Abstract
Have you ever heard someone mention having a burning feeling in their chest after eating a large spicy meal, and wondered what it was? That uncomfortable feeling is often a symptom of a condition called gastroesophageal reflux disease (GERD). GERD occurs when the “door” between the food pipe (esophagus) and the stomach does not close properly, allowing stomach acid to flow back upward. This backflow causes the painful burning feeling known as heartburn. Certain things, like large or fatty meals, lying down too soon after eating, pregnancy, obesity, or some medicines, can make this backflow more likely. Over time, repeated acid splash attacks can injure the food pipe and lead to serious problems. In this paper, we explore what goes wrong in GERD, why symptoms flare up, and how simple habits, medications, and sometimes surgery can help restore balance and keep the burn from returning.
The Gastroesophageal Junction
The food you eat begins its journey in the mouth, where chewing breaks it down into smaller particles, making it easier for the stomach to digest. After you swallow, the food travels down the esophagus, a muscular “hallway” that pushes it along with wave-like movements. Before food reaches the stomach, it passes through a one-way door made of muscle, called the lower esophageal sphincter (LES) (Figure 1).
- Figure 1 - A simple picture of the digestive tract from the mouth to the stomach shows possible causes of GERD in red.
- These include having less saliva in the mouth, a weaker food pipe, a muscle “door” (LES) that does not close tightly, and food emptying from the stomach more slowly than usual.
Normally, the LES stays shut to keep stomach contents in, but it briefly relaxes when you swallow so food can pass into the stomach. This opening and closing is controlled by signals from nerves and certain chemicals the body releases [1]. In gastroesophageal reflux disease (GERD), this “LES door” can be faulty. Sometimes it relaxes at the wrong time (called transient LES relaxation), does not squeeze shut tightly enough, or it can “leak” when there is increased abdominal pressure like during pregnancy or if a person has obesity. Additionally, the risk of GERD can increase if a person is not producing enough saliva or if the stomach empties into the intestines more slowly than usual.
How Does GERD Affect the Body?
The stomach makes strong digestive juices, including hydrochloric acid and an enzyme called pepsin, to break down food. When the “door” between the stomach and esophagus stays open too long, the stomach acid flows upward to the esophagus (Figure 2). The esophagus does not have the same protective coating that the stomach has, so the acid can irritate and even damage the lining of the esophagus, leading to a burning feeling [2]. This irritation happens because the digestive juices break down the “glue” between the cells of the esophagus [1]. If the esophagus gets too irritated, swallowing food can become difficult or painful. At times, this may make it hard to swallow. After a meal, people often feel a burning pain in their chest that can resemble heart trouble, which is often referred to as heartburn. This happens because the esophagus lies close to the heart and the nerve signals from both travel along similar paths, making it confusing for the body to figure out where the pain is coming from.
- Figure 2 - Stomach acid and enzymes help to break down food.
- Normally, despite the food moving around inside the stomach, the acids remains inside because the LES keeps it trapped. In GERD, when the LES is not working effectively, to the stomach contents can go through the LES into the esophagus (Figure created using Biorender: https://BioRender.com/b1zbpmh).
GERD can run in families as well—if parents or grandparents have a weak LES door, there is a higher chance that their kids might have one, too [3]. Certain genes involved in controlling the glue between the cells or the release of stomach acid may increase the likelihood of getting GERD [4].
What Makes GERD Worse?
Large meals, especially right before bedtime, increase the pressure in the abdomen, making it hard for the LES door to stay closed against gravity when it is time to lie down. GERD pain is often felt 30–60 min after eating [1].
Some foods and drinks can weaken the LES door, letting more acid sneak up, while others make the stomach create extra acid. If too much food fills up the stomach, the LES might not be able to close properly, letting acid escape. Eating greasy or fatty foods can slow down how quickly food leaves the stomach, so the digested material sticks around longer, making it more likely to get pushed back up. Chocolate and peppermint have properties that relax the LES, causing it to not close as tight. Soda, tomatoes, citrus, and spicy foods can irritate the esophagus, so eating those when you have GERD worsens the pain. Certain medicines, like pain relievers, can make the esophagus’s walls weaker, so they get hurt more easily by the acid.
Some people have a condition where part of the stomach moves up too high, making it harder for the LES door to stay closed properly. This is called a hiatal hernia. It is like a door that is not sitting in the right spot, so it keeps swinging open!
Complications of GERD
Stomach acid is very powerful, so the stomach has a special protective lining. Other areas of the body, such as the esophagus, do not have the same type of protective lining. Repeated exposure of the esophagus to stomach acid can be very damaging and lead to serious problems [2]. Esophagitis is when the esophagus becomes inflamed (red, swollen, irritated) from exposure to stomach acid. Esophagitis can make it much more painful to swallow and, over time, can become an ulcer, which is like a sore on the skin. An ulcer can bleed or even become cancerous.
Esophageal stricture happens when the body replaces damaged tissue in the esophagus with scar tissue. This scar tissue is not as stretchy as the original tissue and can make the esophagus stiff and narrower. This narrowing can make it much harder and more painful to swallow foods or drinks.
