What is GERD commonly known in Singapore?

Gastroesophageal reflux disease or GERD is a common condition in Singapore where acidic content in your stomach frequently flows up into your oesophagus, the tube connecting your stomach to your mouth. This results in a “burning sensation” behind the chest wall that we often refer to as heartburn. 

What is the difference between Heartburn, Acid Reflux and GERD? 

Acid Reflux

A condition where the acidic contents of the stomach flow back into the oesophagus, causing symptoms like heartburn. 

GERD

When acid reflux is chronic and more severe, this will be classified as a medical condition, GERD. 

Heartburn

Heartburn is a symptom, not a condition in itself. The term “heartburn” refers to a burning sensation in the chest, which usually originates from the oesophagus and not from the heart. 

What are the common causes of GERD in Singapore?

Healthy Stomach

GERD

Acid goes up into your oesophagus when the Lower Oesophageal Sphincter (LES) relaxes abnormally or loosens. The LES regulates the flow of food content from the oesophagus into the stomach and prevents stomach acid from being pushed back into the oesophagus. 

Stomach acid backing up into the oesophagus is also known as acid reflux. When acid reflux occurs frequently or is more severe than usual, one has GERD.

Those at higher risk of developing GERD:

Obese

Pregnant

Have a hiatal hernia - when the top of your stomach bulges through the muscle separating your abdomen and chest

Have a connective tissue disorder

Behaviours or habits which increase the risk of developing GERD are:

Smoking

Eating large meals or eating late at night

Eating fatty, spicy or fried foods often

Drinking carbonated or acidic beverages often

Frequently taking certain medications such as progesterone, sedatives, or narcotics

These underlying conditions and behaviours cause the diaphragm to weaken or become less intact, which compromises the ability of the LES to prevent acid reflux. 

Eating large meals, in particular, causes distension or over-stretching of the upper stomach. This leads to insufficient pressure at the LES to prevent acid reflux.

Common Symptoms of GERD in Singapore

GERD can be broken down into four stages: Mild, Moderate, Severe and Precancer or Cancer. Each stage has different symptoms: 

Mild

A little acid reflux occurs once or twice a month, which may happen together with heartburn. Heartburn will feel like a burning pain behind the breastbone in the chest. 

The pain is usually tolerable and can be easily managed with painkillers. Over-the-counter acid reflux medication and lifestyle changes will be enough to ease symptoms.  

Moderate

Acid reflux and heartburn occur a lot more frequently, with increasing intensity. The pain can affect daily activities, and patients will need to be prescribed daily acid reflux medication as over-the-counter medication may not work anymore.

Severe

The symptoms are painful and do not ease even after medication is taken. Such symptoms include heartburn, chest pain, problems swallowing, regurgitation of food or stomach acid, persistent dry cough, and the chronic feeling of a lump in the throat. 

Quality of life is severely worsened, and your gastroenterologist may recommend surgery to treat GERD.

Cancer or precancer

Sometimes, GERD may also escalate into Barrett’s oesophagus, a condition where the oesophageal cells mutate into intestinal cells. Barrett's oesophagus predisposes to the development of adenocarcinoma of the oesophagus. Barrett’s oesophagus usually has no symptoms, but when developed from GERD, there may be additional symptoms present compared to the Severe stage:

• Swallowing becomes more painful
• Chronic sore throat
• Sour taste in the mouth 
• Bad breath
• Unexpected weight loss
• Bloody stools
• Vomiting

What is Barrett’s Oesophagus?

Barrett’s Oesophagus is a risk factor for cancer of the lower oesophagus. It is a condition where the oesophagus becomes damaged (thickens and reddens) as a serious complication of GERD and the chronic exposure to stomach acid. 

It is also important to note that generally, symptoms of Barrett’s Oesophagus are similar to normal acid reflux until the condition becomes severe. 

Is it GERD or something else?

Sometimes, the symptoms of GERD may overlap with other conditions or be described with confusing terminology. Some examples include heartburn and acid reflux. 

How is GERD diagnosed?

To diagnose GERD, your gastroenterologist requires more than a physical examination. Some tests recommended may include:

Gastroscopy

A gastroscopy, also known as an oesophago-gastro-duodenoscopy (OGD), allows the gastroenterologist to examine the upper gastrointestinal (GI) tract for any structural abnormalities. It involves the insertion of an endoscope into your throat and into the duodenum.

