https://www.ncbi.nlm.nih.

gov/pubmed/15685294
https://www.nice.org.uk/guidance/CG184

PEN

Gastrointestinal System - Gastroesophageal/Gastro-

oesophageal Reflux Disease (GERD/GORD)
Practice Guidance Toolkit

Description and Key Nutrition Issues

Disclaimer

Description
There is a lack of consensus among different organizations and countries regarding the
definition of gastroesophageal/gastro-oesophageal reflux disease (GERD/GORD). Consensus
among international gastroenterological and medical groups describes GERD as a collection of
symptoms of heartburn and regurgitation affecting the esophagus, larynx, mouth or lung (1). An
international consensus conference resulted in the Montreal Definition of GERD which is a
condition which develops when the reflux of stomach contents causes troublesome symptoms
and/or complications (2). The American Guidelines for the Diagnosis and Management of
GERD use a working definition of GERD as symptoms or complications resulting from the
reflux of gastric contents into the esophagus or beyond, into the oral cavity (including larynx) or
lung (3). GERD can be further classified as the presence of symptoms without erosions on
endoscopic examination (nonerosive disease or NERD) or GERD symptoms with erosions
present (ERD). This definition incorporates the 2006 consensus Montreal Definition and an
updated Medical Position Statement in 2008 by the American Gastroenterological Society (3).

The Gastroenterological Society of Australia (GESA) 2011 Guidelines state: Reflux of gastric
contents into the oesphagus is a normal physiological event, occurring usually during the
postprandial period (1). However, disease occurs when symptoms affecting quality of life or
clinical physical complications occur after excessive esophageal exposure to acidic and erosive
gastric contents, pepsin and potentially bile and pancreatic enzymes.

See Additional Content: Gastroesophageal/Gastro-oesophageal Reflux Disease Background.

Key Nutrition Issues

This toolkit discusses the following key nutrition issues:

the relationship between GERD and overweight/obesity

possible dietary triggers of GERD symptoms

the effect of non-dietary lifestyle factors on GERD symptoms

GERD in individuals with COPD.

Background

Gastrointestinal System - Gastroesophageal/Gastro-

oesophageal Reflux Disease (GERD/GORD) Background
Definition of GERD
The Gastroenterological Society of Australia (GESA) 2011 Guidelines state: Reflux
of gastric contents into the oesphagus is a normal physiological event, occurring
usually during the postprandial period (1). However, disease occurs when
symptoms affecting quality of life or clinical physical complications occur after
excessive esophageal exposure to acidic and erosive gastric contents, pepsin and
potentially bile and pancreatic enzymes. Consensus among international
gastroenterological and medical groups describes <span class="tip" data-
arr="1">gastroesophageal reflux disease</span class="tip"> (GERD) as a
collection of symptoms of heartburn and regurgitation affecting the esophagus,
larynx, mouth or lung. An international consensus conference resulted in the
Montreal Definition of GERD which is a condition which develops when the reflux of
stomach contents causes troublesome symptoms and/or complications (2). The
American Guidelines for the Diagnosis and Management of GERD use a working
definition of GERD as symptoms or complications resulting from the reflux of
gastric contents into the esophagus or beyond, into the oral cavity (including
larynx) or lung (3). GERD can be further classified as the presence of symptoms
without erosions on endoscopic examination (nonerosive disease or NERD) or GERD
symptoms with erosions present (ERD). This definition incorporates the 2006
consensus Montreal Definition and an updated Medical Position Statement in 2008
by the American Gastroenterological Society (3).

Disease Etiology
Postulated causes of GERD may include transient lower esophageal sphincter
(LES/LOS) relaxation or decreased LES tone, impaired esophageal clearance,
delayed gastric emptying and decreased salivation (4).

The etiology of GERD has a complex history. Past attempts at definition included
esophagitis, hiatus hernia, a motility disorder due to sphincter or peristaltic
dysfunction, or an acid-peptic disorder (5). The introduction of proton-pump inhibitor
(PPI) therapy meant that many problems due to acid effects on gut mucosa (reflux
esophagitis, ulcers and recurrent strictures) were suppressed. Although it seemed
that effective treatment or even eradication of GERD was a possibility, some
individuals still had symptoms of non-erosive disease (heartburn, regurgitation,
dysphagia) and extra-esophagael symptoms (respiratory or oropharyngeal
symptoms, e.g. asthma, cough, laryngitis, dental erosion) that were unresponsive to
PPIs. The 2006 international consensus Montreal Definition was developed:a
condition which develops when the reflux of stomach contents causes troublesome
symptoms and/or complications (2,6).

