Gastroesophageal Reflux Disease
(GERD)
Gastroesophageal reflux disease, or GERD, occurs when
the lower esophageal
sphincter (LES) does not close properly and stomach contents leak back, or
reflux, into the esophagus. The LES is a
ring of muscle at the bottom of the esophagus that acts like a valve between the
esophagus and stomach. The esophagus carries food from the mouth to the stomach.
When refluxed stomach acid touches the lining of the
esophagus, it causes a burning sensation in the chest or throat called heartburn. The fluid may even be
tasted in the back of the mouth, and this is called acid indigestion.
Occasional heartburn is common but does not necessarily mean one has GERD.
Heartburn that occurs more than twice a week may be considered GERD, and it can
eventually lead to more serious health problems.
Anyone, including infants, children, and pregnant women, can have GERD.
The main symptoms are persistent heartburn and acid regurgitation. Some
people have GERD without heartburn. Instead, they experience pain in the chest,
hoarseness in the morning, or trouble swallowing. You may feel like you have
food stuck in your throat or like you are choking or your throat is tight. GERD
can also cause a dry cough and bad breath.
Studies* show that GERD is common and may be overlooked in infants and
children. It can cause repeated vomiting, coughing, and other respiratory problems.
Children's immature digestive systems are usually to blame, and most infants
grow out of GERD by the time they are 1 year old. Still, you should talk to your
child's doctor if the problem occurs regularly and causes discomfort. Your
doctor may recommend simple strategies for avoiding reflux, like burping the
infant several times during feeding or keeping the infant in an upright
position for 30 minutes after feeding. If your child is older, the doctor may
recommend avoiding
- sodas that contain caffeine
- chocolate and
peppermint
- spicy foods like pizza
- acidic foods like oranges and tomatoes
- fried and fatty foods
Avoiding food 2 to 3 hours before bed may also help. The
doctor may recommend that the child sleep with head raised. If these changes do
not work, the doctor may prescribe medicine for your child. In rare cases, a
child may need surgery.
*Jung AD.
Gastroesophageal reflux in infants and children. American Family Physician. 2001;64(11):1853-1860.
No one knows why people get GERD. A hiatal hernia may
contribute. A hiatal hernia occurs when the upper part of the stomach is above the diaphragm, the
muscle wall that separates the stomach from the chest. The diaphragm helps the
LES keep acid from coming up into the esophagus. When a hiatal hernia is
present, it is easier for the acid to come up. In this way, a hiatal hernia can
cause reflux. A hiatal hernia can happen in people of any age; many otherwise
healthy people over 50 have a small one.
Other factors that may contribute to GERD include
Also, certain foods can be associated with reflux events, including
- citrus fruits
- chocolate
- drinks with caffeine
- fatty and fried foods
- garlic and onions
- mint flavorings
- spicy foods
- tomato-based foods, like spaghetti sauce, chili, and pizza
If you have had heartburn or any of the other symptoms for a while, you
should see your doctor. You may want to visit an internist, a doctor who
specializes in internal medicine, or a gastroenterologist, a doctor who treats
diseases of the stomach and intestines. Depending on how severe your GERD is,
treatment may involve one or more of the following lifestyle changes and
medications or surgery.
Lifestyle Changes
- If you smoke, stop.
- Do not drink alcohol.
- Lose weight if needed.
- Eat small meals.
- Wear loose-fitting clothes.
- Avoid lying down for 3 hours after a meal.
- Raise the head of your bed 6 to 8 inches by putting blocks of wood under
the bedposts-just using extra pillows will not help.
Medications
Your doctor may recommend over-the-counter
antacids, which you can buy without a prescription, or medications that stop acid production or help the
muscles that empty your stomach.
Antacids, such as Alka-Seltzer, Maalox, Mylanta, Pepto-Bismol,
Rolaids, and Riopan, are usually the first drugs recommended to relieve
heartburn and other mild GERD symptoms. Many brands on the market use different
combinations of three basic salts-magnesium, calcium, and aluminum-with
hydroxide or bicarbonate ions to neutralize the acid in your stomach. Antacids,
however, have side effects. Magnesium
salt can lead to diarrhea, and aluminum salts can
cause constipation. Aluminum and magnesium salts are often combined in a single
product to balance these effects.
