Gastroesophageal Reflux Disease (GERD) - Symptoms, Causes, Diagnosis & Treatment

GERD Definition

Gastroesophageal reflux disease (GERD) or chronic acid reflux is a long-term condition where acid from the stomach comes up into the esophagus, a muscular tube connecting the stomach with the throat (pharynx). Flowing back up acid into the esophagus causes irritation to the esophagus lining. Common symptoms include heartburn (a burning sensation behind the sternum), acid regurgitation (sour or burning fluid in the throat or mouth), chest pain, dysphagia (difficulty swallowing), nausea, bloating, and sore throat.

The causes of GERD involve factors that impair lower esophageal sphincter (LES) function or increase abdominal pressure, such as obesity, pregnancy, hiatal hernia, smoking, certain medications, and unhealthy lifestyle habits. If untreated, GERD can lead to serious complications, including esophagitis, esophageal strictures, Barrett's esophagus, gastrointestinal bleeding, and increased risk of esophageal adenocarcinoma.

A gastroenterologist, a physician specialised in digestive system disorders, can accurately diagnose and provide the correct treatment for GERD.

GERD is the chronic form of heartburn and acid reflux. If you have symptoms of acid reflux more than twice a week, you might have a condition known as gastroesophageal reflux disease (GERD).

GERD Epidemiology Worldwide

GERD presents a significant and growing global public health burden, with its prevalence and incidence rising steadily over recent decades. The global prevalence of GERD was estimated at over 8,250 lakh cases. This increase is caused by several factors, such as an ageing global population, higher obesity rates, and changes toward more Western diets and lifestyles. The epidemiology of GERD acid reflux shows significant geographic variations, with higher prevalence rates traditionally seen in Western countries compared to East Asia.

In India, the epidemiology of GERD has seen a significant increase in prevalence, with recent studies showing a pooled rate of approximately 15.6%. Once considered less common than in Western nations, the prevalence is now recognised as similar or even higher in some areas, especially in urban settings. Some southern India studies report rates as high as 22.2%, while northern regions show 16.2% among certain hospital staff. The rise is mainly due to lifestyle changes that are linked to socioeconomic growth and Western habits.

Gastroesophageal reflux disease (GERD) can be categorised by the presence or absence of physical damage to the esophagus, and by the location of the reflux. The GERD classification is as follows:

• Based on esophageal damage
• Non-erosive reflux disease (NERD)
• Erosive reflux disease (ERD)
• Based on the location of reflux
• Gastroesophageal reflux disease (GERD)
• Laryngopharyngeal reflux (LPR)
• Extraesophageal reflux disorder (EERD)
• Based on severity and progression
• Silent GERD (asymptomatic GERD)
• Mild GERD
• Moderate GERD
• Severe GERD
• Refractory GERD

NERD is a form of GERD in which patients experience reflux symptoms such as heartburn and regurgitation but do not show visible damage to the esophageal lining upon endoscopic examination. The absence of mucosal erosion does not indicate that the condition is minor; rather, symptoms develop as a result of acid exposure, esophageal hypersensitivity, or functional abnormalities.

Erosive reflux disease (ERD) occurs when reflux of acidic stomach contents leads to visible mucosal injury or inflammation in the esophagus. These ulcers or erosion can be seen during an upper gastrointestinal (GI) endoscopy. ERD is a more advanced stage of GERD than NERD, which is linked to severe symptoms and a higher risk of complications such as esophagitis, bleeding, strictures, or Barrett’s esophagus.

LPR is a subtype of reflux where the refluxate travels beyond the esophagus and reaches the throat (pharynx) and voice box (larynx). Common symptoms include hoarseness, sore throat, severe cough, throat clearing, and a sensation of a lump in the throat. It is often managed jointly by gastroenterologists and ear, nose, and throat (ENT) specialists.

EERD refers to reflux that affects organs and tissues outside the esophagus, such as the respiratory tract, mouth, and sinuses. The refluxed material causes asthma-like symptoms, chronic bronchitis, dental erosions, sinusitis, or even otitis media in children. EERD reflects the systemic impact of reflux and highlights that GERD can influence multiple organ systems beyond the digestive tract.

Silent GERD,is refers to the presence of esophageal mucosal injury without any noticeable reflux symptoms. It is often discovered incidentally during endoscopic evaluation for other conditions. Despite the absence of symptoms, silent GERD is clinically significant because it can still lead to complications such as Barrett’s esophagus or esophageal adenocarcinoma if left untreated.

