Risk factors

Conditions that cause difficulty with digestion can increase the risk of heartburn. These include:

• Obesity
• Excess weight puts extra pressure on your stomach and diaphragm — the large muscle that separates your chest and abdomen — forcing open the lower esophageal sphincter and allowing stomach acids to back up into your esophagus. Eating very large meals or meals high in fat may cause similar effects.
• Hiatal hernia
  
• If this protrusion of part of your stomach into your lower chest is large, it can worsen heartburn by further weakening the lower esophageal sphincter muscle.
• Pregnancy
  
• Pregnancy results in greater pressure on the stomach and a higher production of the hormone progesterone. This hormone relaxes many of your muscles, including the lower esophageal sphincter.
• Asthma
  
• Doctors aren't certain of the exact relationship between asthma and heartburn. It may be that coughing and difficulty exhaling lead to pressure changes in your chest and abdomen, triggering regurgitation of stomach acid into your esophagus. Some asthma medications that widen (dilate) airways may also relax the lower esophageal sphincter and allow reflux. Or it's possible that the acid reflux that causes heartburn may worsen asthma symptoms. For example, you may inhale small amounts of the digestive juices from your esophagus and pharynx, damaging lung airways.
• Diabetes
  
• One of the many complications of diabetes is gastroparesis, a disorder in which your stomach takes too long to empty. If left in your stomach too long, stomach contents can regurgitate into your esophagus and cause heartburn.
• Gastric outlet obstruction
  
• This is a partial blockage caused by scarring, an ulcer or a growth near the valve (pylorus) in the stomach that controls the flow of food into the small intestine. It can keep this valve from working properly or can obstruct the release of food from the stomach. Food doesn't empty from your stomach as fast as it should, causing stomach acid to build up and back up into your esophagus. This usually causes more signs and symptoms than just heartburn, such as abdominal pain, difficulty eating, weight loss, nausea and vomiting. If you experience any of these signs and symptoms, consult your doctor.
• Delayed stomach emptying
  
• In addition to diabetes or an ulcer, abnormal nerve or muscle functions can delay emptying of your stomach, causing acid backup into the esophagus. Medications may also lead to delayed stomach emptying. These include narcotics, some antidepressants and antihistamines.
• Connective tissue disorders. Diseases such as scleroderma that cause muscular tissue to thicken and swell can keep digestive muscles from relaxing and contracting as they should, allowing acid reflux.
• Zollinger-Ellison syndrome. One of the complications of this rare disorder is that your stomach produces extremely high amounts of acid, increasing the risk of acid reflux.

Emptying of the stomach

Most reflux during the day occurs after meals. This reflux probably is due to transient LES relaxations that are caused by distention of the stomach with food. A minority of patients with GERD, about 20%, has been found to have stomachs that empty abnormally slowly after a meal. The slower emptying of the stomach prolongs the distention of the stomach with food after meals. Therefore, the slower emptying prolongs the period of time during which reflux is more likely to occur.

Esophageal contractions

As previously mentioned, swallows are important in eliminating acid in the esophagus. Swallowing causes a ring-like wave of contraction of the esophageal muscles, which narrows the lumen (inner cavity) of the esophagus. The contraction, referred to as peristalsis, begins in the upper esophagus and travels to the lower esophagus. It pushes food, saliva, and whatever else is in the esophagus into the stomach.

When the wave of contraction is defective, refluxed acid is not pushed back into the stomach. In patients with GERD, several abnormalities of contraction have been described. For example, waves of contraction may not begin after each swallow or the waves of contraction may die out before they reach the stomach. Also, the pressure generated by the contractions may be too weak to push the acid back into the stomach. Such abnormalities of contraction, which reduce the clearance of acid from the esophagus, are found frequently in patients with GERD. In fact, they are found most frequently in those patients with the most severe GERD. The effects of abnormal esophageal contractions would be expected to be worse at night when gravity is not helping to return refluxed acid to the stomach. Note that smoking also substantially reduces the clearance of acid from the esophagus. This effect continues for at least 6 hours after the last cigarette.