Calcium carbonate antacids, such as Tums, Titralac, and Alka-2, can also be a
supplemental source of calcium. They can cause constipation as well.
Foaming agents, such as Gaviscon, work by covering your stomach
contents with foam to prevent reflux. These drugs may help those who have no
damage to the esophagus.
H2 blockers, such as cimetidine (Tagamet HB), famotidine (Pepcid AC),
nizatidine (Axid AR), and ranitidine (Zantac 75), impede acid production. They
are available in prescription strength and over the counter. These drugs provide
short-term relief, but over-the-counter H2 blockers should not be used for more
than a few weeks at a time. They are effective for about half of those who have
GERD symptoms. Many people benefit from taking H2 blockers at bedtime in
combination with a proton pump inhibitor.
Proton pump inhibitors include omeprazole (Prilosec), lansoprazole
(Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex), and esomeprazole
(Nexium), which are all available by prescription. Proton pump inhibitors are
more effective than H2 blockers and can relieve symptoms in almost everyone who
has GERD.
Another group of drugs, prokinetics, helps strengthen the sphincter and makes
the stomach empty faster. This group includes bethanechol (Urecholine) and
metoclopramide (Reglan). Metoclopramide also improves muscle action in the
digestive tract, but these drugs have frequent side effects that limit their
usefulness.
Because drugs work in different ways, combinations of
drugs may help control
symptoms. People who get heartburn after eating may take both antacids and H2
blockers. The antacids work first to neutralize the acid in the stomach, while
the H2 blockers act on acid production. By the time the antacid stops working,
the H2 blocker will have stopped acid production. Your doctor is the best source
of information on how to use medications for GERD.
If your heartburn does not improve with lifestyle changes or drugs, you may
need additional tests.
- A barium swallow
radiograph uses x rays to help spot abnormalities such as a hiatal hernia
and severe inflammation of the
esophagus. With this test, you drink a solution and then x rays are taken.
Mild irritation will not appear on this test, although narrowing of the
esophagus-called stricture-ulcers, hiatal hernia, and other problems will.
- Upper endoscopy is more
accurate than a barium swallow radiograph and may be performed in a hospital
or a doctor's office. The doctor will spray your throat to numb it and slide down a thin, flexible plastic tube
called an endoscope. A tiny
camera in the endoscope allows the doctor to see the surface of the esophagus
and to search for abnormalities. If you have had moderate to severe symptoms
and this procedure reveals injury to the
esophagus, usually no other tests are needed to confirm GERD.
The doctor may use tiny tweezers (forceps) in the
endoscope to remove a small piece of tissue for biopsy. A biopsy viewed under a microscope can reveal
damage caused by acid reflux and rule out other
problems if no infecting organisms or abnormal growths are found.
- In an ambulatory pH monitoring examination, the doctor puts a
tiny tube into the esophagus that will stay there for 24 hours. While you go
about your normal activities, it measures when and how much acid comes up
into your esophagus. This test is useful in people with GERD symptoms but no
esophageal damage. The procedure is also helpful in detecting whether
respiratory symptoms, including wheezing and coughing, are triggered by
reflux.
Surgery
Surgery is an option when medicine and lifestyle changes do not work.
Surgery may also be a reasonable alternative to a lifetime of drugs and
discomfort.
Fundoplication, usually a specific variation called Nissen fundoplication, is
the standard surgical treatment for GERD. The upper part of the stomach is
wrapped around the LES to strengthen the sphincter and prevent acid reflux and
to repair a hiatal hernia.
This fundoplication procedure may be done using a laparoscope and requires
only tiny incisions in the abdomen. To perform the fundoplication, surgeons use
small instruments that hold a tiny camera. Laparoscopic fundoplication has been
used safely and effectively in people of all ages, even babies. When performed
by experienced surgeons, the procedure is reported to be as good as standard
fundoplication. Furthermore, people can leave the hospital in 1 to 3 days and
return to work in 2 to 3 weeks.
In 2000, the U.S. Food and Drug Administration (FDA) approved two endoscopic devices to treat chronic
heartburn. The Bard EndoCinch system puts stitches in the LES to create little
pleats that help strengthen the muscle. The Stretta system uses electrodes to
create tiny cuts on the LES. When the cuts heal, the
scar tissue helps toughen the muscle. The long-term effects of these two
procedures are unknown.
