GERD & Breath Alcohol Testing
Part 1 - What is GERD?
Counterpoint Volume 5: Issue 2 - Article 1 (February 2021)
An article for participants in the myCAMprogram
Jan Semenoff, BA, EMA
Forensic Criminalist
Article information:
2000 words (approximately 12-15 minutes); Video - 22:00 minutes.
Important Note:
This information is intended for participants in Family Monitoring Programs where a small, legally allowable alcohol concentration is permitted. If you are under a zero-tolerance program, any alcohol use is a violation — regardless of your medical condition. ALWAYS follow your specific program rules.
This information is intended for participants in Family Monitoring Programs where a small, legally allowable alcohol concentration is permitted. If you are under a zero-tolerance program, any alcohol use is a violation — regardless of your medical condition. ALWAYS follow your specific program rules.
This article, Part 1 in a series, is an introduction to GERD (Gastroesophageal Reflux Disease). What is GERD? How does it manifest itself? What treatments are common? Finally, what implications does it have for Breath Alcohol Testing? In Part 2, we will examine the results of the only studies ever to be carried out on breath testing with GERD patients, and critically examine the findings. Is GERD an issue for your client? Let's take a look...
Video presentation:
Video duration 21:59
Gastroesophageal Reflux Disorder (GERD)
Figure 1 - The Lower Esophageal Valve, shown here partly open, has been damaged by chronic erosion of stomach acid over time, allowing for refluxation of acidic stomach contents back into the lower esophagus.
Gastro Esophageal Reflux Disorder (GERD) is a chronic condition that is believed to be caused by a partial weakening or failure of the Lower Esophageal Valve (LEV). This may also be called the LES, or Lower Esophageal Sphincter. This is a valve that separates the Esophagus from the Stomach. When stimulated, the LEV will open momentarily, allowing liquid consisting of acidic stomach contents to partially regurgitate, or reflux, back into the esophagus. This creates an uncomfortable burning sensation, often likened as severe heartburn.
In 2008, about 7-20% of adults in the USA suffered from GERD, with the majority requiring some sort of medical intervention in its management. These rates seem to be increasing (Kahrilas, 2008). A 2014 systematic review showed that the prevalence of GERD is about 15 – 30% in North America, and 10 –25% in Europe. Between 20 – 30 percent of adult Americans experience acid reflux symptoms every week.
A diagnosis of GERD will be made when the patient complains of mild reflux that occurs at least twice a week, or moderate to severe reflux that occurs at least once a week. It has been estimated that 60 million Americans have heartburn that occurs once a month
Complications when GERD gets bad
Keep in mind that GERD, and its complications, are chronic conditions. If you or your client suffer from GERD, it has probably been occurring, and increasing in intensity, for some time. At first, you swallowed a couple of antacids to control the burning sensation, successfully. As time goes on, you may have to avoid certain foods, or eating at certain times of the day. You may go on like this for years before you even mention it to your doctor, and even then, intervention and treatment may not begin immediately.
Most people are able to manage their GERD with over the counter medications, or with minor lifestyle changes - i.e. - avoiding food triggers, etc. However, others need stronger prescribed medications or medical intervention, treatment, or surgery to manage their chronic condition. The concern, of course, is when the situation gets out of hand, and damage starts to occur to physical structures in the body.
Esophageal Stricture occurs when there is damage to the lower esophagus from stomach acid which causes scar tissue to form. The scar tissue narrows the structure of the lower esophagus, causing problems with swallowing food as the lower esophagus is constricted. or narrowed.
Esophageal Ulcers will occur when the stomach acid eats away at tissues in the esophagus, causing the formation of open sores. Esophageal ulcers can bleed, painfully, and make it very difficult for the patient to swallow.
Barrett’s Esophagus is thought to be a major complication of GERD. The patient will experience cellular damage and change in the lower esophagus resulting from the chronic acid and inflammation caused by the GERD. Persons with this syndrome will have frequent and long-standing heartburn, and often experience trouble in swallowing, and keeping their stomach contents intact. They often experience frequent chest pain and vomiting of bloody stomach bile. They are at high risk for developing fatal esophageal cancers.
