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Interviewer: Gastroesophageal reflux disease or GERD is a condition that impacts up to 20% of people. But many people aren't even aware they have it or recognize its symptoms which can lead to really serious health issues if it's left untreated.
To help us better understand GERD and how to recognize it we're joined by gastroenterologist Dr. Jessica Stout with University of Utah Health.
Dr. Stout first of all is it a fair statement to say most people don't even know they have GERD or are experiencing GERD symptoms?
Symptoms of Gastroesophageal Reflux Disease (GERD)
Dr. Stout: Yeah. That's a really fair statement actually. I mean it's a very very common disease. And a lot of people either don't know they have it because they have the silent symptoms which means no symptoms or they have atypical symptoms which means that they don't present with the typical symptoms of GERD. And a lot of people if they do have symptoms that are pretty classic which is that heartburn sensation or just the sensation that things are refluxing up into their esophagus or even their mouth they just don't really do much about it because either maybe it's not too bothersome or you know they're just busy with their day-to-day lives and don't have time to go see somebody about it or educate themselves on how or what they should do about it.
Typical GERD Symptoms
Interviewer: Let's talk about those typical symptoms and then the atypical and maybe even the silent symptoms. So what are we looking for?
Dr. Stout: Yeah. I think the typical symptoms most people are quite aware of and that's that heartburn sensation or "I have this like just burning sensation in the center of my chest." And oftentimes people use their hand to motion this upward kind of movement of the burning sensation and that is really oftentimes the acid in the esophagus just refluxing up causing a burning sensation.
The reflux is also pretty self-explanatory. You know you just feel like you have food or fluid that's moving upwards in the chest and then some people even get it that fluid will get into their mouth. It'll have like a gross bitter sour taste or they'll even feel like food and things like that. And oftentimes people feel this the most when they're sleeping. Maybe that's because they're (a) not as busy and they're more aware of what's going on when they're lying down and it's quiet. Also literally gravity isn't helping keep those fluids and foods and things like that down.
So those are the really typical symptoms which are just heartburn and reflux that people will get.
Atypical GERD Symptoms
Interviewer: All right. And then those atypical symptoms what do those look like?
Dr. Stout: So atypical symptoms are . . . Really what it probably is is acid and like fluid contents from the stomach moving so high up into the esophagus that it's actually spilling over into the windpipe. We call them extraesophageal symptoms in the world of GI or like if you're really fancy you'll call them laryngopharyngeal reflux symptoms. But again literally it's that acid or fluid moving into the windpipe oftentimes and it can be really difficult to determine whether or not this is really due to reflux. A lot of these patients will end up seeing ear nose and throat doctors first because they have hoarseness or they'll see a lung doctor or a pulmonologist first because they've got symptoms of cough or maybe they're having shortness of breath because over time the acid and fluid that's spilling over into the lungs is actually causing inflammation and damage. Some people will have a lot of post-nasal drip or maybe they'll have like what we call globus sensation or just the feeling that something is stuck way up high.
There are patients who get referred first to other specialists because they're thinking "Oh this is a lung problem" or "This is a throat problem." And then oftentimes rightfully so after the pulmonologist or ENT doctor has done their whole workup they're like "You know what? I think this actually might be reflux" and then they come to our gastrointestinal or GI clinics.
The symptoms that we will see too are something called dysphagia or people who are having trouble swallowing or even odynophagia which is a fancy word for painful swallowing.
Silent GERD Symptoms
Interviewer: Then there are these silent symptoms. You know this could be happening and you're not even really experiencing symptoms. What are some of those?
Dr. Stout: Silent GERD is silent. Oftentimes people just don't have any symptoms or they're just not aware of the symptoms that they're having. And I would say if you really tease things out you know like in hindsight when you look backward people probably did have some of the either typical or atypical GERD symptoms that we've already talked about. They just ignored them or didn't realize what they were or they weren't so bothersome that they decided to go in and seek care. But really a lot of times silent GERD is just that. People really have no symptoms at all whatsoever but there is an abnormal number of reflux episodes that are happening.
How Dentists Can Detect GERD
Interviewer: Another indication you might have it that could surprise some people is when you go to your dentist and they say "Do you think you have acid reflux?" And I'm like "Why?" "Because we can see these pits in your teeth that indicate that perhaps acid is coming into your mouth." How often do patients come to you after they've been to their dentist?
Dr. Stout: Honestly not super often but I have definitely had that more than a handful of times you know happen. "My dentist thinks that I have acid reflux" you know and then you start to ask them more questions and you agree either by what they're saying or maybe they are having silent reflux you know and have no symptoms. And then that's when I kind of start to recommend more testing like endoscopy or these little reflux monitoring probe placements to definitively say yes or no you do or don't have acid.