GERD is a multi-factorial disease. Boeckxstaens, et al. describe factors such as

obesity, age, genetics, pregnancy and trauma as instigating factors that act on a
normal esophageal junction to cause laxity of the LES and surrounding crural
diaphragm (CD), which leads to increased intra-abdominal pressure, ultimately
causing a hiatal hernia (5). The other factors that may exacerbate impaired function
of the esophageal junction include individual-specific diet-triggers, neuromuscular
dysfunction and esophageal fibrosis.

Reflux is a normal physiological function (1,5). Lower esophageal relaxation allows

for the venting of gas. In this situation, there is normally rapid clearance of any acid
reflux that is confined to the distal esophagus. Problems arise with increased
occurrences of transitory lower esophageal relaxation with reflux of both gas and
liquids leading to esophageal hypersensitivity. These changes may result in reflux
symptoms including heartburn, regurgitation and chest pain. At a pathological level,
the esophagus is exposed to acid with resulting mucosal disease, which in turn may
cause esophagitis, stricture, metaplasia or cancer (5).

Screening/Diagnosis
Diagnostic testing is not generally required for individuals presenting with mild
heartburn or regurgitation. The 2013 American College of Gastroenterology (ACG)
uses a presumptive diagnosis based on symptoms; exclusion of cardiac causes of
chest pain; and endoscopy (3). Canadian guidelines describe uncomplicated GERD
(based on history of symptoms of heartburn and regurgitation) and alarm symptoms
of dysphagia, odynophagia, bleeding/ anemia, weight loss and persistent vomiting;
these definitions guide investigation and treatment options (4,6). Endoscopy is used
only in the presence of alarm symptoms and for screening high risk individuals (4).
Diagnostic procedures which should not be performed in the presence of typical
GERD symptoms include barium radiographs, upper endoscopy, routine biopsies
from the distal esophagus, and screening for Helicobacter pylori infection. Other
procedures are used for pre-operative assessment of individuals who do not respond
to medical therapy and include esophageal manometry and ambulatory esophageal
reflux monitoring (3). Esophageal manometry is used to exclude achalasia or severe
hypomotility, as these are contraindications for a Nissen fundoplication procedure.
Ambulatory esophageal reflux monitoring tests for abnormal acid exposure and
frequency of reflux.
A medication trial of proton pump inhibitors (PPIs) is used to assess other GERD-
related symptoms such as dyspepsia, epigastric pain (which needs cardiac
exclusion), nausea, bloating and belching (3). The Royal College of Surgeons
Association of Upper Gastrointestinal Surgeons (RCS AUGIS) guidelines recommend
a secondary assessment for possible cancer diagnosis when the following symptoms
are present: dysphagia, progressive unintentional weight loss, persistent vomiting,
dyspepsia, reflux, iron-deficiency anemia, gastrointestinal bleeding, and any
worsening reflux in individuals with Barretts esophagus or family history or
symptoms of gastrointestinal cancer (7).

The RCS AUGIS also recommends taking a history of prescribed and over-the-
counter (OTC) medications, specifically non-steroidal anti-inflammatory drugs
(NSAIDs), corticosteroids, bisphosphonates, nitrates and theophylline (7). A GerdQ
Questionnaire is used to assess symptoms and physical examination should exclude
upper abdominal mass.

Prevalence
The overall prevalence worldwide is 2.5-27.8% (5). A 2005 systematic review found
a prevalence of 10-20% in Western countries for heartburn and a 6% prevalence of
significant heartburn and reports of 16% for regurgitation (8). A 2014 systematic
review shows prevalence is increasing worldwide: "18.1-27.8% in North America,
8.8-25.9% in Europe, 2.5-7.8% in East Asia, 8.7-33.1% in the Middle East, 11.6% in
Australia, and 23.0% in South America" (9). Incidence of GERD increases after the
age of 40 (4).

Symptoms
The most common symptoms of GERD include heartburn (6%) and regurgitation
(16%) (3). Pregnant women may experience heartburn (6-72% reported) with
heartburn generally increasing in the third trimester. Symptoms of GERD also
include chest pain and dysphagia (which need further investigation to exclude other
disease), chronic non-specific cough (possible in 21-41% of patients), asthma
(possible GERD symptoms in 51-59% asthma patients), and chronic laryngitis. Other
symptoms may include dyspepsia (38%), epigastric pain, nausea, bloating and
belching. A 2011 systematic review suggested intensity of symptoms might
decrease after age 50 (10).

