GERD, or gastroesophageal reflux disease, is when reflux (backward flow) of stomach contents in the body causes symptoms or complications. While the stomach lining has protection against the effects of its own acid, the esophagus and upper gastrointestinal tract do not. The acid and the enzymes of digestion produced can cause damage when they are passed above the stomach level, and heartburn is the number one symptom, as well as pain and discomfort in the neck, throat and sometimes even the face. GERD may affect up to one in five adults, with half of those complaining of daily discomfort.
Most people with GERD have mild disease, but damage to the mucosal lining of the esophagus (also called reflux esophagitis) can occur in a third of cases and more serious complications may occur in others.
When functioning normally, food, enzymes and acid are prevented from flowing backward in the gastrointestinal tract by a ring-shaped muscle called the lower esophageal sphincter (LES). When a person is standing, all the contents naturally flow downward, so symptoms of GERD are minimized. That’s generally why heartburn is worse while lying down. Smoking and certain foods (chocolate is implicated) may also interfere with the sphincter muscle, making reflux worse. And reflux is worse after a meal, when the stomach is full and the acidity in trying to digest contents is highest.
As mentioned, heartburn is the primary symptom. It is worse up to an hour after meals and when lying down. The flow back of contents starts to transform or change normal cells in the esophagus, which leads to complications as will be mentioned below. The degree of heartburn doesn’t always correlate with the actual physical damage being done, so even mild symptoms can have striking and pathologic changes.
There are some unusual signs and symptoms of GERD, including cough, asthma, chronic pain and even chest pain. One of the more difficult differential diagnoses is with cardiac chest pain. Some people may feel pain that mimics a heart attack; others may actually be having angina or cardiac disease and dismiss the pain as heartburn. Physical signs and examination are usually normal in most people with GERD.
What are the major complications of GERD? Barrett’s esophagus is a condition in which the squamous epithelium of the normal esophagus is replaced by metaplastic cells. Some types of the metaplastic cells (usually specialized intestinal metaplasia type) go on to become esophageal adenocarcinoma—one of the most deadly gastro-intestinal cancers. One half of a percent of patients diagnosed with Barrett’s esophagus are diagnosed with adenocarcinoma each year. That’s a 40-fold increase in risk over those without Barrett’s, which emphasizes the need for prompt and ongoing treatment.
Another complication is peptic stricture, which is the gradual development of inability to swallow. This is progressive over months to years and may occur in 5 percent of affected people. The stricture is virtually a narrowing of the esophagus by scarring and may need to be manually dilated periodically with surgical instrumentation.
Medical treatment involves antacids and smaller amounts of non-acidic food if symptoms are mild. Antacids have been used for years, but are limited by their short (two hours or less) duration of action. Newer medicines include H2 receptor antagonists (many of the now over-the-counter formulations found in most pharmacies) or longer term therapy with proton pump inhibitors, which not only control heartburn symptoms but heal the erosive esophagitis in more than 80 percent. These are used for more extended periods of time or can be continual therapy. Surgical treatment (fundoplication) may be used when medical treatment is ineffective.
Most people with GERD have their symptoms well controlled and do not go on to develop serious disease or complications, resulting in both standard and preferred issues. Barrett’s esophagus may require a rating or rarely be declined, depending on how extensive it is and what the pathological changes are. In those cases, an underwriter may want to see results of endoscopy (a tube/endoscope inserted by the gastroenterologist to assess damage and healing and to biopsy if needed) to show healing and a good response to therapy.
Robert Goldstone, MD, FACE, FLMI
Goldstone, board certified internist and endocrinologist, is vice president and chief medical officer for Pacific Life and Pacific Life and Annuity. He has extensive brokerage and life insurance experience, having been medical director at both MetLife Brokerage and Transamerica Occidental Life. Goldstone is board certified in insurance medicine and the inaugural recipient of the W. John Elder Award for Insurance Medicine Journalism Excellence. He was also honored as a fellow of the prestigious American College of Endocrinology and has written monthly for Broker World since 1990. Goldstone can be reached by telephone at 949-420-8390. Email: firstname.lastname@example.org.