Complications of Untreated GERD
Interviewer: You know of all of the kind of . . . I don't know if GERD's typically referred to as a disease or condition or what but I've done these podcasts for a long time and a lot of times one of the questions I ask is you know ultimately if somebody doesn't do something about this condition you know what's going to be the outcome? And I feel like not doing something about GERD is one of the more serious things you should actually do something about because the down-the-road ramifications don't sound fun.
Dr. Stout: Yeah. And I mean a lot of people will live and die with GERD that's not been adequately treated and they'll do okay you know. But I mean having strictures and not being able to eat or getting esophageal cancer I mean those are very very serious dreaded complications of the disease and can vary . . .
Interviewer: Or losing your voice. Like that's the thing . . .
Dr. Stout: Or losing your voice. . .
Interviewer: . . . that I don't want to ever have happen to me.
Dr. Stout: You would be in trouble right? I think my husband would be super excited if that happened to me. But yeah I mean all those things are really serious and can be prevented I think. So it is definitely worth treating and not ignoring.
Managing GERD
Interviewer: When it comes to managing acid reflux I understand lifestyle has a lot to do with it. Can you talk a little bit about lifestyle modifications to help manage symptoms?
Dr. Stout: So this is always huge for me in the clinic. You know I always try to talk to patients first about lifestyle modifications and hey just like really take a deep dive. Look at what you're doing on a day-to-day basis that you have control over. Unfortunately, we as humans like to do what we like to do and we don't like to change things that we enjoy. And so it ends up being a conversation that's actually quite a bit more difficult for people to implement once they go back out of my office you know. But I like to think that I have these wonderful motivating conversations with people.
So one of the things, like, dear god, I hope that nobody is still smoking, but unfortunately, people are smoking, and we know that this increases your risk of having reflux episodes. Booze, it seems like also increases the, like, number of lower esophageal sphincter, that little valve at the bottom of the esophagus, increases the amount of times that that opens up. Also, it seems like citrus foods, tomato-based foods, really like fatty foods, carbonated beverages, chocolates, and unfortunately, things like coffee, which, you know, I really, really love, all of those have been shown to increase the number of lower esophageal sphincter openings, which can allow acid to pop back up the wrong way.
There are other things like if you eat a big meal and then you lay down, now you don't have gravity as your friend helping to pull, you know, the fluid and acid and things like that back into the stomach, and it can wash up more freely. So a lot of times I'll tell patients guidelines say to not eat two to three hours before you lay down flat. I actually oftentimes tell patients because once they reach my clinic, it's probably a pretty severe case of reflux, I tell them not to eat about four hours before they go to bed, just because that's about how long it takes the stomach to empty almost everything in it. Raising the head of the bed, with either a wedge pillow or boards or bricks or something underneath the front, raising it about 20 degrees can be helpful for people just to keep those reflux episodes from happening at nighttime.
And then one of the biggest things in this, I spend a lot of time trying to be very sensitive when I'm talking about this. But if you carry extra weight in the, like, abdominal area, that increases pressure, intra-abdominal pressure, and it can actually . . . I mean, there are a lot of reasons why being overweight or obese can cause reflux, not just this, like, very physiologic and kind of anatomic explanation, but I think this is the easiest to understand. But if you have extra weight in your midsection, some of that is pushing on your stomach, and it's quite literally pushing things back up the wrong way. And there's been great research to show that a body mass index over 25, which in the United States, I think now the statistic is, like, over 60% of us are overweight or have a BMI over 25. But as that weight increases, the number of reflux episodes and the amount of people who become symptomatic from GERD goes up.
And so, you know, it's really hard to lose weight. I think a lot of people are aware that they want to or should lose weight, but that is a really huge thing that everybody could be . . . not everybody, because I do have patients who are rail thin who have a lot of other reasons to have reflux. Weight loss, though, and just intentional exercise, is a huge lifestyle modification that a lot of people could make to improve their symptoms of GERD.
Impact of Age and Weight on GERD
Interviewer: Is getting older a risk factor as well, or is it just getting older also comes with we tend to put on more weight as we get older? The accumulative effect of the GERD that we've been ignoring for a while just is getting worse.
Dr. Stout: It might be a little bit of both, but it seems like age is an independent risk factor for reflux, you know. And some of that just might be that the sphincter has been around for a long time and is relaxing more than it used to.
Interviewer: Sure.
Dr. Stout: But yeah, so age is a risk factor for GERD.
Should You Self-Treat or See a Doctor for GERD?
