Causes and Risk Factors of Gastroesophageal Reflux Disease (GERD)

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Gastroesophageal reflux disease (GERD) is caused by reflux of stomach acid into the esophagus when your lower esophageal sphincter (LES) is either weak or it relaxes when it shouldn't. Other potential causes can include obesity, smoking, diet, and pregnancy, among others. GERD can also be due to various conditions, including abnormal biologic or structural factors. If you suffer from frequent heartburn, it's important that you consult with your physician to find the cause of your acid reflux and agree on a treatment plan.

GERD causes and risk factors
© Verywell, 2018 

Common Causes

There are a number of factors that can cause GERD. Sometimes the cause of your GERD can be complex and involve multiple factors.

Malfunctioning Lower Esophageal Sphincter (LES): In most sufferers, acid reflux is due to a relaxation of the LES, which is responsible for closing and opening the lower end of the esophagus and acts as a pressure barrier against the contents of the stomach. If it's weak or loses tone, the LES will not close completely after food passes into your stomach. Stomach acid can then back up into your esophagus.

The esophagus lining isn't the same as that of the stomach and isn't able to cope with acid as well, so it's easily injured. It is this reflux of acid into the esophagus that produces symptoms and potential damage to it. Sometimes this malfunction is structural, but certain foods and beverages, drugs, and other factors can weaken the LES and impair its function.

Obesity: Being obese increases the pressure on your abdomen, making GERD symptoms worse. The exact link between GERD and obesity isn't fully understood, but being obese is considered both a potential cause and a risk factor for developing GERD.

Medications: There are various drugs that can affect one's risk of GERD and worsening symptoms.

Nonsteroidal anti-inflammatory drugs (NSAIDs) include aspirin, Motrin or Advil (ibuprofen), and Aleve (naproxen), and gastrointestinal side effects are common when taking them. These medications are usually associated with causing peptic ulcers, and can also make heartburn and esophageal irritation worse, perhaps by weakening or relaxing the LES. 

In people who already have GERD, these medications may increase the severity of symptoms; in people who don't, long-term use of NSAIDs may contribute to developing GERD.

Certain prescription drugs may also cause or worsen the symptoms of GERD. It's important to consult your doctor if you start experiencing any symptoms while on medication. Here are some common culprits:

  • Calcium channel blockers, used to treat high blood pressure and heart disease
  • Anticholinergics, used in drugs that treat urinary tract disorders, allergies, and glaucoma
  • Beta-adrenergic agonists, used for asthma and obstructive lung diseases
  • Tricyclic antidepressants such as amitriptyline, Tofranil (imipramine), and Pamelor (nortriptyline)
  • Antihistamines, used for allergies
  • Prescription painkillers like codeine and medications containing acetaminophen and hydrocodone
  • Progesterone
  • Quinidine, an antimalarial drug used to treat heart arrhythmias and malaria
  • Sedatives and benzodiazepines, such as Valium (diazepam)
  • Theophylline, used in bronchodilators for asthma, chronic bronchitis, and other lung diseases
  • Diazepam, used to treat seizures
  • Dopamine, used in Parkinson's disease
  • Bisphosphonates used to treat osteoporosis
  • Antibiotics, like tetracycline
  • Potassium supplements
  • Iron supplements

Smoking: Smoking or breathing in secondhand smoke is also considered both a cause and a risk factor for developing GERD. There are many ways in which smoking can lead to heartburn, such as decreasing the amount of saliva you produce, causing your stomach to empty more slowly, and creating more stomach acid. Smoking cessation is probably one of the best things you can do to lessen your symptoms or lower your risk of developing reflux in the first place.

Hiatal Hernia: A hiatal hernia occurs when the upper part of your stomach is above the diaphragm, the muscle wall that separates the stomach from the chest. This lowers the pressure on the LES, which causes reflux. A hiatal hernia can happen in people of any age; many otherwise healthy people over 50 have a small one.

Impaired Stomach Function: Those with GERD may have abnormal nerve or muscle function in the stomach which, in turn, causes food and stomach acid to be digested too slowly. This causes a delay in the stomach emptying its contents, raising pressure inside it and increasing the risk of acid reflux.

Motility Abnormalities: In normal digestion, food is moved through the digestive tract by rhythmic contractions called peristalsis. If you suffer from a digestive motility abnormality, these contractions are abnormal. This abnormality can be due to one of two causes: A problem within the muscle itself, or a problem with the nerves or hormones that control the muscle's contractions. Problems in peristalsis in the esophagus are common in GERD, although it's not clear if such occurrences are a cause or a result of the long-term effects of GERD.

Pregnancy: The increase of the hormones estrogen and progesterone during pregnancy relax the LES, plus your expanding belly puts more pressure on your abdomen. Because of this, it's pretty normal for pregnant women to experience heartburn, which can lead to GERD.

