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Gastroesophageal reflux disease (GERD)
Heartburn, Hiatal Hernia, and 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.
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
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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.
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.
Hope Through Research
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.
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