Gastroesophageal Reflux Disease (GERD)

Gastroesophageal Reflux Disease (GERD) is a condition where stomach acid regularly flows back into the oesophagus, the tube connecting the mouth to the stomach. This acid reflux can irritate and inflame the oesophageal lining, potentially causing long-term damage to the tissue. GERD can affect individuals of all ages and, if left untreated, may lead to complications such as oesophageal narrowing, precancerous changes, and respiratory issues.

Dr. Chok Aik Yong

Colorectal Surgeon & General Surgeon

MBBS | MRCS (UK) | MMed (Surgery) | FRCS (UK)

Symptoms Causes Diagnosis Treatment Prevention FAQ

Symptoms of Gastroesophageal Reflux Disease

The following symptoms may indicate the presence of GERD, although their severity can vary from person to person.

Heartburn

A burning sensation in the chest, often occurring after eating, and may worsen when lying down or bending over. The discomfort can move upward from the stomach to the chest and throat.
Regurgitation

The sensation of stomach contents or sour liquid backing up into the throat or mouth. This occurs when the lower oesophageal sphincter does not close properly.
Dysphagia

Difficulty swallowing or a feeling of food being stuck in the throat or chest. This may result from oesophageal inflammation and narrowing due to repeated acid exposure.
Chest Pain

A discomfort similar to heart attack pain, often occurring at night and sometimes waking the individual from sleep. This is due to severe irritation of the oesophageal lining.
Chronic Cough

A persistent cough that does not respond to common treatments, often worsening at night. Reflux acid can irritate the throat or enter the lungs.
Laryngitis

Inflammation of the voice box, leading to hoarseness, frequent throat clearing, or a lump-like sensation in the throat. This occurs when acid reaches the larynx.
Disrupted Sleep

Waking up choking or coughing due to refluxed contents reaching the throat or airways, leading to fatigue and reduced daytime alertness.

Causes and Risk Factors

GERD occurs when stomach acid frequently flows back into the oesophagus due to structural issues, lifestyle habits, or underlying medical conditions. The following factors can contribute to its onset or worsen symptoms:

Hiatal Hernia

A condition where the upper part of the stomach pushes through the diaphragm into the chest cavity. This disrupts the natural barrier between the stomach and oesophagus, increasing the likelihood of acid reflux.

Weakened Lower Oesophageal Sphincter

The muscle that normally prevents stomach contents from flowing backward becomes weakened or relaxed, allowing acid to enter the oesophagus—especially when lying down or bending over.

Obesity

Excess weight puts increased pressure on the abdomen, forcing stomach contents upward against the lower oesophageal sphincter and weakening its ability to stay closed.

Pregnancy

Hormonal changes and increased abdominal pressure can trigger GERD symptoms, which usually resolve after childbirth.

Smoking

Tobacco use relaxes the lower oesophageal sphincter, increases stomach acid production, and reduces salivation, all of which can worsen acid reflux. These effects significantly increase the risk of developing GERD and its symptoms.

Diet

Certain foods and beverages can relax the lower oesophageal sphincter or increase stomach acid production. Common triggers include fatty foods, spicy foods, citrus fruits, tomatoes, chocolate, coffee, and alcohol.

Medications

Some drugs can weaken the lower oesophageal sphincter or directly irritate the oesophagus. These include certain pain relievers, calcium channel blockers, antihistamines, sedatives, and asthma medications.

Delayed Stomach Emptying

When the stomach empties slowly, acid has more time to reflux into the oesophagus. This is often linked to diabetes and certain neurological disorders.

Diagnostic Methods

Upper Endoscopy

A flexible tube with a camera (endoscope) is inserted through the mouth to examine the oesophagus, stomach, and upper small intestine. This procedure allows direct visualisation of inflammation, ulcers, or other abnormalities. Tissue samples can be taken to check for complications such as Barrett’s oesophagus or rule out other conditions.
Ambulatory Acid (pH) Probe Test

A thin tube with an acid sensor is placed through the nose into the oesophagus, or a wireless sensor is attached during endoscopy. This test monitors acid levels for 24 to 96 hours while the patient carries out normal activities. This helps to determine how frequently acid reflux occurs and whether it correlates with the patient’s symptoms.
Oesophageal Manometry

A thin, pressure-sensitive tube is passed through the nose into the oesophagus to measure muscle strength and coordination during swallowing. This test assesses lower oesophageal sphincter function and detects abnormal contractions that may contribute to GERD.
Barium Swallow Radiograph

The patient drinks a liquid containing barium, which coats the oesophagus and stomach, making them visible on X-rays. This test helps identify structural abnormalities such as hiatal hernias, strictures, or other issues linked to GERD.
Impedance Testing

This test combines pH monitoring with the measurement of non-acidic reflux. Sensors on a catheter detect acidic and non-acidic reflux episodes, making it useful for patients with persistent symptoms despite taking acid-suppressing medication.