Asthma: More than 75 percent of people with asthma are believed to also have GERD. No one really knows whether asthma causes GERD, or if it's the other way around. There are a couple of reasons why the two conditions are associated with each other. The first is that the coughing that accompanies asthma attacks may lead to changes in chest pressure, which can trigger reflux. Then there is the fact that certain asthma medications dilate the airways, relaxing the LES and leading to reflux. Both diseases worsen the other's symptoms, but treating GERD usually helps asthma symptoms as well.

Foods: There is an ongoing debate as to whether certain foods can cause heartburn. If you rarely have heartburn, food usually isn't associated with an attack. But if you have it on a recurring basis, you may notice that some foods or simply eating too much of anything seems to trigger it for you. Some choices stimulate acid production and some relax the LES.

Foods That Relax the Lower Esophageal Sphincter: Normally, the LES closes tightly to keep food and stomach acid in your stomach. If it relaxes when it shouldn't, food and stomach acid come back up into your esophagus and you may feel heartburn.

The following are examples of foods that can relax the LES:

  • Fried (greasy) foods
  • High-fat meats
  • Butter and margarine
  • Mayonnaise
  • Creamy sauces
  • Salad dressings
  • Whole-milk dairy products
  • Chocolate
  • Peppermint
  • Caffeinated beverages like soft drinks, coffee, tea, and cocoa

Foods That Stimulate Acid Production: Heartburn may also occur when your stomach produces too much acid, which backs up into your esophagus. Foods that may stimulate acid production and increase heartburn are:

  • Caffeinated beverages
  • Carbonated beverages
  • Alcohol
  • Spicy foods
  • Black pepper
  • Citrus fruit and juices like orange or grapefruit
  • Tomato juice

Salt: Studies have shown that a diet that's high in sodium may cause acid reflux that can lead to GERD. However, in healthy people, an excessively salty diet doesn't seem to increase acid reflux. More studies need to be done, but at the very least, salt may be a heartburn trigger for certain people. The only way to know for sure is to try limiting your salt intake to see if it makes a difference.

Genetics

Multiple studies have shown that there is a genetic component in many cases of GERD, which may sometimes be because of inherited muscular or structural problems in the esophagus or stomach. One study found that a DNA variation called GNB3 C825T was present in every study participant with GERD, but it wasn't present in the control group who did not have GERD.

Genetic factors also appear to play a big role in a patient's susceptibility to Barrett's esophagus, a precancerous condition caused by very severe gastroesophageal reflux. One study found that GERD, Barrett's esophagus, and esophageal cancer all have a significant genetic overlap.

Scientists believe that developing GERD takes a combination of genetic and environmental factors, as well as lifestyle choices. Just because your parent or sibling has GERD doesn't mean you necessarily will, though your risk is increased. More research needs to be done on the genetic component so that diagnosis and treatment for GERD can be even more effective and targeted.

Health Risk Factors

Many adults experience heartburn and anyone at any age can develop GERD. Here are some factors that may increase your risk.

Scleroderma: This autoimmune disorder, in which the immune system attacks healthy cells in the body, increases your risk for GERD. Many people with this concern also have GERD because the esophagus is the most commonly affected organ in scleroderma.

Asthma and COPD: Again, experts aren't sure which is the chicken or the egg when it comes to asthma and GERD, but most agree there is an important connection. In addition to the aforementioned concerns, GERD has been associated with a number of other upper respiratory problems and may be a cause of asthma that starts in adulthood, rather than a result.

Chronic obstructive pulmonary disease (COPD) also puts you at a higher risk of developing GERD, and having GERD may make your COPD symptoms worse.

Diabetes: People with diabetes, especially type 1 diabetes, often develop a condition called gastroparesis. This condition is characterized by delayed stomach emptying. The pressure within the stomach can increase, which in turn can result in reflux, making you more prone to develop GERD.

Celiac Disease: People with celiac disease seem to have a much higher rate of GERD than the general population, especially when they're newly diagnosed. Studies have shown that a gluten-free diet significantly reduces symptoms of GERD. Experts aren't sure whether consuming gluten causes GERD or if GERD is an associated condition of celiac disease. Sometimes GERD doesn't occur until after a person is diagnosed with celiac disease, which indicates that there may be something else causing it.

Lifestyle Risk Factors

There are certain lifestyle risk factors associated with developing GERD. These may be factors you can change or control.

Obesity/Overweight: Remember, obesity is both a cause and a risk factor for developing GERD. Excess weight around your belly area, in particular, puts you at a higher risk for developing GERD and its associated complications such as Barrett's esophagus and esophageal cancer. Doing what you can to maintain a healthy weight can go a long way in taming GERD.

Smoking: Like obesity, smoking is both a cause and a risk factor for developing GERD. If you smoke, the risk of GERD is yet another good reason to quit.

Eating Patterns: Eating big meals all at once, especially if you lie down afterward, and eating right before bed all increase your risk of developing acid reflux, which can lead to GERD. Try eating smaller, more frequent meals and don't eat for several hours before bedtime.

Hormone Replacement Therapy: Women who are on hormone replacement therapy are more likely to develop GERD. The longer you're on it and the higher the dose of estrogen, the higher the risk. 

How Gastroesophageal Reflux Disease (GERD) Is Diagnosed
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