An endoscopy can also be used for a biopsy, where a small part of the oesophagus is collected and tested for other conditions such as Barrett’s Oesophagus or oesophageal cancer. 

A gastroscopy, also known as an oesophago-gastro-duodenoscopy (OGD), allows the gastroenterologist to examine the upper gastrointestinal (GI) tract for any structural abnormalities. It involves the insertion of an endoscope into your throat and into the duodenum.

An endoscopy can also be used for a biopsy, where a small part of the oesophagus is collected and tested for other conditions such as Barrett’s Oesophagus or oesophageal cancer. 

Ambulatory (24 hours) Esophageal pH Test

A catheter containing a pH probe is inserted via the nose and positioned 5cm above the LES for 24 hours to record changes in acid reflux with regard to your meals and other daily activity. 

If a catheter is too uncomfortable, your gastroenterologist may recommend a wireless capsule which is endoscopically inserted and positioned at the same location. Since the capsule can transmit data while attached, no retrieval process is needed, and it can be passed out, and then disposed of immediately after the test. 

Oesophageal Manometry

After numbing medication is applied, a catheter is inserted into the oesophagus via your nose. Then, your gastroenterologist will ask you to swallow small sips of water and a computer connected to the catheter will measure the speed, pattern and strength of your oesophageal muscle contractions.

X-Ray 

Barium pills or liquid are ingested, which allows the gastroenterologist to see a silhouette of your upper gastrointestinal tract on the X-ray. 

Can GERD be cured?

When factors like pregnancy or obesity are the primary trigger for GERD, GERD can be resolved when those factors are managed. 

Generally, surgery is only recommended when symptoms are not responding to the medications or complications such as cancer has occurred. Otherwise, medication can be prescribed along with proper lifestyle management. 

What are the treatments for GERD?

Lifestyle Changes

For those with mild GERD, lifestyle changes may easily help reverse the damage caused. These changes include:

• Quitting smoking
• Losing weight
• Eating smaller meals 
• Sitting upright for a few hours after every meal
• Avoiding alcohol intake
• Reducing pressure on the stomach

Foods to avoid:

• Fatty and oily food and beverage
• Spicy food
• Citruses 
• Carbonated drinks
• Tomato and tomato-based foods
• Fried food
• Onion and garlic
• Mint
• Chocolate
• Coffee

These foods are thought to worsen GERD by increasing the acidity of your stomach or irritating the oesophagus lining. Hence, it would be best to reduce your consumption of these foods if you have GERD.

Medication

When lifestyle and diet changes are not enough to cure GERD, your gastroenterologist may prescribe you medicines like Proton Pump Inhibitors (PPI), antacids or H2-receptor antagonists (H2RAs) to treat GERD. 

Proton Pump Inhibitors (PPI)

PPIs block and reduce the production of stomach acid, reduce the severity and frequency of acid reflux, and give the oesophageal tissue time to heal, reducing and preventing heartburn. 

Antacids

Antacids neutralise stomach acid, making the stomach contents less corrosive. This provides short-term relief for acid reflux.

Histamine 2 Receptor Antagonists (H2RAs)

H2RAs block the production of histamine on cells in the stomach. Histamines signal for the production of stomach acid. With H2RAs, stomach acid secreted will be reduced, which, in turn, reduces the effects of acid reflux. 

Surgery

When medication and lifestyle changes do not suffice to resolve GERD symptoms, surgery may be needed. 

Surgical therapy for GERD can be laparoscopic or endoscopic, which are less invasive compared to traditional open surgery. 

• Laparoscopic surgery – small incisions are made for surgical tools to be inserted into the body to carry out the surgery.
  • Nissen fundoplication:
    • Part of the upper stomach is wrapped around the LES, tightening the sphincter and preventing acid reflux.
  • Anterior fundoplication:
    • Similar to Nissen fundoplication, except the stomach only wraps around part of the oesophagus.
  • Magnetic sphincter augmentation (MSA)
    • A small device made of tiny magnetic titanium beads (LINX) is implanted into the sphincter, strengthening it.
  • Bariatric surgery
    • For obese patients
    • Helps reduce the size of meals they eat and the pressure on their stomachs.

