Hitch up your pants and install your pocket protector. If you have reflux, chances are it’s not just GERD, it’s NERD!

by Patricia L. Raymond, M.D., FACP, FACG

You come to my office with heartburn, I give you a pill you take once a day, and you get better. I am a goddess of gastroenterology.

Unless it doesn’t work.

For many of my patients, the scenario is more like: You come to my office already taking a powerful pill two, even three, times daily. You still have reflux, and the discomfort has a huge impact on your wellbeing. We endoscope you … and see absolutely nothing.

What are you, nuts? Nah, you’re likely a NERD.

No, I haven’t implied that you’re a socially awkward, intelligent young person with glasses, braces and high-riding pants. I’m talking about a relatively new heartburn classification. You’re likely already familiar with the term GERD, or good old gastroesophageal reflux disease. Well, now you need to meet someone new.

WHAT IS NERD?
We now know GERD (a.k.a. heartburn, indigestion, dyspepsia) is made up of various subcategories. Before we had uber-strong acid suppressors, we thought the main reflux was ERD, or erosive reflux disease. But we’ve found that 40 percent or less of people with reflux have that. Instead, most have NERD.

NERD stands for non-erosive esophageal reflux disease. This means that when we gastroenterologists scope you, there are no erosions or ulcers to see. Unfortunately for the NERDs, this lack of signs makes it harder to treat. Much harder.

HOW NERD WORKS
At the top of your stomach is a flap that keeps juices down where they belong. It’s called the lower esophageal sphincter. That little flap is the problem for some people with reflux: It’s weakened and lets juices come up into the esophagus. Not so with NERD. The LES usually works fine for these folks.

Further, NERDs have more reflux episodes without acid. In fact, only 50 percent of NERDs have prolonged acid contact time. So there’s pain with limited acid, which explains why all the anti-acid meds in the world won’t completely stop the burning.

The esophagus in people with NERD is more sensitive to acid. Even weak acid can cause pain. The spaces between the esophageal lining cells appear to be wider in these folks. Researchers hypothesize that this may be responsible for the enhanced sensitivity, but they’re not sure how.

DO YOU HAVE NERD?
According to a 2008 study in Digestion, if you have heartburn, the likelihood that it’s NERD increases if you:

• 

  Are of a younger age than people with ERD (no specific one stated, so just … younger).
  
• Are female.
  
• Don’t have a hiatus hernia (when the stomach pokes up into the chest cavity through the abdomen).
• Have a normal to low body-mass index.
  
• Have tested positive for the bacteria Helicobacter pylori. (H. pylori in your stomach, which can cause ulcers, usually decrease acid secretion.)

It was easy to spot a nerd in high school; you looked for the pocket protector, thick glasses or slide rule. Diagnosing NERD in medical practice has not reached primetime.

Gastroenterologists might suspect NERD if you fail to respond completely to strong acid-suppression medications. Testing will show that your lower esophageal sphincter works fine, and you don’t have a lot of extra acid making it up your esophagus.

So we can make a good guess at what you have. The bad news is, we can’t successfully treat it—not yet, anyway.

TREATMENT FOR NERD

Acid-suppressing medication doesn’t work well for NERDs. Mediciness to make your esophagus contract more effectively don’t help; it’s moving just fine, thank you. Surgery to help your lower esophageal sphincter work better isn’t as helpful in NERD as it is with some other GERD types. (That’s controversial, though, because some believe the surgery, called Nissan fundoplication, is useful in all kinds of GERD.)

Nevertheless, don’t despair. With up to 12 percent of the population having NERD, the pharmaceutical industry will no doubt be working hard at this condition.

PATRICIA RAYMOND, M.D., is a board-certified gastroenterologist with Simply Screening in Chesapeake, Va.; author of Colonoscopy: It’ll Crack U Up!; and assistant professor of clinical internal medicine at Eastern Virginia Medical School.

Last updated and/or approved March 2010. Article originally appeared in the May/June 2009 former print magazine.

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H Pylori
written by Kurt Bockoven , June 22, 2011

Loved your article. Enjoyed your writing style. I always wondered why some medications just didn't work. I always thought it was because of an h. pylori infection but now I have something else to look into. I write a daily medical blog for my patients and also have written posts about heartburn and the dreaded h. pylori stomach infections.

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Holistic Cure for Acid Reflux
written by Randy , June 15, 2011

This was a good article to read. I hate thinking about how much people go to the hospital and doctors don't see anything wrong with them when their actually is something wrong, and not just heartburn but for other medical conditions as well. I think we should have more funding so we can research more things so we can discover new things and get to where when people do go to the hospitals the doctors will be able to find things that are wrong that they wouldn't have before.

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