Treatment for GERD and its complications
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These conditions are partially controllable through daily doses of medication, and alteration of the patient’s diet. Increasing evidence indicates that smoking raises the risk for GERD. Studies suggest that smoking reduces LEV muscle function, increases acid secretion, impairs muscle reflexes in the throat, and damages protective mucous membranes. Asthmatic symptoms, such as coughing and wheezing, may occur. In fact, in one study, GERD alone accounted for 41% of cases of chronic cough in non-smoking persons. |
GERD, Esophageal Stricture, Esophageal Ulcers and Barrett’s Esophagus are chronic conditions. Symptoms and patient complaint of reflux may occur years after the condition begins, that is to say, a person may be asymptomatic for a long while before seeking medical attention. Once they begin, they are usually life-long conditions. Moreover, after the esophagus has healed with treatment and treatment is stopped, the injury will return in most patients within a few months.
Once treatment for GERD, Esophageal Stricture, Esophageal Ulcers and Barrett’s Esophagus has begun, therefore, they usually will need to be continued indefinitely. It is somewhat manageable by daily medication, and changes to the diet.
GERD can be stimulated by the consumption of alcoholic beverages. GERD has been associated with non-cardiac chest pain, ulcers, gastritis, asthma, hoarseness, and chronic cough. Symptoms such as chronic cough or chest pain can be caused by acid reflux into the esophagus, because they do not experience classic heartburn symptoms or acid regurgitation. It has been suggested in studies that the GERD is a pre-cursor to the chronic cough, creating its condition.
The Importance of Obtaining a Valid Medical History
Remember that the symptoms of heartburn and reflux may go on for years and be treated by the patient for some time using over the counter (OTC) medications. When confronted with an inexplicably high BrAC reading (one not supported by a reliable drinking pattern), it may be advantageous to inquire about medical problems that can lead to false-positive breath alcohol test results. Specifically, with GERD or Barrett’s in mind, your intake questionnaire should ask:
Remember that the symptoms of heartburn and reflux may go on for years and be treated by the patient for some time using over the counter (OTC) medications. When confronted with an inexplicably high BrAC reading (one not supported by a reliable drinking pattern), it may be advantageous to inquire about medical problems that can lead to false-positive breath alcohol test results. Specifically, with GERD or Barrett’s in mind, your intake questionnaire should ask:
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A diagnosis of GERD will probably be required to establish medical circumstances that give rise to inflated breath test results.
What stimulates GERD?
When stimulated, the LEV will open momentarily, allowing liquid consisting of acidic stomach contents to partially regurgitate, or reflux, back into the esophagus. This creates an uncomfortable burning sensation, often likened as severe heartburn.
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This stimulation can be caused by:
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Diet and Lifestyle Changes
There are several things your client (or you, if you suffer from GERD) can do to mitigate the symptoms of GERD:
- Avoid food or beverages that trigger reflux.
- Eat slowly, and with smaller servings
- Chew your food more thoroughly
- STOP smoking
- Maintain a healthy weight
- Elevate your head when you sleep
- Wear looser clothing, particularly around the lower part of your esophagus
Concurrent medical conditions
GERD doesn't always exist on its own. One study outlines that about 60% of people who suffer from Sleep Apnea also suffer from GERD. Additionally, people with Diabetes are also more likely to have GERD.
Asthmatic symptoms, such as coughing and wheezing, may also occur. In fact, in one study, GERD alone accounted for 41% of cases of chronic cough in non-smoking persons. Most asthma medications WORSEN acid reflux.
Delayed gastric emptying
A minority of patients with GERD, about 20%, have been found to have stomachs that empty abnormally slowly after a meal. If the stomach empties slowly, then stomach contents, including consumed alcoholic beverages, will remain in the stomach, unabsorbed, for some time after consumption. Dr. A. W. Jones (2005) identified the presence of unabsorbed alcohol in the stomach among GERD patients “several hours” after drinking.