Hiatal hernia

Hiatal hernias contribute to reflux, although the way in which they contribute is not clear. A majority of patients with GERD have hiatal hernias, but many do not. Therefore, it is not necessary to have a hiatal hernia in order to have GERD. Moreover, many people have hiatal hernias but do not have GERD. It is not known for certain how or why hiatal hernias develop.

Normally, the LES is located at the same level where the esophagus passes from the chest through the diaphragm and into the abdomen. (The diaphragm is a muscular, horizontal partition that separates the chest from the abdomen.) When there is a hiatal hernia, a small part of the upper stomach that attaches to the esophagus pushes up through the diaphragm. As a result, a small part of the stomach and the LES come to lie in the chest, and the LES is no longer at the level of the diaphragm.

It appears that the diaphragm that surrounds the LES is important in preventing reflux. That is, in individuals without hiatal hernias, the diaphragm surrounding the esophagus is continuously contracted, but then relaxes with swallows, just like the LES. Note that the effects of the LES and diaphragm occur at the same location in patients without hiatal hernias. Therefore, the barrier to reflux is equal to the sum of the pressures generated by the LES and the diaphragm. When the LES moves into the chest with a hiatal hernia, the diaphragm and the LES continue to exert their pressures and barrier effect. However, they now do so at different locations. Consequently, the pressures are no longer additive. Instead, a single, high-pressure barrier to reflux is replaced by two barriers of lower pressure, and reflux thus occurs more easily. So, decreasing the pressure barrier is one way that an hiatal hernia can contribute to reflux.

There is a second way in which hiatal hernias might contribute to reflux. When a hiatal hernia is present, there is a hernial sac, which is a small pouch of stomach above the diaphragm. The sac is pinched off from the esophagus above by the LES and from the stomach below by the diaphragm. What's important about this situation is that the sac can trap acid that comes from the stomach. This trap keeps the acid close to the esophagus. As a result, it is easier for the acid to reflux when the LES relaxes with a swallow or a transient relaxation.

Finally, there is a third way in which hiatal hernias might contribute to reflux. The esophagus normally joins the stomach obliquely, which means not straight on or at a 90-degree angle. Due to this oblique angle of entry, a flap of tissue is formed between the stomach and esophagus. This flap of tissue is believed to act like a valve, shutting off the esophagus from the stomach and preventing reflux. When there is a hiatal hernia, the entry of the esophagus into the stomach is pulled up into the chest. Therefore, the valve-like flap is distorted or disappears and it no longer can help prevent reflux.

Lower esophageal sphincter

The action of the lower esophageal sphincter (LES) is perhaps the most important factor (mechanism) for preventing reflux. The esophagus is a muscular tube that extends from the lower throat to the stomach. The LES is a specialized ring of muscle that surrounds the lower-most end of the esophagus where it joins the stomach. The muscle that makes up the LES is active most of the time. This means that it is contracting and closing off the passage from the esophagus into the stomach. This closing of the passage prevents reflux. When food or saliva is swallowed, the LES relaxes for a few seconds to allow the food or saliva to pass from the esophagus into the stomach, and then it closes again.

Several different abnormalities of the LES have been found in patients with GERD. Two of them involve the function of the LES. The first is abnormally weak contraction of the LES, which reduces its ability to prevent reflux. The second is abnormal relaxations of the LES, called transient LES relaxations. They are abnormal in that they do not accompany swallows and they last for a long time, up to several minutes. These prolonged relaxations allow reflux to occur more easily. The transient LES relaxations occur in patients with GERD most commonly after meals when the stomach is distended with food. Transient LES relaxations also occur in individuals without GERD, but they are infrequent.

The most recently-described abnormality in patients with GERD is laxity of the LES. Specifically, similar distending pressures open the LES more in patients with GERD than in individuals without GERD. At least theoretically, this would allow easier opening of the LES and/or greater backward flow of acid into the esophagus when the LES is open.

What causes GERD?

The cause of GERD is complex. There probably are multiple causes, and different causes may be operative in different individuals or even in the same individual at various times. A small number of patients with GERD produce abnormally large amounts of acid, but this is uncommon and not a contributing factor in the vast majority of patients. The factors that contribute to causing GERD are the lower esophageal sphincter, hiatal hernias, esophageal contractions, and emptying of the stomach.