Co-Morbidities/Associated Disease
Approximately 2% of the adult population suffers from complicated GERD that is
associated with macroscopic or histological damage to the esophagus (6). Hiatal
hernia (HH) may result in GERD although individuals with HH do not always
experience GERD and individuals with GERD do not necessarily experience hiatal
hernia (4). The severity of symptoms may lead to complications.

Obesity is associated with a significant increase in the risk for GERD but it is central
adiposity, independent of BMI, which has been identified in a 2013 meta-analysis as
increasing the risk of Barretts esophagus and esophageal adenocarcinoma (11).

GERD is associated with Barrett's epithelium and esophageal adenocarcinoma, but

the risk of malignancy is low (7). About one-third of GERD patients on endoscopy
will show esophagitis or Barretts esophagus (columnar-lining of the esophagus).
The risk of progression to cancer in individuals with non-dysplastic Barrett
esophagus is reported to be about 0.1% to 0.3% per year (12). A 2011 systematic
review of 19 studies showed GERD increased time off work and decreased
productivity, sleep and physical functioning (13). A systematic review of 17 studies
(differing in design, population, diagnostic method, follow up and findings) showed a
strong association with GERD and dental erosion so that inspection of the oral cavity
was recommended as a routine dental practice in these individuals (14).

Medical Treatment
Recommendations for treatment can range from lifestyle measures to medical and,
if necessary, surgical therapies. Initially if there are no alarm symptoms,
management consists of lifestyle modifications, antacids, alginates or histamine 2
receptor antagonists (H2RA) and/or proton-pump inhibitors (PPIs) (3).

See Additional Content: What are the dietary and/or lifestyle modifications currently
recommended to control the symptoms of gastroesophageal reflux disease (GERD)?

Practice guidelines also recognize the value of an empirical trial of proton-pump

inhibitors (1,3,7). Medical therapy is an eight-week course of PPIs with adjustment
of dosage and/or trial of different PPIs as needed (3). If symptoms return after
cessation of PPIs or if there is erosive esophagitis or Barretts esophagus, then
maintenance PPI therapy is used in the lowest possible dose to manage symptoms.
If there is no erosive disease patients may respond to H2-receptor antagonist
maintenance therapy. In some patients H2RAs may be used at bedtime in
combination with PPI therapy, but monitoring is needed for tachyphylaxis. The The
Royal College of Surgeons Association of Upper Gastrointestinal Surgeons guidelines
also include using alginate antacid combination/ H2RAs treatments for mild
heartburn (7).

Management in pregnancy includes use of antacids and alginates, and therapy with
PPIs (3). Information for safe drug use in pregnancy and lactation should be
discussed.

Surgical therapy is an option for long-term GERD patients but only if they have
responded positively to a trial of PPI therapy which is a predictor of surgical success
(15). Bariatric or gastric bypass surgery is the preferred option for individuals with
morbid obesity (3).

Key Resources for Professionals

Australia
Title: Gastro-oesophageal Reflux Disease in Adults Reflux Disease
Description: Information about gastrointestinal disorders, including reflux disease
for professionals and consumers from the Gastroenterological Society of Australia
(GESA).

Canada
Title: Guideline for the Treatment of Gastroesophgeal Reflux Disease in Adults
Description: Clinical practice guidelines for gastroesophageal reflux disease
(GERD) developed by the Alberta Medical Association, Alberta Health Services for
the treatment of GERD in adults.

Title: Canadian Consensus Conference on the Management of Gastroesophageal

Reflux Disease in Adults - Update 2004
Description: Consensus recommendations developed by a multidisciplinary group
of professionals on the treatment and management of reflux disease in adults.

Title: The Montreal Definition and Classification of Gastroesophageal Reflux

Disease: a Global Evidence-based Consensus
Description: A review of the development of a consensus definition and
classification of gastroesophageal disease for use by individuals with the disease,
physicians and regulatory agencies.

United Kingdom
Title: Commissioning Guide: Gastro-oesophageal Reflux Disease (GORD)
Description: A commissioning guide from the Royal College of Surgeons (RCS) on
gastro-oesophageal reflux disease.

United States
Title: Guidelines for the Diagnosis and Management of Gastroesophageal Reflux
Disease
Description: Guidelines from the American College of Gastroenterology on the
diagnosis and management of gastroespohageal relux disease in adults.

Additional Resources /Readings for the Professional

Title: Symptomatic Reflux Disease: The Past, the Present, and the Future
Description: A history of reflux disease published in Gut outlining the complicated
nature of the disease, its etiology, epidemiology, pathogenesis and current
treatments.