• Endoscopic surgery (endoluminal therapy) – Surgical tools are attached to the endoscope, which is inserted into the oesophagus via the mouth.
  
  • Transoral incision-less fundoplication (TIF):
    • A TIF device is attached to the endoscope, which allows the doctor to repair or re-create the LES such that it becomes a stronger barrier against acid reflux.
      
  • Stretta Procedure
    • At the end of the endoscope, an electrode is attached and heats the oesophageal tissue to create tiny cuts in it. The tiny cuts scar the oesophagus, forming scar tissue that strengthen the surrounding muscles.

What complications can arise if GERD is left untreated?

While getting GERD does not inevitably lead to oesophageal cancer, allowing Barrett’s Oesophagus to develop from GERD will increase your risk of developing oesophageal cancer. 

Untreated GERD can lead to other complications such as oesophagitis, which is the inflammation of the oesophagus lining and will result in bleeding, ulcers and painful swallowing. 

Hence, if you suspect that you have GERD and are unable to resolve its symptoms with over-the-counter medications and lifestyle changes, do seek medical help.

When should I contact a Gastroenterologist? 

If you experience GERD symptoms such as chronic acid reflux, please consult your Gastroenterologist. More importantly, keep a lookout for these symptoms:

• Recurrent vomiting
• Difficulty swallowing
• Sudden weight loss for no reason
• Black stools or blood in stools (take a photo to show your gastroenterologist)

Upon seeing these symptoms, do contact your gastroenterologist at your earliest convenience, as they may be a sign that complications of GERD have set in. 

Summary

“GERD is a very common gastrointestinal condition that can often be treated with a combination of lifestyle modifications and medications. However, if your symptoms persist or if you have any of the red flag symptoms highlighted in the article, it is advisable to consult a Gastroenterologist for further evaluation”, advises Dr Benjamin Yip. 

A gastroscopy could be conducted to check for any structural abnormalities, such as the presence of erosions, ulcers or changes in the oesophagus. That being said, prevention is always better than cure. Small things you can do to prevent GERD include refraining from eating 2 hours before bedtime, quitting smoking, losing weight and refraining from alcohol. Doing these few things will decrease your risk of getting GERD.

References

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2. Fass, R. (n.d.). Causes of GERD. About GERD. Retrieved April 22, 2022, from https://aboutgerd.org/what-is/introduction-to-gerd/causes-of-gerd/
3. Gastroesophageal reflux disease (GERD) - Symptoms and causes. (2020, May 22). Mayo Clinic. Retrieved April 22, 2022, from https://www.mayoclinic.org/diseases-conditions/gerd/symptoms-causes/syc-20361940
4. Gastroesophageal Reflux Disease Symptoms, Diagnosis & Treatment. (n.d.). American Academy of Allergy, Asthma & Immunology. Retrieved April 22, 2022, from https://www.aaaai.org/Conditions-Treatments/related-conditions/gastroesophageal-reflux-disease
5. GERD: Can certain medications make it worse? (n.d.). Mayo Clinic. Retrieved April 22, 2022, from https://www.mayoclinic.org/diseases-conditions/gerd/expert-answers/heartburn-gerd/faq-20058535
6. GERD (Chronic Acid Reflux): Symptoms, Treatment, & Causes. (2019, December 6). Cleveland Clinic. Retrieved April 22, 2022, from https://my.clevelandclinic.org/health/diseases/17019-gerd-or-acid-reflux-or-heartburn-overview
7. Gotfried, J., & Katz, L. (n.d.). Ambulatory pH Monitoring - Gastrointestinal Disorders - MSD Manual Professional Edition. MSD Manuals. Retrieved April 26, 2022, from https://www.msdmanuals.com/en-sg/professional/gastrointestinal-disorders/diagnostic-and-therapeutic-gastrointestinal-procedures/ambulatory-ph-monitoring
8. H2 Receptor Antagonist (H2RA) and Proton Pump Inhibitors (PPI) - Chambers' Apothecary. (2016, August 29). Chambers Apothecary. Retrieved April 26, 2022, from https://www.chambersapothecary.com/blog/2016/08/29/h2-receptor-antagonist-h2ra-and-proton-pump-inhibitors-ppi/