Gastroesophageal reflux disease occurs when acid from your stomach goes up to your esophagus. GERD cough is a common symptom.
The initials GERD stand for gastroesophageal reflux disease. In this condition, an unusual amount of acid from the stomach goes up to the esophagus. Because the esophagus tissue is not built to resist an acid environment, the acid causes tissue damage as well as pain combined with other symptoms.
In very broad terms, the digestive system is a giant tube that begins in the mouth and ends in the rectum. All the parts of this tube are connected. The mouth unites with the pharynx, which connects with the esophagus that joins with the stomach that continues with the small intestines. This knowledge helps us understand why GERD causes not only digestive symptoms but respiratory symptoms as well, as the GERD cough. GERD is one of the most widespread causes of chronic cough in the world.
GERD is a very frequent disease; some studies suggest that it affects up to 40% of Americans at some point in their lives. And up to 10% of Americans experience daily GERD symptoms.
Experts estimate that a significant percentage of patients suffer from silent reflux; these patients have a higher risk of complications because they don’t receive treatment in time. Although GERD is prevalent in every age group, it is more frequent in those over the age of 40. There is no significant difference in frequency between genders.
What is the difference between acid reflux and GERD?
GERD is a more difficult sort of reflux. Acid reflux is moderate reflux of gastric acid (from the stomach) into the esophagus, which typically causes heartburn (a burning sensation in the chest). GERD is the chronic, more severe form of acid reflux in which symptoms occur more than two times a week.
What causes GERD?
Everybody experiences some degree of esophageal reflux after eating. Yet, when reflux events occur frequently, and the amount of acid involved is enough to cause esophageal injury, at that moment, is when GERD comes into play.
For many years, the medical community believed that GERD was a direct cause of a defect in the lower esophageal sphincter (LOES). This sphincter is what separates the stomach from the esophagus, and (in theory) it should stop stomach acid from moving back to the esophagus. Although LOES malfunction is, without a doubt, an essential component of the disease, it is not the only one involved.
A delayed stomach emptying, for example, causes more pressure to build into the stomach. This pressure can overcome the LOES causing harmful gastric acid to pour into the esophagus.
A hiatal hernia, in which the stomach bugles up through the diaphragm into the chest, can also cause GERD. Most Hiatal hernias are asymptomatic (do not cause any symptoms) and do not cause any problems; however, very big ones can cause heartburn and GERD symptoms. Obesity is also a significant risk factor in developing GERD. Still, the mechanism by which obesity promotes GERD is not fully understood.
What is GERD related chronic cough? Or the GERD cough?
Chronic cough is when (for whatever cause) a person has a persistent cough that lasts for more than eight weeks. Chronic cough causes are numerous; some are quite severe, and others are very easy to treat.
Many patients with GERD cough suffer from silent GERD from the GI standpoint. This means that they have dry cough as their only symptoms and do not feel gastrointestinal symptoms such as heartburn. Therefore, diagnosing GERD cough can be a challenge for most physicians.
There is a criterion that points towards GERD in chronic cough patients.
- No history of asthma or other respiratory diseases
- No history of smoking
- Not taking antihypertensive medication with ACE inhibitors
- Normal chest physical exam and normal chest Xray
It is essential to distinguish GERD cough from other causes such as asthma because the treatment is entirely different.
Regarding GERD cough, what is the connection between acid reflux and coughing?
Currently, gastroenterologists do not know for sure what mechanism is responsible for GERD-related chronic cough. Right now, there are two main theories.
The first theory is the reflux cough theory. According to this theory, reflux flows very high up in the esophagus, surpasses it, and becomes laryngopharyngeal reflux. Then, gastric acid goes into the larynx and into the lungs; this causes a cough reflex as a defense mechanism.
The second theory is the reflex theory. This one claims that, because the respiratory tract and the digestive tract have the same embryologic origin, esophageal irritation causes cough as a reflex. Some other studies show that cough is also promoting reflux leading to a cough reflux vicious cycle.
As you may imagine by now, GERD cough is a very complex problem.
What symptoms are associated with GERD cough?
Although cough or GERD cough is a fairly common GERD symptom, it is not the only one nor the GERD hallmark sign.
Other common symptoms include:
- Heartburn: It is the most common symptom. This is a sensation of burning and discomfort behind the sternum, in the middle of the chest; it usually occurs when lying down or after eating. In some cases, reflux pain is so intense that it resembles a heart attack.
- Regurgitation: The return of gastric contents into the pharynx (this would be in the back of your mouth).
- Dysphagia: It is an unpleasant sensation while eating. Patients express dysphagia due to GERD as a feeling of having food stuck inside their throat.