Other
Nil

References
1. Gastroenterological Society of Australia (GESA). Gastro-oesophageal Reflux
Disease in Adults Reflux Disease. 5th Edition. Digestive Health Foundation;
2011. Available from: http://www.gesa.org.au

2. Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R; Global Consensus Group.
The Montreal definition and classification of gastroesophageal reflux disease:
a global evidence-based consensus. Am J Gastroenterol. 2006
Aug;101(8):1900-20. Abstract available from:
https://www.ncbi.nlm.nih.gov/pubmed/16928254

3. Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of
gastroesophageal reflux disease. Am J Gastroenterol. 2013 Mar;108(3):308-
28. doi: 10.1038/ajg.2012.444. Abstract available from:
https://www.ncbi.nlm.nih.gov/pubmed/23419381

4. Alberta Medical Association, Alberta Health Services. TOP clinical practice

guideline - treatment of gastroesophageal reflux disease (GERD) in adults.
Updated 2009. Edmonton (AB): Toward Optimized Practice (TOP); 2009 [cited
2015 Jun 25]. Available from: http://www.topalbertadoctors.org/cpgs.php?
sid=14&cpg_cats=52

5. Boeckxstaens G, El-Serag HB, Smout AJ, Kahrilas PJ. Symptomatic reflux

disease: the present, the past and the future. Gut. 2014 Jul;63(7):1185-93.
doi: 10.1136/gutjnl-2013-306393. Epub 2014 Mar 7. Abstract available from:
https://www.ncbi.nlm.nih.gov/pubmed/24607936

6. Armstrong D, Marshall JK, Chiba N, Enns R, Fallone CA, Fass R, et al. Canadian
Consensus Conference on the management of gastroesophageal reflux
disease in adults - update 2004. Can J Gastroenterol. 2005;19(1):15-35.
Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/15685294

7. Royal College of Surgeons (RCS), Association of Upper Gastrointestinal

Surgeons (AUGIS). Commissioning guide: gastro-oesophageal reflux disease
 (GORD). 2013 [cited 2015 Jun 25]. Available from:
https://www.rcseng.ac.uk/healthcare-bodies/docs/published-guides/gord

8. Dent J, El-Serag HB, Wallander MA, Johansson S. Epidemiology of gastro-

oesophageal reflux disease: a systematic review. Gut. 2005 May;54(5):710-7.
Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/15831922

9. El-Serag HB, Sweet S, Winchester CC, Dent J. Update on the epidemiology of

gastro-oesophageal reflux disease: a systematic review. Gut. 2014
Jun;63(6):871-80. doi: 10.1136/gutjnl-2012-304269. Epub 2013 Jul 13.

10.Becher A, Dent J. Systematic review: ageing and gastro-oesophageal reflux

disease symptoms, oesophageal function and reflux oesophagitis. Aliment
Pharmacol Ther. 2011 Feb;33(4):44254. Abstract available from:
https://www.ncbi.nlm.nih.gov/pubmed/21138458

11.Singh S, Sharma AN, Murad MH, Buttar NS, El-Serag HB, Katzka DA, et al.
Central adiposity is associated with increased risk of esophageal
inflammation, metaplasia, and adenocarcinoma: a systematic review and
meta-analysis. Clin Gastroenterol Hepatol. 2013 Nov;11(11):1399-1412.e7.
doi: 10.1016/j.cgh.2013.05.009. Epub 2013 May 22. Abstract available from:
https://www.ncbi.nlm.nih.gov/pubmed/23707461

12.Rubenstein JH (Richter JE ed) Clinical prediction and screening for barrett

esophagus Gastroenterol Hepatol (NY). 2014 Mar;10(3):187-9. Abstract
available from: https://www.ncbi.nlm.nih.gov/pubmed/24829547

13.Becher A, El-Serag H. Systematic review: the association between

symptomatic response to proton pump inhibitors and health-related quality of
life in patients with gastro-oesophageal reflux disease. Aliment Pharmacol
Ther. 2011 Sep;34(6):618-27. Abstract available from:
https://www.ncbi.nlm.nih.gov/pubmed/21770991
 14.Milosevic A. Gastro-oesophageal reflux and dental erosion. Evid Based Dent.
2008; 9(2):54. doi: 10.1038/sj.ebd.6400586. Abstract available from:
https://www.ncbi.nlm.nih.gov/pubmed/18584008

