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The Progressive Stages of GERD

Young man with doctor
Laura Cox's picture
by Laura Cox December 5, 2012

About the progression of GERD

GERD is a long-term chronic condition that varies in severity.

Everyone starts off with a normal lower esophageal sphincter and no reflux. The severity of GERD probably correlates best with the degree of damage to the sphincter, but this is not easy to determine in practice. In general, the degree of damage to the sphincter correlates with severity of reflux (determined by the frequency, volume, and duration of reflux episodes). This, in turn, correlates (not completely accurate) with symptoms of GERD, such as heartburn and regurgitation

Like many diseases, GERD has several stages ranging from mild to life threatening.

Heartburn can be serious!

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It is likely that there is an early stage of lower esophageal sphincter damage that does not cause symptoms. At present, we do not have any way of detecting such early asymptomatic disease. By present criteria for the diagnosis of GERD, the disease is recognized only when symptoms arise.  In most people, the severity of GERD is assessed by the severity (frequency and duration) of heartburn and the presence of regurgitation. By using these clinical symptoms, RefluxMD has developed a method of assessing the severity of your GERD. This is what we describe here.

If you have GERD, your goal should be to contain your disease while improving the quality of your life.

You must understand that damage to your lower esophageal sphincter caused by GERD is permanent and cannot be reversed by any drugs. However, most patients with early stages of GERD can learn to live within the functional capability of a slightly damaged sphincter. What this means is that by changing certain simple things in your lifestyle (eating, sleeping) you can decrease or even prevent reflux episodes despite the presence of a damaged sphincter. This is a valuable objective.

GERD stages are best defined by symptoms in conjunction with tests such as endoscopy, pH testing, and biopsy. 

In general, though, these tests are not indicated in early stages of disease, except in special circumstances. RefluxMD will give you information regarding the appropriate time these tests become worth the effort, discomfort, and expense.

Learn more: What's your stage?

Stage 1 – Mild GERD

The majority of adults today have minor damage to their LES and experience mild GERD occasionally.  In most cases they either tolerate occasional heartburn or use over-the-counter acid suppressive medications with the onset of symptoms.  Because their symptoms are controlled quickly, easily, and inexpensively with these drugs, their quality of life is unaffected. 


Stage 1 Example

I am a 45-year-old man working as a traveling salesman for an auto parts company.  Because of my job I spend most of my time away from home and find myself eating fast food frequently.  I have gained 25 pounds over the past 20 years but consider myself healthy.  I started getting occasional episodes of discomfort under my breastbone about 10 years ago.  These lasted a short time and occurred almost always when I ate a double cheeseburger with fries and a large soda.  I used to ignore these but recently the episodes have become more severe, they last longer, and they are more frequent.  I now have these problems about twice a week.

Last week, I got up at night with a similar pain in my chest and I worried that I was having a heart attack.  The discomfort has increased and is now a burning pain that I think is heartburn.  I carry a packet of antacids in my pocket now and take a couple of these when I start getting the pain.  Fortunately, they control it very quickly and are inexpensive.  Now I take Tums before I eat a cheeseburger because I’ve found that this prevents my pain. My quality of life is pretty normal except that I worry that I have a disease that may be serious.  I have never experienced food regurgitation, I sleep lying flat in my bed, and I have never been to a physician.


What you can learn from this patient

There is one important thing in this story. This person opted to continue eating cheeseburgers because he learned that he can prevent heartburn by taking Tums before the meal. This is not a good choice. Though his heartburn is controlled, continuing to eat heavy meals rich in fat will likely increase the damage to his sphincter. In time, the Tums will not control his heartburn because his disease will progress as sphincter damage increases. A better choice for him would be to understand what is causing his disease and try to prevent his progression. Not eating the cheeseburger and replacing it with a smaller, less fatty meal will both prevent his heartburn AND decrease progression of his sphincter damage. The first course will take him to the higher stages with time; the second course will keep him in Stage 1 for a longer time - and hopefully for the rest of his life.

Learn more: What diet matters for ALL people with GERD

Stage 2 –Moderate GERD

Stage 2 GERD is more difficult to control with acid suppressive drugs and reflux is more frequently accompanied by higher intensity symptoms.  Damage to the LES is more extensive compared to Stage 1. Many symptoms can be satisfactorily managed long-term with acid suppressive medications.  Over-the-counter medications often provide inadequate relief, so prescription strength medications are necessary to manage symptoms.  Many sufferers can benefit from being treated by a knowledgeable GERD specialist. 


Stage 2 Example

I am a 43-year-old woman working as an executive in a commercial bank managing real estate loans.  My weight is in proportion to my height and I exercise several times each week to maintain my weight level.  I started getting heartburn during my second pregnancy seven years ago.  Although the symptoms decreased after my baby was born, they did not completely disappear.  In fact, over the last three years they have increased significantly.  I now get an episode almost every day, which is troubling to me. I am afraid to eat normally and have changed my eating habits.  I also wake up frequently at night with a pain in my chest that goes away quickly when I sit up.  I have tried a variety of acid suppressive drugs that I purchased at the pharmacy, but even the recommended dosage of Prilosec-OTC did not fully control my symptoms. I went to my family doctor who prescribed a stronger drug that I use daily and my symptoms have improved, but not resolved. I am still afraid of eating, and I sleep with two pillows to avoid the burning sensation I sometimes get at night.  I would say that my life is generally all right but not perfect.  I still have occasional episodes of regurgitation, but I don’t consider them to be too troublesome.  My family doctor has told me that there is nothing more that can be done for me. Surgery is the only alternative to drug treatment and my family doctor had little to offer concerning that alternative.  I have not seen a GERD specialist and have never had an endoscopic exam or any other testing for my problem.