- Hoarseness: Caused by vocal cord irritation due to regurgitation.
What’s the difference between indigestion and heartburn?
Although colloquially, both terms are often used interchangeably, heartburn and indigestion are two different things.
The medical term for what people usually call indigestion is actually dyspepsia. Dyspepsia is a painful or uncomfortable feeling in the upper part of the abdomen that can appear during or after meals.
Dyspepsia or indigestion is often the result of eating too much, talking while eating (swallowing air), or eating foods that you don’t use to, such as fatty meals, alcoholic or caffeinated drinks. Smoking is also a frequent indigestion trigger. Other indigestion symptoms may include things like nausea, vomiting, bloating, gas, and diarrhea.
On the other hand, heartburn is the result of acid reflux burning the walls of your esophagus. It does not receive the name of bloating but rather an uncomfortable, burning sensation in the chest.
Confusion between both terms probably comes from the fact that both conditions have very similar triggers. Important heartburn triggers also include substantial fatty meals, heavy alcohol drinking, caffeine consumption, and smoking. Unlike indigestion, heartburn rarely comes with gas, diarrhea, and bloating.
Besides GERD cough, what are the complications of GERD?
Unlike stomach cells, esophagus cells are not build to resist constant exposure to gastric acid. Therefore, if GERD goes untreated for too long, complications will inevitably arise.
Esophagitis is the most common GERD complication; it happens in more than 50% of GERD patients. It has different degrees of severity. The Savary-Miller classification divides these degrees of severity into four different grades:
- I Grade: It is the lowest degree of severity; in the upper GI endoscopy, the esophagus appears a little more red than usual.
- II Grade: In the stage, some linear erosions begin to appear on the surface of the esophagus.
- III Grade: In this stage, the eruptions that appeared in grade II begin to get bigger and bigger, acquiring a circular or confluent shape.
- IV Grade: It is the most severe stage.
In stage four, there are two different possibilities; the patient can develop esophageal strictures or Barret’s esophagus.
Strictures are a consequence of chronic injury and abnormal scarring. In advanced GERD cases, scarring tissue forms strictures that narrow the esophagus, making it more difficult for food to go through it. Consequently, it causes symptoms like difficulty swallowing and/or chest pain while eating.
Barret’s esophagus is the result of chronic exposure to gastric acid. In this stage, the esophagus surface cells transform into stomach cells ( more or less) as an adaptative mechanism to resist acid exposure. Although this may sound like a good defense mechanism, it is a precancerous change. Having Barret’s esophagus increases the risk of suffering from esophageal cancer. Specifically, esophageal adenocarcinoma.
How is someone diagnosed with GERD?
The gold standard for GERD diagnosis is upper gastrointestinal tract endoscopy (upper GI endoscopy). An upper GI endoscopy is a medical procedure performed under sedation.
In this procedure, the gastroenterologist will introduce a special tube with a small camera in it through your mouth, down through your esophagus all the way up to your stomach and the proximal part of your intestines.
Through this camera, the gastroenterologist can see the extent of the damage due to GERD (esophagitis, strictures, Barret’s esophagus, etc.). It can also aid in discarding other conditions that cause similar symptoms like peptic ulcer disease and gastritis.
During the procedure, the doctor will also take a biopsy sample from several places of the esophagus and stomach to observe under the microscope. This way, he will rule out Helicobacter pylori infection or confirm Barret’s esophagus diagnosis.
Esophageal manometry is another important test in GERD. This exam tests the strength of the lower esophageal sphincter and the peristalsis (esophagus’ movements) in both the distal esophagus (closer to the stomach) and the proximal esophagus (closer to the pharynx).
Not every patient needs an esophageal manometry, only those who meet one or more of the following criteria:
- Persistence of symptoms weeks after the beginning of treatment.
- Those requiring a diagnosis confirmation before surgery
- Presence of atypical symptoms such as chest pain or asthma in patients with a normal upper GI endoscopy.
- Recurrence of symptoms after finishing treatment
Ambulatory Ph monitoring quantifies the gastroesophageal reflux over 24 hours to correlate it with the occurrence of reflux symptoms. Patients with evidence of esophagitis in an upper GI endoscopy do not need this test. A chest X-ray might be useful to detect lung abnormalities in patients with cough and to detect Hiatal hernias.
What is the treatment for GERD?
The treatment has three main objectives, improving symptoms, healing esophagitis, and preventing complications like esophageal cancer and strictures. GERD treatment basically consists of decreasing acid production in the stomach.
