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.
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.
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.
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?
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.
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 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.
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 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.
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 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
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