(GERD, Acid Reflux, or Heartburn)

August, 2006

Definition of the Problem
Gastro-esophageal Reflux Disease (GERD) occurs when the valve between the esophagus and stomach fails to keep stomach contents from leaking up into the esophagus. This valve, usually called the Lower Esophageal Sphincter (LES), is a ring of muscle.

When working normally, it opens to allow swallowed food into the stomach, then shuts to prevent acidic stomach contents from coming back up into the esophagus. When the valve is weakened or enlarged, or when the pressure of gastric contents is too strong, leakage can occur, sometimes in large amounts.

The stomach is protected against acid, but the esophagus is not. So, people experience burning pain and pressure (heartburn). They can also have other acid-related symptoms not only in the esophagus, but also in the unprotected throat, windpipe (trachea) and bronchial tubes (Wolfe and Nesi, 1997).

Authors of a recent study estimated that 25% of Americans suffer from heartburn at least once a week (Moyaaedi and Talley, 2006). To be classified as GERD, heartburn or other symptoms must be frequent and severe. GERD is frequently accompanied and made worse by hiatal hernia.

GERD is a major public health problem. Some experts estimate that one third to one half of all asthma cases are caused or worsened by GERD (Harding, 2001; Harding, Suzzo, and Richter, 2000; Wolfe and Nessi, 1997). Acid reflux can also cause chronic bronchitis and pneumonia (Everhart, 1994).

Severe cases lead to a condition called “Barrett’s Esophagus,” in which the esophageal wall becomes lined with gastric cells for protection against acid. These cells are often pre-cancerous (Wolfe and Nesi, 1997). Other complications include painful ulcers and narrowing of the esophagus. Both of these conditions can interfere with swallowing and nutrition.

Scope and Costs of the Problem
Heartburn, in one form or another, affects more than 100 million Americans, according to Dr. M. Michael Wolfe, Chief of Gastroenterology at Boston Medical Center, with more than 25 million take antacids at least twice a week (Wolfe and Nesi, 1997).

Heartburn sufferers spend over $6 billion a year on over-the-counter and prescription heartburn medications (Kleinman, McIntosh, et al, 2002). There are nearly 200,000 emergency room visits per year by people with heartburn who fear they are having a heart attack (Wolfe and Nesi).

Work loss due to GERD average about $1,000 per year per patient (Henke, Levin, et al, 2000). Total direct and indirect costs of GERD were about $10 billion in 2000, making it the most expensive digestive disease, according to the American Gastroenterological Association (Frequently asked questions about GERD, 2001). Treatment costs of GERD-related esophageal cancer and asthma are unknown but probably substantial.

Medical Treatment
Medicinal treatments include antacids, which neutralize the acid. These are available over-the-counter and are purchased by 25 million Americans every month (Wolf and Nesi, 1997). They are effective for mild, occasional heartburn, but inadequate for moderate to severe cases.

A class a prescription medicine called H2- blockers, such as Tagamet, Zantac, and Pepcid AC, reduce the output of stomach acid. They are more effective than antacids, but must be taken three to four times a day for maximum effect. Propulsid (Cisapride) helps to get some contents out of the stomach before they can leak through the LES. The newest and most effective drugs for GERD are the proton-pump inhibitors.

These are usually taken only once a day and reduce acid production much more than other medications. About 10% of patients on these drugs experience side effects, including diarrhea and headache. The drugs don’t cure GERD, however; they often must be taken for life, or until lifestyle changes reduce the need for them.

Laparoscopic surgery is sometimes performed to tighten the LES to keep acid from getting back up into the esophagus (Guidelines for surgical treatment, 2001).

Non-drug Therapy Including Relaxation and Imagery
Stress plays a major role in gastrointestinal disorders including GERD (Baker, Lieberman, and Oehlke, 1995). Experimentally induced stress increases reported GERD symptoms in 40–50% of patients. The effect of stress on actual acid exposure in the esophagus is still in question (Kamolz, Granderath, et al, 2001). Relaxation training and hypnosis have been shown to reduce GERD symptoms and medication usage in as many as 58% of patients in various studies (Drossman, 1998; McDonald-Haile, Bradley, et al, 1994).

In many cases, the best treatment for GERD is behavior change such as avoiding trigger foods and losing weight (Gitnick and Cooksey, 2000). Relaxation and guided imagery can aid patients undertaking behavior change (The Chronic Disease Self-Management Workshop Leaders Manual, 1999).

Guided imagery can assist some patients with behavior change, improve coping, and reduce GERD symptoms and medication use.

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[no authors listed] Burden of Chronic Gastrointestinal Diseases Study. American Gastroenterological Association. 2001. May.
[no authors listed] The Chronic Disease Self-Management Workshop Leaders Manual. Sandord Patient Education Research Center. 1999. Stanford University.

Drossman DA. Presidential address: Gastrointestinal illness and the biopsychosocial model. Psychosom Med. 1998 May-Jun;60(3):258-67.

Everhart JE, Ed. Digestive Diseases in the United States: Epidemiology and Impact. National Digestive Diseases Data Working Group. US Department of Health and Human Services, Public Health Service. National Institutes of Health, NIH Publication No. 94-1447, May 1994.
Frequently asked questions about GERD. American Gastroenterological Association (AGA).
August, 2006.

Gitnick GL, Cooksey K. (2000). Freedom from Digestive Distress. New York: Three Rivers Press. pp. 21-25.

[no authors] Guidelines for surgical treatment of gastroesophageal reflux disease (GERD). Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Publication #22. June, 2001.
Accessed August, 2006.

Harding SM. Gastroesophageal reflux, asthma, and mechanisms of interaction. Am J Med. 2001 Dec 3;111 Suppl 8A:8S-12S.

Harding SM, Guzzo MR, Richter JE. The prevalence of gastro-esophageal reflux in asthma patients without reflux symptoms. Am J Respir Crit Care Med. 2000 Jul;162(1):34-9.

Henke CJ, Levin TR, Henning JM, Potter LP. Work loss costs due to peptic ulcer disease and gastroesophageal reflux disease in a health maintenance organization. Am. J. Gastroenterol. 2000 Mar;95(3):788-92.

Kamolz T, Granderath FA, Bammer T, Pasiut M, Pointner R. Psychological intervention influences the outcome of laparoscopic antireflux surgery in patients with stress-related symptoms of gastroesophageal reflux disease. Scand J Gastroenterol. 2001 Aug;36(8):800-5.

Kleinman L, McIntosh E, Ryan M, Schmier J, Crawley J, Locke GR 3rd, De Lissovoy G. Willingness to pay for complete symptom relief of gastroesophageal reflux disease. Arch Intern Med. 2002 Jun 24;162(12):1361-6.

McDonald-Haile J, Bradley LA, Bailey MA, Schan CA, Richter JE. Relaxation training reduces symptom reports and acid exposure in patients with gastroesophageal reflux disease. Gastroenterology. 1994 Jul;107(1):61-9.
Moyaaedi P, Talley NJ. Gastro-oesophageal reflux disease. Lancet. 2006 Jun 24:367(9528):2086-100

Wolfe MM, Nesi, TJ. (1997). Heartburn. New York: W.W. Norton. pp.12-13; 20; 103; 105-106; 176-8.