Nowadays, we have many different drugs capable of achieving this task. However, since the 1980s, proton pump inhibitors have become the standard of care.
Some drug groups commonly used in GERD include:
- Antiacids: Antiacids are basic substances that do not prevent acid secretion. They neutralize it because of their basic properties. Hence, they should be taken immediately after meals and before bedtime. These drugs are still quite popular for treating mild heartburn; nevertheless, they are not as potent as other drugs that stop acid secretion rather than neutralizing it. Side effects are rare and include constipation and diarrhea.
- H2 receptor antagonists: Some examples include cimetidine, ranitidine, and famotidine. These drugs prevent the production of gastric acid rather than just neutralizing it. These drugs are effective for mild esophagitis and to provide maintaining therapy is healed patients to avoid relapse.
- Proton pump inhibitors: Drugs like omeprazole, esomeprazole, lansoprazole are the most effective drugs in the therapeutic arsenal for GERD treatment. Several clinical trials have proven that proton pump inhibitors are superior to H2 receptor antagonists. They resolve GERD symptoms within four weeks after the beginning of treatment and heal mild to moderate esophagitis after eight weeks. However, long-term use of proton pump inhibitors can lead to renal injury, interfere with calcium metabolism, cause cardiac arrhythmias, and increase the risk of having community-acquired pneumonia.
Does GERD ever require surgery?
More than 80% of patients have a nonprogressive form of the disease that heals with medication only. However, the other 20% suffer from a progressive form of the disease with a high potential for complications. Patients that develop complications like Barret’s esophagus and strictures should receive surgical treatment.
Many decades ago, GERD surgery was dangerous and rarely effective. Nowadays, procedures have come a long way, and GERD surgery has become both safe and effective.
The most common GERD surgery nowadays is Nissen fundoplication. The idea of Nissen fundoplication is to reinforce the lower esophageal sphincter. In the procedure, the surgeon binds the upper part of the stomach around the lower part of the esophagus. This strengthens the lower esophageal sphincter making it harder for acid reflux to occur.
There are two ways of doing a fundoplication, open transabdominal surgery, and through laparoscopic surgery. Lately, laparoscopic surgery has gained a lot of popularity because it decreases how long a patient stays under anesthesia and has a shorter recovery time.
Indications for GERD surgery include the following:
- Patients in which proton pump inhibitor therapy does not improve the symptoms
- Presence of Barret’s esophagus
- Presence of extraesophageal manifestations, like sore throat, cough, and hoarseness
- Patient with heart arrhythmias in which pump inhibitor therapy might lead to complications
- Postmenopausal women with osteoporosis
- Young patients
- Poor compliance with medical therapy
Except for the presence of Barret’s esophagus, all of these indications are relative. This means that the presence of any of these factors is not a definitive indication for surgery. Your doctor will assess all the factors involved. Then, the doctor will make the final decision balancing risks and benefits in each particular case.
What foods are bad for GERD?
Lifestyle modifications are as important in GERD management as pharmacologic therapy; one does not work without the other.
Some foods to avoid:
- High-fat meals and fatty foods: Fatty foods tend to delay stomach emptying, which increases gastric pressure and increases the risk for reflux events. Some examples include complete milk, ice cream, french fries, potato chips, butter, salad dressings, cheese, high-fat cuts of red milk (prime rib, for example).
- Spicy foods: This one is a controversial subject. Although logic might indicate that spicy foods worsen acid reflux symptoms, some authors suggest that capsaicin (the ingredient that turns chilly spicy) might actually improve acid reflux symptoms. In the end, it is up to you to assess your own spice tolerance.
- Fruits: Although fruits generally are good for your overall health, some specific fruits can worsen GERD symptoms. Citric fruits like oranges, lemons, limes, and grapefruit contain acid. Tomatoes and all derivates such as sauces and dips can also worsen GERD symptoms because they have a certain acid level. Garlic and onions are also not recommended.
- Beverages: Some beverages you should certainly avoid would be alcoholic drinks, coffee, tea and infusions, and carbonated beverages (like soda, for example).
Are there other lifestyle modifications beyond diet that help with GERD?
Other useful tips include:
- Losing weight (if overweight)
- Avoiding large meals
- Do not lie immediately after a meal; wait at least three hours
- Elevating the head of the bed
- Avoid eating within three hours of going to bed
Do you have a GERD cough or other symptoms?
This tool is a GERD Symptoms Checker. It gathers the most important signs, symptoms, and risk factors for this disease. Therefore, the tool will tell anybody who uses it the likelihood of their symptoms because of Gastroesophageal reflux disease. Using this tool is free and would only take a few minutes.