Gastroesophageal Reflux Disease

GERDGastroesophageal reflux disease (reflux, GERD) occurs when the stomach’s acidic liquid contents “backflow” upward into the esophagus, towards the mouth and throat. This usually occurs due to either slowed propulsion of food through the GI tract (slow motility), or failure of the lower esophageal sphincter (LES) muscle to act as a valve preventing backward flow from the stomach to the esophagus. While usually infrequent and mild, GERD may cause inflammation of the lining of the lower esophagus (esophagitis) in some, possibly leading to a pre-cancerous condition called Barrett esophagus.

Symptoms of reflux include heartburn, food regurgitating upwards, nausea, vomiting, and/or pain upon swallowing. Not uncommonly, the refluxed, partially digested food at the back of the throat aspirates into lungs/throat/mouth/sinuses, triggering (nighttime) cough and/or nasal stuffiness, wheezing/asthma, hoarseness, sore throat (especially after eating), chest pain or dental erosions. About half of patients have inflammation of the lower esophagus (esophagitis). On occasion, this inflammation can lead to scarring/narrowing of the lower esophagus (stricture) and may require dilation/opening. Reflux-induced esophagitis differs from, but may occur with, eosinophilic esophagitis due to food allergy.

While the diagnosis is often made by symptoms, it is recommended more chronic/recurrent sufferers obtain endoscopy (camera study and biopsy) of the esophagus, stomach and initial portion of the small intestine to rule out other conditions (stricture, ulcer, gastritis, more serious conditions) and to evaluate for Barrett esophagus. During the endoscopy study, the LES closing pressure is measured: treatment may vary somewhat for those with slow motility (delayed gastric emptying) versus a weak or abnormal LES.

Management of GERD includes non-medical recommendations made in both Western and Eastern medicines: loose weight if overweight; favor small, frequent, lower-fat meals rather than large meals; avoid laying supine for at least 3-4 hours after meals; take only liquids by mouth for 4 hours before bed; elevate the head of the bed on blocks 8 inches; and avoid bending/stooping after meals. Since reflux occurs when the LES opens up/loosens, foods/agents that open/loosen the LES muscle should be avoided – especially alcohol, caffeine, nicotine, chocolate and peppermint. Acidic foods, like citrus and tomato products also should be avoided. Eastern medicine has an additional concept of easily digested foods, which loosely correlates to “low residue foods” in the West (but includes fiber from all cooked vegetables and legumes); these should be favored to prevent taxing the digestive system. Certain medications, especially progesterone, nitrates, anticholinergics (like those for bladder spasm), anti-hypertensives (calcium channel blockers like Norvasc) and those for asthma (albuterol) can all also relax the LES and cause reflux.

Pharmaceuticals for GERD are well known to most and available over the counter: antacids (TUMS, Rolaids), H2 antagonists (Zantac, Tagamet, etc), proton pump inhibitors (Pepcid, Prevacid, Nexium), and occasionally agents that increase gut motility to move food along (used less today). For some patients with severe disease and/or Barrett esophagus, surgical treatment may be an option.[1]

In Traditional Chinese Medicine (TCM), GERD may have several patterned etiologies. The mildest, most common form correlates to “Rebellious Stomach Qi”. Slow motility type, especially when accompanying irritable bowel syndrome may relate to “Liver Qi Invading Stomach”; esophagitis or gastritis will demonstrate “Stomach Heat” on TCM physical examination. Acupuncture is especially helpful for starting to “bring down” the “Rebellious Stomach Qi”; Chinese Herbal Medicine addresses “Stomach Heat” as well as the “Liver Qi’ responsible for motility. As mentioned above, dietary modification is imperative: dietary modifications as recommended in Ayurveda (medicine of India) teach that eating tasty, easily digested food avoids overtaxing the digestive mechanism so that that “Digestive Ability” remains strong, thus preventing stomach and esophageal abnormalities.[2, 3]

Learn more about Gastroesophageal Reflux Disease/Heartburn
Learn more about Barrett Esophagus


These brief overviews of conditions represent distillations of basic and current medical reviews from the following sources:

[1]    Conventional Medical Sources

“Harrison’s Principles of Internal Medicine: Volumes 1 and 2, 18th Edition”. Dan Longo Anthony Fauci, Dennis Kasper, Stephen Hauser, J. Jameson, Joseph Loscalzo. McGraw-Hill Professional; (July, 2011)

Medscape eMedicine Physician’s online resource. Various review articles accessed March 2014

Irritable Bowel Syndrome
Jenifer K Lehrer, MD Attending Physician, Department of Gastroenterology and Hepatology, Aria Health System, Philadelphia

Inflammatory Bowel Disease
William A Rowe, MD  President, Gastroenterology Associates of Central Pennsylvania, PC; Manager, Endoscopy Center of Central Pennsylvania, LLC; Clinical Associate Professor of Surgery, Division of Colon and Rectal Surgery, Milton S Hershey Medical Center, Pennsylvania State University College of Medicine

Gastroesophageal Reflux Disease
Marco G Patti, MD  Professor of Surgery, Director, Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine

Biliary (Gallbladder) Disease
Annie T Chemmanur, MD  Attending Physician, Metrowest Medical Center and University of Massachusetts Memorial Hospital, Marlborough Campus

 [2], [3]   

“Acupuncture Energetics: A Clinical Approach for Physicians”. Joseph M. Helms. Medical Acupuncture Publishers; 1st Edition. (1995)

  • “Foundations of Chinese Medicine: A Comprehensive Text for Acupuncturists and Herbalists”. Giovanni Maciocia. Churchill Livingstone; 2 Edition (July, 2005).
  • “Diagnosis in Chinese Medicine: A Comprehensive Guide”. Giovanni Maciocia. Churchill Livingstone; 1st Edition (January, 2004).

4. “Chinese Scalp Acupuncture”. Jason Ji-shun Hao, Linda Ling-zhi Hao and Honora Lee Wolfe. Blue Poppy Press; 1st Edition. (November, 2011)

5. Vazquez-Roque MI, Camilleri M, Smyrk T, Murray JA, Marietta E, O’Neill J, et al. A Controlled Trial of Gluten-Free Diet in Patients with Irritable Bowel Syndrome-Diarrhea: Effects on Bowel Frequency and Intestinal Function. Gastroenterology. Jan 25 2013;[Medline].

6. Yamini D, Pimentel M. Irritable bowel syndrome and small intestinal bacterial overgrowth. J Clin Gastroenterol. 2010;44:672-675.

7 Kassinen A, Krogius-Kurikka L, Mäkivuokko H, Rinttilä T, Paulin L, Corander J, et al. The fecal microbiota of irritable bowel syndrome patients differs significantly from that of healthy subjects. Gastroenterology. Jul 2007;133(1):24-33. [Medline].

8 Rioux JD, Xavier RJ, Taylor KD, Silverberg MS, Goyette P, Huett A, et al. Genome-wide association study identifies new susceptibility loci for Crohn disease and implicates autophagy in disease pathogenesis. Nat Genet. May 2007;39(5):596-604. [Medline]. [Full Text].

9 Evans PR1, Bak YT, Dowsett JF, Smith RC, Kellow JE. Small bowel dysmotility in patients with postcholecystectomy sphincter of Oddi dysfunction. Dig Dis Sci. 1997 Jul;42(7):1507-12.

10 Mohammad Reza Farahmandfar1, Mohsen Chabok, Michael Alade1, Amina Bouhelal, Bijendra Patel. Post Cholecystectomy Diarrhoea—A Systematic Review. Surgical Science, 2012, 3, 332-338 Published Online June 2012 (