Implant
Recently the FDA approved an implant that may help people with GERD
who wish to avoid surgery. Enteryx is a solution that becomes spongy and
reinforces the LES to keep stomach acid from flowing into the esophagus. It is
injected during endoscopy. The implant is approved for people who have GERD and
who require and respond to proton pump inhibitors. The long-term effects of the
implant are unknown.
Sometimes GERD can cause serious complications.
Inflammation of the esophagus from stomach acid causes bleeding or ulcers. In
addition, scars from tissue damage can narrow the esophagus and make swallowing
difficult. Some people develop Barrett's esophagus, where cells in the
esophageal lining take on an abnormal shape and color, which over time can lead
to cancer.
Also, studies have shown that asthma, chronic cough, and
pulmonary fibrosis
may be aggravated or even caused by GERD.
For information about Barrett's esophagus, please see
the Barrett's Esophagus fact sheet from the National Institute of Diabetes and
Digestive and Kidney
Diseases.
- Heartburn, also called acid indigestion, is the most
common symptom of GERD. Anyone experiencing heartburn twice a week or more may
have GERD.
- You can have GERD without having heartburn. Your
symptoms could be excessive clearing of the throat, problems swallowing, the
feeling that food is stuck in your throat, burning in the mouth, or pain in
the chest.
- In infants and children, GERD may cause repeated
vomiting, coughing, and other respiratory problems. Most babies grow out of
GERD by their first birthday.
- If you have been using antacids for more than 2
weeks, it is time to see a doctor. Most doctors can treat GERD. Or you may
want to visit an internist-a doctor who specializes in internal medicine-or a
gastroenterologist-a doctor who treats diseases of the stomach and intestines.
- Doctors usually recommend lifestyle and dietary
changes to relieve heartburn. Many people with GERD also need medication. Surgery may be an option.
No one knows why some people who have heartburn develop
GERD. Several factors may be involved, and research is under way on many levels.
Risk factors-what makes some people get GERD but not others-are being explored,
as is GERD's role in other conditions such as asthma and bronchitis.
The role of hiatal hernia in GERD continues to be debated and explored. It is
a complex topic because some people have a hiatal hernia without having reflux,
while others have reflux without having a hernia.
Much research is needed into the role of the bacterium
Helicobacter pylori.
Our ability to eliminate H. pylori has been responsible for reduced rates of
peptic ulcer disease and some gastric cancers. At the same time, GERD, Barrett's
esophagus, and cancers of the esophagus have increased. Researchers wonder
whether having H. pylori helps prevent GERD and other diseases. Future treatment
will be greatly affected by the results of this research.
American College of Gastroenterology (ACG)
4900-B
South 31st Street
Arlington, VA 22206-1656
Phone: 703-820-7400
Fax: 703-931-4520
Internet: www.acg.gi.org
American Gastroenterological Association
(AGA)
National Office
4930 Del Ray
Avenue
Bethesda, MD 20814
Phone: 301-654-2055
Fax: 301-652-3890
Email: webinfo@gastro.org
Internet: www.gastro.org
International Foundation for Functional
Gastrointestinal Disorders (IFFGD) Inc.
P.O.
Box 170864
Milwaukee, WI 53217-8076
Phone: 1-888-964-2001 or
414-964-1799
Fax: 414-964-7176
Email: iffgd@iffgd.org
Internet:
www.aboutgerd.org
North American Society for Pediatric
Gastroenterology, Hepatology, and Nutrition (NASPGHAN)
P.O. Box 6
Flourtown, PA 19031
Phone: 215-233-0808
Fax:
215-233-3939
Email: naspghan@naspghan.org
Internet: www.naspghan.org
Pediatric/Adolescent Gastroesophageal Reflux
Association Inc. (PAGER)
P.O.
Box 1153
Germantown, MD 20875-1153
Phone: 301-601-9541
Email: gergroup@aol.com
Internet: www.reflux.org
Source: National Digestive Diseases Information Clearinghouse
(NDDIC), National Institutes of Health
Last Editorial Review: 2/7/2006