What you can learn from this patient

This patient is an example of a person who is not uncommon in the population. She has GERD that is controlled by long term prescription strength proton pump inhibitors to a level that is tolerable. Her GERD affects her eating and sleeping habits, but she does not consider these intolerable because she can still continue with her normal life. The damage to her lower esophageal sphincter is likely to be significantly greater than in Stage 1. As long as the patient is comfortable with this level of control, RefluxMD does not recommend specialized testing for GERD.

Learn more: What you should know before taking PPIs

Stage 3 – Severe GERD

Stage 3 GERD results in a substantially lower quality of life and is considered to be a very serious problem by RefluxMD. Prescription level acid suppressive drugs do not control symptoms to the individual’s satisfaction and regurgitation is frequent.  It is also likely that one or more of the complications associated with erosive GERD may be present.  RefluxMD highly recommends a very thorough examination by a knowledgeable GERD specialist.


Stage 3 Example

I am a 52-year-old man and I work in a car dealership as a salesman. I am moderately overweight, but certainly not obese. I have had heartburn on and off for the past twenty years and until I was put on a prescription medication by my gastroenterologist, I experienced heartburn almost daily.  I have been to numerous physicians that have performed a variety of tests, including endoscopic evaluation of my throat.  Although my daily prescription acid suppressive drugs worked well for many years, over the last two years I have developed frequent regurgitation. I can no longer sleep in my bed and for nine months I’ve been forced to sleep in my recliner. I am afraid to eat knowing that I will develop heartburn followed by regurgitation. Last week I awoke in the middle of the night with an episode of coughing and shortness of breath. This really scared me because I thought I was suffocating. I spoke with my gastroenterologist the next day and he told me not to worry and recommended continuation of my prescription drugs. When I asked him about surgical options, he told me that he would prefer for me to continue with my current treatment plan.  He thought surgery was a “last resort” option and did not think it was necessary at this point.


What you can learn from this patient

This is a person who needs referral to a GERD specialist. There are two important reasons for this. Firstly, at this severity and duration of GERD, there is a significant risk that there is Barrett’s esophagus, a premalignant condition that can only be detected by an upper endoscopy and biopsy. Upper endoscopy is generally performed by a gastroenterologist, not by a family doctor or internist. Even if he has had an endoscopy in the past, it should be repeated to see if he has progressed to Barrett’s esophagus (Stage 4). Secondly, the patient is at the limit of effectiveness of drug treatment of GERD. Because his quality of life has declined to an extent that seems unacceptable, he should understand that drugs will never improve his condition and he should consider surgical repair of his sphincter. Some gastroenterologists have a negative perception of surgical repair of the sphincter, largely because surgical expertise for this procedure is variable in the community. In many patients like this, a successful anti-reflux procedure results in a dramatic improvement in the quality of life.

Learn more: Overview of antireflux surgical alternatives

Stage 4 – Pre-cancerous condition or reflux induced esophageal cancer

Stage 4 is the result of many years of severe reflux. 10-15% of long-term sufferers progress to this very advanced condition. Due to long-term reflux, the lining of the esophagus has been damaged, resulting in cellular changes. Interestingly, these changes may occur in some with only minimal symptoms. Stage 4 involves the development of a pre-cancerous condition called Barrett’s esophagus, or a more severe condition called dysplasia. These conditions are not cancers, but raise the risk of developing actual reflux-induced esophageal cancer. At this stage, typical GERD symptoms may also be accompanied by burning in the throat, chronic cough and hoarseness.  Strictures, or a narrowing of the esophagus, can also occur which is characterized by the sensation that food is sticking in the esophagus.  This same symptom can also be caused by esophageal cancer.  Stage 4 GERD can only be diagnosed with an endoscopic examination and a biopsy of cells taken in the lower esophagus.  RefluxMD highly recommends Stage 4 disease be cared for in an ongoing way by a knowledgeable GERD specialist.

Learn more: Inside your esophagus: The damage caused by GERD


Stage 4 Example

I am a 62-year-old male that retired two years ago.  I have had heartburn for fifteen years and my symptoms have been well controlled with acid suppressive drugs until last year when I experienced regurgitation that is getting worse monthly. I also developed a troublesome and constant cough and my voice has become hoarse.

Last month, my physician referred me to a gastroenterologist who performed an endoscopic examination on my throat and told me that I had Barrett’s esophagus.  He told me that while Barrett’s esophagus indicated an increased risk of cancer, the risk was very small and that I should not worry.  He increased my dosage of acid suppressive drugs and told me that I needed annual endoscopic examinations.  I asked him if I had any other options and he mentioned surgery.   However, he indicated that he would prefer to monitor me and, if necessary, he would suggest that alternative.


These examples are real!

Not everyone progresses to each stage of GERD, but you must treat your disease as if you will.  Do not ignore your symptoms - take them seriously.  Educate yourself on your disease, track and monitor your symptoms, try your best to prevent progression of your disease, not just control your symptoms, and stay vigilant!


Reviewed by: Dr. Chandrasoma, RefluxMD Scientific Director

Total votes: 265

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