15.Kim D, Velanovich V. Surgical treatment of GERD: where have we been and

where are we going? Gastroenterol Clin North Am 2014;43:135-45. Abstract
available from: http://dx.doi.org/10.1016/j.gtc.2013.12.002

Target Group: All Adults

Knowledge Pathways: Gastrointestinal System - Gastroesophageal/Gastro-oesophageal
Reflux Disease (GERD/GORD)
Last Updated: 2016-06-02

Evidence Summary

[C] The following conclusions are supported by limited evidence or expert

opinion:
A systematic review of RCTs, prospective cohort intervention studies and population-
based studies shows evidence for recommending weight loss to manage GERD
symptoms. However, given study limitations, additional longitudinal studies are
needed to examine the therapeutic value of weight loss.
A meta-analysis of observational studies also showed an association with increasing
BMI/obesity and GERD symptoms. Further research is needed to examine the effect
of increasing BMI on GERD symptoms.

Another systematic review of observational studies, and other observational

studies, examining the effect of overweight and obesity and prevalence of GERD
symptoms show there is an association between obesity and overweight (measured
by BMI and waist circumference) and GERD symptoms. Being overweight was an
independent predictor of GERD. Even though reflux symptoms were associated with
overweight and obese categories, there was insufficient or conflicting evidence that
weight loss improved GERD symptoms.

An intervention study provided limited evidence for a correlation between weight

loss and reduction of GERD symptoms.

Consensus-based clinical guidelines recommend weight loss in overweight or obese

patients with GERD to treat symptoms or prevent further complications.

Systematic reviews of observational studies and uncontrolled trials have identified

limited evidence that avoidance of dietary factors is a useful strategy to manage
symptoms. These studies have shown that exposure to alcohol, chocolate, high fat
meals, and carbonated beverages decreases lower esophageal sphincter (LES)
pressure.

A systematic review examined 14 studies to identify the relationship between

caffeine (and /or coffee) and GERD symptoms. Evidence was conflicting regarding
an effect of coffee or caffeine and GERD symptoms.

One RCT found physiological evidence for increased reflux with a late night meal.

Consensus-based clinical guidelines do not recommend general exclusion of

potential triggers of GERD symptoms from the diet for all individuals. There is
acknowledgement, however, that some individuals may experience improvement in
symptoms from avoiding dietary triggers specific to their experience.

The evidence is limited or conflicting regarding an effect of other lifestyle

interventions for management of GERD.

A case-control study examining elevation of head of bed (HOB) found effects

on physiologic measures and symptoms, while two RCTs showed conflicting
outcomes: one showed an improvement in acid exposure and the other did
not show better symptom relief.
 Three studies concluded that sleeping on the left side may avoid the
prolonged reflux time, acid clearance and LES relaxation, which were
significantly associated with sleeping on the right side in the right-lateral
decubitis (RLD) position.

The American and Australian Clinical guidelines make no recommendations

for smoking cessation as part of GERD treatment. The U.K. recommends that
all patients stop smoking, in spite of weak evidence. Twelve studies showed
tobacco worsened symptoms. Three intervention studies produced conflicting
outcomes: one showed a rise in LES pressure and three case-control studies
showed no effect on symptoms. A population-based study identified smoking
as a risk factor for GERD.

The relationship between physical activity and GERD is controversial, with

some observational studies suggesting a positive association between
vigorous exercise and GERD symptoms; however, mild-moderate exercise or
leisure time physical activity may protect against GERD symptoms.

Consensus-based clinical guidelines acknowledge that other lifestyle factors

elevating the HOB, RLD position and smoking may contribute to symptom
occurrence or management in GERD for individual patients.

[D] A conclusion is either not possible or extremely limited because

evidence is unavailable and/or of poor quality and/or is contradictory:
No published evidence was identified to indicate that dietary measures improve
GERD symptoms.

A systematic review (including a survey, an observational study and a case-control

study) identified that self-reported heartburn was associated with drinking citrus
juice; however, this was not supported by observational studies measuring
physiologic effect. No studies were found that examined GERD symptoms and
avoidance of citrus.

A systematic review (including a survey and a case-control study) identified self-

reported heartburn from spicy foods and that onion increased reflux episodes and
acid exposure. The review did not find any published studies that examined the
effect of eliminating spicy foods on GERD symptoms.

Note: See relevant practice questions in this knowledge pathway for references.
Target Group: All Adults
Knowledge Pathways: Gastrointestinal System - Gastroesophageal/Gastro-oesophageal
Reflux Disease (GERD/GORD)
Last Updated: 2016-06-02