Anti-H2 (H2 antihistamines) | Famotidine (Pepcid), ranitidine (withdrawn from the market) | Moderate reduction of gastric acidity; useful for mild to moderate or nocturnal symptoms |
| Proton pump inhibitors (PPIs) | Omeprazole, pantoprazole, esomeprazole, rabeprazole, lansoprazole | Reference treatment for moderate to severe GERD and esophagitis; to be taken 30 to 60 minutes before the main meal; optimal efficacy with a 4- to 8-week course of treatment |
| Prokinetics | Domperidone, metoclopramide | Accelerates gastric emptying; limited use due to side effects; reserved for forms with gastric stasis component |
| Alginate barrier agents | Gaviscon Advance | Formation of a floating raft over gastric contents, reducing postprandial reflux episodes; useful as a complement to PPIs |
Hygienic, dietary and postural measures
In addition to or instead of drug treatment in mild forms, several lifestyle modifications significantly reduce the frequency and intensity of reflux:
- Raise the head of the bed 15 to 20 cm (place wedges under the foot of the bed, not under the pillows alone) to reduce nighttime reflux.
- Avoid lying down for 2 to 3 hours after a meal
- Split meals into smaller, more frequent portions
- Maintain a healthy weight: losing 5 to 10 % of body weight significantly reduces symptoms
- Quit smoking: tobacco aggravates GERD through several simultaneous mechanisms
- Wear loose-fitting clothing, avoid tight belts that compress the abdomen
- Prefer to sleep on the left side: this position reduces acid exposure of the esophagus at night.
- Chew sugar-free gum after meals: stimulates the production of saliva, a natural buffer against acid
Complications of untreated GERD
Inadequately controlled chronic reflux may progress to complications requiring specialized management:
| Complication | Description | Support |
|---|---|---|
| Erosive esophagitis | Inflammation and erosions of the esophageal mucosa due to repeated exposure to acid | Therapeutic dose PPI; follow-up endoscopy |
| Peptic stenosis | Scarring of the esophagus causing progressive dysphagia | Endoscopic dilatation and long-term PPI therapy |
| Barrett's esophagus | Replacement of normal esophageal epithelium by metaplastic intestinal epithelium; precancerous lesion | Regular endoscopic monitoring; endoscopic treatment if dysplasia detected |
| Esophageal adenocarcinoma | Rare but serious complication of Barrett's esophagus progressing to high-grade dysplasia | Specialized oncology management; endoscopic screening of at-risk patients |
Certain symptoms associated with heartburn should prompt immediate medical consultation, as they may signal a serious complication or other pathology: progressive dysphagia (increasing difficulty swallowing), unexplained involuntary weight loss, repeated vomiting or blood in vomit, black tarry stools (melena), intense chest pain radiating into the arm or jaw, or unexplained iron-deficiency anemia. These signs warrant priority endoscopic investigation.
In the event of severe chest pain with breathing difficulties, call 911 immediately.
For persistent or recurrent reflux symptoms with no warning signs, a consultation at Clinique Omicron provides rapid assessment and appropriate treatment.
Consult at Clinique Omicron
Clinique Omicron manages gastroesophageal reflux disease (GERD) and related digestive disorders at several points of service in Quebec. A physician or specialized nurse practitioner (SNP) can assess your symptoms, initiate appropriate treatment, prescribe the necessary tests and refer you to a gastroenterologist if required. In-person and telemedicine consultations are available. To book an appointment at one of our Quebec branches, in Montreal or elsewhere in the province, visit cliniqueomicron.ca.
The content of this page is provided for informational purposes only and is not intended to replace the advice of a qualified healthcare professional. Consult a physician for any symptoms, questions or decisions you may have regarding your health.
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