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.
What are the symptoms of 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.
GERD in Children
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.
What causes GERD?
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
- alcohol use
- overweight
- pregnancy
- smoking
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
How is GERD treated?
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.
What if symptoms persist?
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.
What are the long-term complications of GERD?
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.
Points to Remember
- 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.
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