Interviewer: All right. So if somebody's listening to us right now and they're like, "All right. I'm pretty sure I have it. I'm going to try to do some things on my own before I see a health care provider." Is that a good way, or should you go see a health care provider first so they can kind of get a baseline to see if the things you're trying . . .
Dr. Stout: That's a really good question. I think, most of the time, if you are having typical GERD symptoms, which is, you know, that classic heartburn or just stuff refluxing up into your esophagus or even your mouth, and you're not having other what we call alarm symptoms along with that, I think that it is appropriate to say, "Hey, this is probably GERD, and I'm going to try some lifestyle modifications," and/or, "I'm going to try some over-the-counter acid-reducing medicines first."
Some of these alarm symptoms that really shouldn't be ignored are trouble swallowing, so that dysphagia, or pain with swallowing food, which is odynophagia. If people have anemia, so say you're just having routine blood work done and your blood counts are a little bit low and you also have these symptoms of reflux, that is considered an alarming symptom. If you're having weight loss that you can't explain along with these symptoms, that's considered an alarm symptom. Obviously, if you're throwing up blood or if you're pooping stuff that looks like blood or black, that can be a sign of blood loss from the upper GI tract. If you're also having chest pain, so it's not just like that very classic heartburn symptom, but you're like, "I don't know. This is, like, a heaviness," or if it just sounds like the chest pain is a little bit less typical, I mean, I would have a very low threshold to ask somebody to go get seen for that.
And then also, if you have a family history of esophageal cancer, you know, and you have reflux, you should go get seen by somebody and not just try to manage it yourself because there's probably additional testing that we need to do other than just assume that this is reflux and put you on medication or recommend lifestyle changes.
Diagnosing GERD
Interviewer: Is there a test that a healthcare provider can do to definitively say this is GERD, or is it mainly asking questions about symptoms and lifestyle and whatnot?
Dr. Stout: There are. There are lots of tests. We have so many tests, actually, that we can do in the clinic. And it can be very complicated. But I think, like, the bulk of people who have these GERD symptoms, they get seen either not by anyone or by their primary care doctors, and just getting a good history is probably enough to say, "I think that this is reflux disease. Why don't we try lifestyle modifications?" Or, "Why don't we try this medication?" And that is totally appropriate.
If you want, like, the true answer, (a) there's no gold standard to diagnose GERD, and to definitively and objectively diagnose GERD, you actually have to look at the tissue, and there has to be evidence of, like, tissue damage because of inappropriate acid exposure. And in order to do that, we have to do an upper endoscopy, which is an ordeal. I mean, it's a very safe test, but you've got to go in, and we give medications to keep people comfortable, and it's an invasive test, and/or we have these little probes that we can stick down in people's esophagus to measure the actual number of episodes of reflux and say, "Yes, this is normal," or, "No, this is not normal." And those are not always comfortable, and/or sometimes they take endoscopy to place these little, tiny probes that can measure the acid in the esophagus.
So in order to definitively define GERD, you actually do need to do more invasive testing. But because it's so common and because it's usually something that can be handled either with lifestyle modifications or just a medication, it is appropriate in the absence of alarm symptoms to try those things first for most people.
Do Not Ignore Symptoms of GERD
Interviewer: What would your kind of final message to somebody be after this conversation? You know, maybe they've pieced together some clues here. They're like, "Huh, that could be me," whether it's the silent symptoms or whether it's pretty obvious that they do have GERD.
Dr. Stout: Most importantly, it is just the symptoms, you know, that you brought up, which the typical ones are heartburn and reflux. And then some of the atypical symptoms like cough or shortness of breath or burping or hoarseness, you know, things like that. And just recognize that any of these can be because of inappropriate acid, like, washing up into the esophagus or GERD. And then knowing that it isn't something that should be ignored because the longstanding effects are like stricturing we talked about and then really also esophageal cancer.
Untreated reflux is a risk factor for developing esophageal cancer. I mean, it's a super, super common disease. Like we talked about, it affects over 20% of the population, and not 20% of the population gets esophageal cancer. But it really increases your risk of esophageal cancers, and then, you know, things like trouble swallowing because of strictures. And so it shouldn't be ignored if you feel like you have these symptoms.
And, you know, I always think the very first thing that physicians or health care providers should talk to patients about are lifestyle modifications. You know, before we just slap medications onto people's lists, which can have side effects, etc., we really should have a conversation in the clinic about the things that they have control over that might make their symptoms better. But it's so hard. You know, again, we're humans, and we just like to do what we like to do, and we don't like to be told to change. And so, oftentimes, it is easier to just start a medication, and the medications that we have are super effective for acid reflux. And so, you know, they work. I just always try to have that difficult conversation in the clinic about lifestyle modifications first, and I would stress that more of us as providers do that.