Treatment Options

Managing GERD involves reducing acid production, healing the oesophagus, and preventing complications through various approaches. Common treatment options include:

Non-Surgical Treatment

Lifestyle Modifications: Maintaining a healthy weight, elevating the head of the bed, avoiding meals close to bedtime, and eliminating trigger foods are key steps in managing GERD symptoms. Quitting smoking and limiting alcohol intake can improve lower oesophageal sphincter function and decrease stomach acid production.
Antacids: Over-the-counter antacids neutralise existing stomach acid, providing quick relief for occasional heartburn. However, they offer temporary relief and do not heal oesophageal inflammation or prevent future reflux episodes.
H₂ Receptor Blockers: Medications like ranitidine and famotidine reduce acid production by blocking histamine receptors in stomach acid-secreting cells. They provide longer-lasting relief than antacids and can help heal mild oesophagitis.
Proton Pump Inhibitors (PPIs): Drugs such as omeprazole and esomeprazole are effective for treating GERD. They block acid production by inhibiting the proton pumps in stomach lining cells, allowing oesophageal healing in most patients with erosive oesophagitis. PPIs typically require several days to reach full effect and are usually taken before the first meal of the day.
Prokinetics: Medications like metoclopramide work by speeding up the stomach’s emptying process, which may help reduce reflux. However, due to potential side effects, their use is generally limited and less common.

Surgical Treatment

Fundoplication: This is the most common surgical procedure for GERD. It involves wrapping the upper part of the stomach around the lower oesophagus to strengthen the barrier between the stomach and oesophagus. The procedure creates a one-way valve, preventing acid reflux while still allowing food to pass into the stomach. Fundoplication is typically performed laparoscopically or through open surgery and provides long-term relief for most patients, often reducing or eliminating the need for daily medication.
LINX Device Implantation: This minimally invasive procedure involves implanting a ring of small magnetic beads around the junction of the stomach and oesophagus. The magnetic beads stay closed at rest but open when swallowing, effectively preventing reflux while allowing food to pass normally. This approach offers a shorter recovery time compared to traditional fundoplication and preserves the ability to belch or vomit.
Transoral Incisionless Fundoplication (TIF): An endoscopic procedure that reconstructs the anti-reflux barrier without the need for incisions. A device inserted through the mouth gathers and secures tissue at the gastroesophageal junction to create a valve. TIF is less invasive than traditional surgery, with fewer side effects, though the long-term effectiveness is still being studied.
Stretta Procedure: A minimally invasive technique that uses radiofrequency energy to treat the muscle at the junction of the stomach and oesophagus. This procedure strengthens the barrier against reflux and reduces sensitivity to acid. It takes about an hour, requires no incisions, and patients typically resume normal activities within a few days.

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Prevention and Management

Adopting long-term habits can help reduce the likelihood of GERD symptoms. Maintaining a balanced diet with smaller, more frequent meals prevents excessive stomach pressure, while avoiding late-night eating minimises nighttime reflux. Sleeping with the head elevated prevents nighttime reflux, while loose clothing avoids pressure on the abdomen. Managing a healthy weight reduces abdominal pressure, while regular exercise, when timed appropriately after meals, supports digestive health. Engaging in stress-reducing activities like meditation or yoga may also help, as stress can contribute to reflux episodes. Quitting smoking and moderating alcohol intake further support oesophageal health and reduce reflux risk.

Frequently Asked Questions (FAQ)

Why do GERD symptoms worsen at night?

GERD symptoms often worsen at night because lying flat makes it easier for stomach acid to move into the oesophagus. During sleep, swallowing frequency decreases, and saliva production, which helps neutralise acid, is reduced.

Can GERD cause ear pain or sinus issues?

GERD can cause ear pain and contribute to sinus problems. Acid reflux can reach the throat and irritate the eustachian tubes, leading to discomfort or a sensation of fullness in the ears. Chronic exposure to stomach acid may also contribute to postnasal drip and sinus inflammation, worsening conditions like sinusitis.

Is GERD more common in older adults?

Yes, GERD is more common in older adults. As people age, the lower oesophageal sphincter may weaken, and stomach motility can decrease, both of which contribute to the development of GERD. Additionally, the use of medications for other age-related conditions can worsen reflux symptoms. Hiatal hernias, which are a known cause of GERD, also become more prevalent with age, further increasing the likelihood of developing the condition.

Dr. Chok Aik Yong

Colorectal Surgeon & General Surgeon

MBBS|MRCS (UK)|MMed (Surgery)|FRCS (UK)

Expertise lies in managing colorectal diseases, particularly advanced colorectal cancer and inflammatory bowel disease.

Dr Chok graduated with degrees in Bachelor of Medicine and Surgery from the National University of Singapore. He was conferred the Master of Medicine (Surgery) in Edinburgh (UK) and a member of the Royal College of Surgeons, UK. He subsequently completed his specialist training in colorectal surgery and became a Fellow of the royal college of Surgeons in Edinburgh in 2016.
Dr Chok was awarded the Health Manpower Development Plan (HMDP) award in 2019 to further advance his colorectal training at Royal Marsden Hospital, one of the top 5 cancer centres in the world. While in London, Dr Chok trained with pioneers in the surgical management of advanced colorectal cancer and inflammatory bowel disease (IBD) and gained extensive experience while appraising the latest clinical and research evidence.

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