What is GERD?

It begins with a gurgle in your stomach.

That slice of Meat Lover’s pizza with triple the meat and double the cheese you scarfed down for lunch before scrambling back to the office doesn’t seem like a good idea anymore.

You feel uneasy.

You want to burp but you can’t. So you sip some water, fidget in your seat and try to get back to work.

But your stomach is still gurgling.

Now you feel queasy.

All of a sudden you let out a muffled belch.

Bam! Your throat tastes like acid, and you find yourself eating bits of Meat Lover’s pizza all over again—with triple the meat and double the cheese. Yum.

If you experience frequent regurgitation of stomach contents, you may be part of the 355 million people in North America and Europe that suffer from Gastroesophageal Reflux Disease, commonly known as GERD in the United States, or GORD in the UK, Australia, and Europe.

GERD causes acidic stomach contents to back up into the esophagus, causing irritation and injury to esophageal tissue. Today, GERD remains the most common gastrointestinal disorder in the US and bears a national management expenditure of $12.1 billion. (1)

GERD has been closely associated with rising rates of obesity. In addition, many studies suggest a correlation between a Western lifestyle and the rapid rise of the disease. (2)

Interestingly, gastroesophageal reflux (GER) is considered a normal physiological process that occurs several times, every day in everyone, even in healthy individuals. (3) (4) Technically, GER is only considered a disease if it causes troublesome symptoms or injury to the mucosal membrane within the esophagus, larynx, or respiratory tract. (5)

Currently, the international consensus among doctors called the Montreal Classification, classifies acid reflux a disease if symptoms occur 2 or more days a week, or moderate to severe symptoms occur at least one day a week. (6)

Typical Acid Reflux Symptoms

There are a broad range of acid reflux symptoms that can indicate GERD, but heartburn and regurgitation are telltale signs. (7) (8) Heartburn causes a burning sensation in the sternum to the base of the neck and is sometimes accompanied with pain (9) This condition usually occurs 30-60 minutes after eating a meal, especially a large one that is rich in fats or acidic ingredients. (9)

But some people can experience heartburn yet show no symptoms of GERD. This condition is called functional heartburn (FH). FH patients will typically have normal acid exposure, a normal endoscopy, and an absence of tissue damage. (10)

Atypical Acid Reflux/Extraesophageal Symptoms

GERD patients with acid reflux symptoms beyond heartburn and regurgitation are classified as patients with extraesophageal symptoms (also called atypical GERD). Chronic extraesophageal acid reflux symptoms significantly reduce quality of life.

Apart from not being able to enjoy certain foods and drinks, people with extraesophageal symptoms may experience decreased work productivity or even depression and anxiety. (11)(12)

The severity of extraesophageal symptoms depends on the duration of acid exposure, reflux frequency, and reflux potency. (13)

Extraesophageal GERD symptoms include:

  • Non-cardiac chest pain unrelated to heartburn. GERD is the number one cause of non-cardiac chest pain. Some studies suggest GERD can cause chest pain for 25 to 55% of patients. (14)

  • Chronic sore throat. One study found that up to 78% of patients who suffered from chronic sore throat had GERD. (15)

  • Chronic cough. Chronic GERD induced coughs usually happen in the daytime, in the upright position, and are not related to asthma, postnasal drip, or smoking. (15) Patients with chronic cough related to GERD will usually have a normal chest X-ray. A 2007 study reported GERD as the third leading cause of chronic cough. (14)

  • Frequent Throat Clearing

  • Pharyngeal dryness. A dryness experienced in the cavity behind the nose and mouth. This sensation may begin with a sour taste in the mouth.
  • Laryngitis. An inflammation of the laryngeal tract that is often accompanied by a burning sensation and hoarseness of voice that makes it difficult to speak. (15)

  • Chronic Bronchitis. An inflammation of the bronchial tubes, which transports air to and from the lungs. Symptoms can include coughing up discolored thick mucus.

  • Asthma. There is a significant correlation between GERD and asthma. (15) Studies have shown that 50 to 80 percent of asthmatic patients have GERD. (14) Asthma patients who experience worsening asthma symptoms after meals should be screened for GERD. (18) Heartburn or regurgitation right before an asthma episode can be an indication of GERD.

  • Globus sensation. A sensation of a lump or obstruction in the throat.

  • Dysphagia. Difficulty swallowing food.

  • Dyspepsia. Dyspepsia is also known as indigestion. Symptoms can include upper stomach pain, belching, bloating, and early satiety/reduced appetite (19)

  • Esophageal hypersensitivity. A hypersensitive esophagus has a more intense perception of pain and reflux than a normal esophagus.

  • Excessive, involuntary belching

  • Dental erosion. Research has established that repeated reflux of acidic stomach contents into the oral cavity can erode enamel and damage teeth (20)

  • Sleep Disturbances. GERD patients may suffer from sleep disturbances that can impact work performance (21)

The Mystery of Extraesophageal Symptoms

Extraesophageal symptoms are still not fully understood by the medical community. (6) (8) Studies have shown that patients who have relatively low acid exposure can have severe acid reflux symptoms, whereas those with high acid exposure can have only a few reflux symptoms.(3)

Extraesophageal symptoms are thought to be caused by microaspiration, that is, acid contents refluxing back into the larynx and airways. (15) Another theory suggests acid contents refluxing into the lower stomach could irritate the vagus nerve, causing cough and asthma symptoms. (14) (15)

Laryngopharyngeal Reflux (LPR)

Laryngopharyngeal reflux (LPR), also known as “silent GERD” is thought to occur when acidic stomach contents reflux up into the larynx and pharyngeal area, causing irritation and sometimes damage. Other fluids thought to irritate the upper airway tract are bile salts, bacteria, pancreatic proteolytic agents, and pepsin. (7)

LPR is thought to be the primary cause of extraesophageal acid reflux symptoms and has the greatest impact on the quality of life. Patients with LPR often suffer from hoarseness, chronic voice loss, sore throat, and laryngitis. (14) These symptoms can be especially detrimental to teachers, singers, sales professionals and other people who use their voice for a living. Some studies found that 50 to 60 percent of patients with chronic laryngitis and sore throat may have GERD. (14)

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