Everyone has probably experienced heartburn at least once in their lifetime. For many people, this happens infrequently and can be related to certain foods or activities and doesn’t cause too much trouble. Television, radio and print advertising spend a lot of time promoting over-the-counter remedies for those persons with only infrequent symptoms. For some people, however, these symptoms occur frequently and disrupt their ability to carry out their daily routine. Their symptoms may also be more severe and include nausea, regurgitation of stomach contents leaving an acid or bitter taste in the mouth, sore throat, or even asthma. Many times they’ve tried all the over-the-counter remedies without the desired degree of symptom relief. This is when a visit to the doctor can be helpful.

First, some common ailments requiring specific treatment (such as peptic ulcers) must be excluded. This typically requires an evaluation of the upper gastrointestinal tract. The two common methods currently being used are a barium test (upper GI series) and an endoscopy (Esophagogastroduodenoscopy or EGD). These tests, particularly the EGD, may detect injury to the lining (called the mucosa) of the esophagus from gastroesophageal reflux disease or GERD. If injury is observed, this indicates the presence of erosive GERD. However, many patients will have the symptoms of GERD without having injury to the esophageal lining and can be diagnosed with nonerosive GERD. Sometimes a specific test, called a 24 hour pH monitoring, will be used to look for abnormal amounts of acid in the lower esophagus to confirm the diagnosis of GERD.

Why do people get GERD? The normal stomach makes a lot of acid and pepsin (an enzyme which helps with breaking down food). Normally, the lining of the stomach can resist the action of this acid and pepsin. If not, then a peptic ulcer may develop. We now know that a bacteria called Helicobactor pylori is an important factor in allowing injury to occur to the stomach lining by disrupting this normal mucosal defense and if peptic ulcers are seen in patients with Helicobacter pylori infections in their stomach, the current treatment includes antibiotics to clear the infection in addition to direct treatment of the ulcer by suppressing acid secretion.

Does a similar process occur in the esophagus? Not exactly. The lining of the esophagus is not designed to resist the actions of acid and pepsin to begin with, so injury can occur without the presence of some “scapegoat” like Helicobacter pylori. The esophagus “defends” itself by creating a barrier to acid/pepsin reflux (the lower esophageal sphincter), squeezing out the refluxed acid (peristalsis), and by neutralizing the remaining acid (swallowed saliva). As you can imagine, everyone has reflux. If these esophageal defense mechanisms are working properly, it’s no big deal. If one or more of these defense mechanisms fails, GERD is likely to occur.

This also tells us how we can treat GERD. You can fix the lower esophageal sphincter (a band of muscle at the lower end of the esophagus), but this requires some major surgery. Or, you can give drugs which either improve peristalsis (the normal coordination of muscles in the esophagus which move food from the mouth to the stomach) or suppress/neutralize acid secretion. Drugs which improve peristalsis are called prokinetic agents (and usually help the lower esophageal sphincter muscle squeeze a little harder as well). The older prokinetic agents usually didn’t work well enough or had too many side effects. Acid suppression can be achieved by taking antacids which directly neutralize the acid (sort of a commercial equivalent of “spit”), but most GERD patients can’t drink enough to block their symptoms. Drugs which block acid secretion include “H2 blockers” (named for their ability to block histamine, which is produced locally in the stomach, from interacting with it’s receptor, the Histamine Type 2 receptor, and stimulate acid secretion) and proton pump inhibitors (named for their ability to block the enzyme which “pumps” acid, or protons, into the stomach).

Currently, we are enrolling patients in clinical trials to test some of the newer prokinetic agents and determine their most appropriate use in patients suffering with GERD.