Mild GERD represents an early stage of the disease, which is characterised by infrequent and mild symptoms, generally occurring less than twice per week. There is minimal or no visible esophageal injury, and complications are rare at this stage. Mild GERD can be managed with lifestyle changes and over-the-counter medications.

In moderate GERD, symptoms happen more often and can be quite bothersome, usually appearing several times a week. Patients may have a lower quality of life, experience disturbed sleep, or show mild esophagitis during an endoscopy. At this point, it’s important to keep a close eye on the condition to avoid worsening it.

Severe GERD is characterised by persistent, intense symptoms that can impair daily life and often indicate advanced esophageal damage such as severe esophagitis or ulceration. Patients may have complications like strictures or Barrett’s esophagus.

Refractory GERD refers to cases where symptoms continue even after the best medical treatment. This usually happens after at least 8 weeks of high-dose PPI therapy. This type of GERD may be caused by non-acid reflux, bile reflux, esophageal hypersensitivity, or a misdiagnosis.

GERD is curable disease, but most of the time people don't know they are suffering from Gastroesophageal reflux disease because its symptoms are associated with many other conditions.

Common symptoms of GERD include:

• Heartburn, usually after eating, which might be worse at night
• Chest pain
• Nausea
• Bloating, gas and belching
• Certain food Intolerance
• Difficulty swallowing
• Regurgitation of food or sour liquid
• Sensation of a lump in your throat

If acid reflux occur during nighttime, one can experience:

• Disrupted sleep
• Chronic cough
• New or worsening asthma
• Laryngitis

Heartburn: This is the most common symptom of GERD, which can be described as a burning sensation in the chest or throat that often appears after eating or when lying down. It happens because the lower esophageal sphincter fails to close properly, allowing acidic stomach contents to flow back into the esophagus. The acid irritates the sensitive esophageal lining, leading to the characteristic burning pain. 

Chest pain: Chest pain in GERD occurs due to acid-induced inflammation of the esophageal wall or spasms of the esophageal muscles. The pain can mimic heart-related (angina) pain, but unlike cardiac pain, GERD-related discomfort is often related to meals and may improve with antacids. 

Nausea:  Nausea results from irritation of the stomach and esophagus caused by refluxed acid. Persistent reflux can slow gastric emptying, leading to a feeling of queasiness (the feeling of wanting to vomit). In some people, severe reflux episodes may even trigger vomiting. Nausea is often more noticeable after eating large or fatty meals, when the stomach is full and pressure increases.

Bloating, gas, and belching: These symptoms occur because GERD affects normal digestion and allows swallowed air to accumulate in the stomach and esophagus. When acid refluxes, it can increase swallowing frequency as a reflex response, leading to more air intake (aerophagia). The excess air causes bloating and pressure in the upper abdomen, prompting frequent belching or burping as the body tries to release the gas.

Certain food intolerance: For some people with GERD, particular foods may trigger or worsen their symptoms, leading to a perceived intolerance. Foods like spicy, fatty, or acidic foods, as well as coffee and alcohol, can relax the LES or increase stomach acid production, causing more severe reflux.

Difficulty swallowing (dysphagia): Difficulty swallowing occurs when chronic acid exposure causes inflammation, scarring, or narrowing (stricture) of the esophagus. Repeated irritation leads to thickening and reduced elasticity of the esophageal wall, making it harder for food to pass smoothly.

Regurgitation of food or sour liquid: Regurgitation is the effortless backflow of stomach contents into the throat or mouth. This happens when the LES becomes weak or opens abnormally, allowing partially digested food and acid to rise upward. Patients often experience a sour or bitter taste, especially when bending forward or lying down.

Sensation of a lump in the throat: Many GERD patients describe feeling as though a lump or foreign body is stuck in the throat. This “globus” sensation is caused by acid reaching the upper esophagus or throat, leading to muscle tightness and inflammation in the laryngopharyngeal area. 

Disrupted sleep: GERD often worsens at night, especially when lying flat, because gravity no longer helps keep stomach contents in place. When acid refluxes into the esophagus during sleep, it can cause burning pain (heartburn), chest discomfort, coughing, or choking sensations that repeatedly awaken the person.

Chronic cough: Stomach acid reflux irritates the esophagus and throat, triggering the cough reflex. Sometimes small amounts of acid are inhaled, further irritating the airways. This cough often worsens after meals or at night. New or worsening asthma: Acid reflux can irritate the airways or trigger nerve reflexes that cause bronchoconstriction, leading to coughing, wheezing, and shortness of breath. GERD can make asthma harder to control, and asthma can, in turn, worsen reflux.