This delayed gastric emptying (called Gastroparesis) will have important implications as we discuss how GERD could be a contributing factor in inflated breath alcohol testing results. more on this in Part 2.
The residual alcohol detection algorithm
Due to the pattern of emanation of alcohol from both the upper digestive tract along with the normal pathway from the lungs in a GERD patient, the Residual Mouth Alcohol Detection systems of modern breath alcohol analyzers are incapable of distinctly separating readings of the two. In short, alcohol emanates from BOTH the lungs AND the upper GI Tract, at roughly the same rate.
Figure 2 - The sharp rise and sudden drop in measured BrAC, as shown in red, indicates the presence of fresh mouth alcohol.
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The residual alcohol detectors are designed to identify a sudden rise with a subsequent sharp drop in measured BrAC from second to second during the breath test, as shown in the red line in Figure 2. False positives associated with GERD do not follow this “rise and drop” pattern and are not easily detected by the programmed algorithms. Under these conditions, it is known that the so-called “slope detectors” can falsely interpret this mouth alcohol bias and over-report the true BAC reading (Hlastala, 2006 and Gullberg, 2000).
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It has been my experience that the slope detectors can, and often are, fooled under a variety of circumstances, most notably, recent consumption or regurgitation of an amount of alcohol, similar to what would occur during GERD emanation, which has a tendency to deposit alcohol-laden air in the oral cavity.
Figure 3 - If there is no sharp rise and sudden drop in the measured BrAC, the Slope Detector cannot identify the presence of fresh mouth alcohol.
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I have routinely observed the slope detector fail to register mouth alcohol that is as much as 12-15 minutes old, often allowing the unit to register an abnormally high reading given a simple swish of alcohol. Published studies indicate failure of the residual alcohol detection system to identify mouth alcohol bias between 37% (Harding et al, 1992) and 48 % failure (Simpson et al, 2004). Gullberg (2000) also reports on the inadequacy of the mouth alcohol detection systems. Harding reported that some of these failures occurred after more than 15 minutes of deprivation.
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Why leakage matters
So why would a leaking LEV matter? The graphic below shows the mathematics behind breath alcohol sampling. Let's say your client has a TRUE blood alcohol concentration of 0.080 grams/210L. What is the weight of ethanol in their breath sample, as captured by a fuel cell device? Most fuel cells grab about 1 millilitre for a sample capture. What is the weight of ethanol actually measured in that 1 mL sample?
So, ultimately four 10-millionths of a gram of ethanol are in that captured breath sample for a 0.080 grams/210L BAC. What would occur if only two 10-millionths of a gram of alcohol escaped from an incompetent LEV? How would that amount of leakage affect the reported breath test results?
If you guessed "catastrophic" or "profound", you are correct. Do the math. It would create a false positive reading of 0.040 grams/210L. When it comes to contamination in breath alcohol testing, a little goes a long way...
Final thoughts
GERD is a chronic medical condition. The question, of course, is: Does GERD affect breath test results? The example above seems to suggest it would, theoretically. What does the science say?
We will critically examine the results of the few studies to have been performed on breath testing and GERD.
We will critically examine the results of the few studies to have been performed on breath testing and GERD.
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For further study:
- Chen, S., Wang, J. and Li, Y., Is Alcohol Consumption Associated with Gastroesophageal Reflux Disease?, Journal of Zhejiang University Science B., 2010 June; 11(6): 423-428, Zhejiang University, 2010.
- Hlastala, M., Lam, W., and Nesci, J., The Slope Detector Does Not Always Detect the Presence of Mouth Alcohol, For the Defense, March 2006.
- Hiltz, S., et al, American Gastroenterological Association Medical Position Statement of the Management of Gastroesophageal Reflux Disease, Gastroenterology 2008; 135: 1383-1391, 2008.
- Kahrilas, P., Gastroesophageal Reflux Disease, New England Journal of Medicine, 2008 October 16; 359(16): 1700-1707, October 2008.
- Scott, M, and Gelhot, A., Gastroesophageal Reflux Disease: Diagnosis and Management, American Family Physician, March 1999.