Barrett’s esophagus happens when the normal flat lining of the esophagus changes after long-term exposure to stomach acid. The body replaces these cells with tougher ones, like those in the intestines, to protect itself. While this helps resist acid damage, it also increases the risk of cancer, so people with Barrett’s often need regular check-ups.
If the stomach acids travel far enough upward, they can reach the voice box (larynx) [1]. Asthma can get worse when the acid from the stomach reaches the airways [1, 2], irritating the airway lining and causing them to narrow, similar to esophagitis. This may worsen asthma symptoms, make breathing difficult, or even lead to a constant cough. If the acid keeps coming up, it can also reach the nose, sinuses, and even the teeth, making them weaker over time.
How is GERD Treated?
Several lifestyle habits and medical treatments can help with GERD [5]. Eating meals at least 3 h before bedtime can help. When obese patients reduce their weight, it often helps take the pressure in the abdomen, improving symptoms. Certain medications can help stop acid from causing trouble—think of them as firefighters coming in to put out the fire. Antacids are medicines that neutralize acid in stomach juices, which takes away the acid’s power to disrupt the cells in the esophagus and the glue that holds them together. Proton pump inhibitors are drugs that help stop the stomach from making too much acid in the first place, so there is less acid to sneak up into the esophagus.
These treatments do not work for everyone, as everyone’s body is different and different factors (like genetics) may cause their GERD. A last resort is Nissen fundoplication, a surgery that involves tightening the LES door, allowing it to close more effectively. This way, there is no leak, and the esophagus stays burn-free. For people who are overweight and have bad GERD, doctors might do a special operation called gastric bypass surgery, which helps the stomach work better and stops acid from escaping. This not only helps people with their GERD symptoms, but can also help them lose weight.
Let Us Review
The esophagus, or the “hallway” between the mouth and the stomach, plays an important role in helping the stuff you eat or drink reach the stomach where it gets digested. The body usually ensures that food movement happens in one direction, but sometimes things can go wrong and the stomach contents can come back up into the esophagus. Over time, this can upset the lining of the esophagus, causing it to become painful and swollen, and it can even lead to cancer in some cases. Simple habits like eating smaller meals and avoiding late dinners can help. When that is not enough, medications like antacids and proton pump inhibitors can help reduce acid and protect the esophagus from damage. Understanding how GERD happens helps people make better choices about their eating habits and daily routines to protect their digestive health. With the lifestyle changes and treatment most people with GERD can manage their symptoms and live comfortably.
Glossary
Lower Esophageal Sphincter (LES): ↑ A ring of muscle that opens and closes the opening between the esophagus and the stomach.
Gastroesophageal Reflux Disease: ↑ This occurs when the stomach acid flows back up into the esophagus. This backward flow is called reflux, and it can irritate the lining and cause a burning feeling.
Heartburn: ↑ A burning feeling in the chest or throat that happens when some of the food and stomach acid come back up from the stomach into the esophagus.
Hiatal Hernia: ↑ A hiatal hernia happens when the top of your stomach bulges through an opening in a muscle that helps with breathing called the diaphragm.
Esophagitis: ↑ Redness and swelling of the esophagus, often caused by repeated exposure to stomach acid.
Esophageal Stricture: ↑ A narrowing of the esophagus due to scar tissue formation.
Barrett’s Esophagus: ↑ This occurs when the cells in the lining of the food pipe changes after being repeatedly exposed to the stomach acid for a long time.
Proton Pump Inhibitor (PPI): ↑ A type of medication that can help reduce the amount of acid made by the stomach.
Conflict of Interest
The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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References
[1] ↑ Kahrilas, P. J. 2003. GERD pathogenesis, pathophysiology, and clinical manifestations. Cleve. Clin. J. Med. 70:S4. doi: 10.3949/ccjm.70.suppl_5.s4
[2] ↑ Schumann, D., Langhorst, J., Dobos, G., and Cramer, H. 2018. Clinical manifestations and complications of gastroesophageal reflux disease (GERD). Aliment. Pharmacol. Therapeut. 47:203–11. doi: 10.1111/j.1742-1241.2005.00370.x
[3] ↑ Locke, G. R. III, Talley, N. J., Fett, S. L., Zinsmeister, A. R., and Melton, L. J. III. 1999. Risk factors associated with symptoms of gastroesophageal reflux. Am. J. Med. 106:642–9. doi: 10.1016/s0002-9343(99)00121-7
[4] ↑ Böhmer, A. C., and Schumacher, J. 2017. Insights into the genetics of gastroesophageal reflux disease (GERD) and GERD-related disorders. Neurogastroenterol. Motil. 29:e13017. doi: 10.1111/nmo.13017
[5] ↑ Kahrilas, P. J. 2008. Clinical practice. Gastroesophageal reflux disease. N. Engl. J. Med. 359:1700–7. doi: 10.1056/NEJMcp0804684