Laryngitis: When acid reaches the throat, it inflames the vocal cords, causing hoarseness, sore throat, frequent throat clearing, or loss of voice. This form of reflux, known as laryngopharyngeal reflux (LPR), often occurs without typical heartburn.

Generally many people have acid reflux symptoms every now and then, especially after eating large meals or lying down right after a meal. If acid reflux occur at least twice per week then it can be classified as GERD (Gastroesophageal reflux disease) sometimes symptoms become moderate to severe. In case of the persistent symptoms, consult a gastroenterologist.

Gastroesophageal reflux disease (GERD) or chronic acid reflux caused by frequently happening acid reflux. The major cause of GERD is a malfunctioning LES. When the LES weakens or relaxes abnormally, stomach acid and contents flow back into the esophagus, creating discomfort and reflux symptoms. Several factors can contribute to this dysfunction:

• Weak or Incompetent lower esophageal sphincter (LES)
• Hiatal hernia
• Esophageal motility disorders
• Impaired mucosal defence

Weak or Incompetent lower esophageal sphincter (LES):  Acid reflux happens when your LES doesn’t tighten or close properly. This allows digestive juices and other contents from your stomach to rise up into your esophagus.

The lower esophageal sphincter (LES) is a circular band of muscle at the end of your esophagus. When it’s working properly, it relaxes and opens when you swallow. Then it tightens and closes again afterwards.

Hiatal hernia: When part of the stomach pushes up through the diaphragm, it weakens the support of the lower esophageal sphincter (LES). This allows stomach acid to flow back more easily into the esophagus, causing reflux.

Esophageal motility disorders: Impaired esophageal muscle movement or weak peristalsis prevents proper clearance of acid from the esophagus, allowing acid to linger longer and cause irritation.

Impaired mucosal defence: The esophageal lining may become more sensitive or less able to resist acid injury, contributing to inflammation and discomfort even with minor reflux episodes.

The risk factors for GERD include several conditions and lifestyle elements that increase the likelihood of acid reflux and impairment of the esophageal barrier. These conditions that can increase risk of GERD:

• Overweight or Obesity 
• Hiatal hernia
• Pregnancy
• Age
• Gender
• Lifestyle factors
• Use of certain drugs
• Anxiety and depression
• Delayed gastric emptying
• Lack of physical activity
• Scleroderma or CREST syndrome

Overweight or Obesity: Obesity is one of the strongest and most well-documented risk factors for GERD. Excess fat, particularly abdominal (visceral) fat, increases intra-abdominal pressure, which pushes against the stomach. This pressure overcomes the lower esophageal sphincter (LES), the valve that normally prevents reflux, allowing stomach acid to move upward into the esophagus.

Hiatal hernia: Bulging of the top of the stomach up into the diaphragm and the chest cavity. The diaphragm normally provides support to the LES by maintaining pressure at the junction between the stomach and esophagus. When this anatomy is altered, the LES becomes weakened or displaced into a low-pressure chest environment, making it unable to close properly.

Pregnancy: Pregnancy leads to GERD by hormonal and physical mechanisms. Increased amounts of hormones relax smooth muscles, particularly the LES. Meanwhile, the growing uterus increases intra-abdominal pressure, especially in the third trimester, compressing the stomach and promoting reflux.

Age: Advancing age leads to physiological changes that make reflux more likely. The LES naturally weakens, esophageal clearance slows, and peristaltic function declines with age. Additionally, older adults are more prone to hiatal hernia and delayed gastric emptying, both of which increase acid reflux.

Gender: While GERD affects both men and women, studies shows some gender-based differences. Men tend to have a higher prevalence of erosive GERD and Barrett’s esophagus, while women more often experience NERD and reflux symptoms during pregnancy or menopause due to hormonal changes.

Lifestyle factors: Unhealthy lifestyle play a major role in triggering reflux. Eating large meals, lying down after eating, or eating late at night increases the likelihood of acid reflux because the stomach is full and gravity no longer helps keep acid down. Smoking weakens the LES and reduces saliva production, which normally helps neutralise acid. Alcohol relaxes the LES and irritates the lining of the esophagus. Triggered food (fatty foods or fried foods) can stimulate acid production and slow down gastric emptying. Over time, these habits cause chronic reflux and inflammation of the esophagus.

Use of certain drugs: Many commonly used medications can increase GERD risk by relaxing the LES or irritating the esophagus. These include calcium channel blockers, vasodilators, bronchodilator, sedatives, anticholinergics, tricyclic antidepressants, and nonsteroidal anti-inflammatory drugs (NSAIDs). Some of these drugs lower LES pressure, while others delay gastric emptying or damage the mucosal barrier. When used long-term, they can significantly worsen or trigger reflux symptoms.

Anxiety and depression: Emotional stress, anxiety, and depression effects gut-brain interaction and autonomic nervous system function. They can increase gastric acid secretion, slow gastric emptying, and heighten esophageal sensitivity to acid, making symptoms feel more intense. Additionally, anxiety can cause muscle tension and poor eating habits that worsen reflux.

Delayed gastric emptying: Delayed gastric emptying (gastroparesis) occurs when the stomach takes longer time to empty into the small intestine. This causes prolonged gastric distension and increased pressure in the stomach, pushing contents upward through the LES. Conditions like diabetes or certain medications can slow gastric emptying. The result is more frequent and severe reflux episodes.

Lack of physical activity: A sedentary lifestyles slow digestion and contributes to weight gain, both of which increase reflux risk. Regular moderate exercise helps improve gastric motility and reduce GERD symptoms.

Scleroderma or CREST Syndrome: In scleroderma, especially CREST syndrome, the muscles of the esophagus become stiff and weak due to fibrosis. This weakening of the LES impairs food movement, allowing stomach acid to flow back easily into the esophagus, leading to chronic GERD.

Frequently asked questions (FAQs) on GERD

Yes, curd or yoghurt can be good for some people with GERD as it is a low-acid dairy product and contains probiotics that may improve digestion. However, tolerance varies; some may find that dairy worsens symptoms. It’s best to try small amounts and see how your body reacts. If curd causes discomfort or increases symptoms, it’s better avoided.

Yes, studies indicate a link between GERD and mouth ulcers. The reflux of gastric contents, which contain highly acidic substances like stomach acid, pepsin, and bile salts, into the oral cavity can damage the protective mucosal tissues. This acid exposure, which may be exacerbated by reduced salivary flow in some GERD patients, may cause inflammation and lead to the development of oral ulcers. 

Non-erosive reflux disease (NERD) is a subtype of GERD, not a distinct disorder. The key difference lies in the presence or absence of visible damage to the esophageal lining. In NERD, patients experience classic GERD symptoms like heartburn, but an endoscopy shows no signs of erosion or injury. NERD accounts for the majority of GERD cases and can be caused by acid, non-acid, or weakly acidic reflux, with symptoms sometimes resulting from a heightened sensitivity to reflux events.

GERD usually does not directly cause blood in mucus. However, severe GERD may lead to irritation, inflammation, or esophageal damage, which can rarely cause bleeding. Blood from the esophagus might sometimes appear in the mucus coughed up. Any presence of blood should be medically evaluated, as it may indicate other causes like infections, injuries, or more serious conditions requiring prompt attention.

Yes, GERD can cause wheezing by irritating the airways and lungs. Acid reflux sometimes reaches the throat and airway, leading to coughing, wheezing, or worsening asthma symptoms. The acid can cause inflammation and tightening of the air passages, making breathing difficult.

Exercise can help reduce GERD symptoms by improving digestion and maintaining a healthy body mass index (BMI), which lowers gastric pressure. However, high-impact or strenuous activities, especially those involving straining of the abdominal muscles, can increase intra-abdominal pressure and make reflux symptoms worse. It is recommended to avoid intense exercise right after eating to prevent reflux.

Consult a doctor for GERD if there is frequent heartburn, regurgitation, or acid reflux that lasts more than a few weeks, especially if symptoms interfere with sleep or daily life. Signs that indicate a need for medical care are:

• Persistent burning sensation in the chest or throat
• Difficulty or pain while swallowing
• Frequent vomiting or regurgitation of food or sour liquid
• Unexplained weight loss or loss of appetite
• Chronic cough, hoarseness, or sore throat
• Chest pain that occurs after eating or lying down

If these symptoms continue or worsen, it is important to see a GERD doctor for an accurate diagnosis and treatment. Seek emergency medical attention if there is a sign of vomiting of blood, black or tarry stools, or severe chest pain, as these may indicate complications such as esophageal bleeding or ulceration. A general physician or gastroenterologist can provide the right GERD treatment to manage symptoms and reduce long-term risks.