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Gastroesophageal reflux disease (GERD) overview

Updated: January 14, 2016

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.

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.

Causes

A hiatal hernia may contribute. A hiatal hernia occurs when the upper part of the stomach is above the diaphragm and this makes it easier for acid to leak back into the esophagus. Other factors may also 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

Clinical picture

The main symptoms are persistent heartburn which is a burning sensation that occurs as a result of gastric acid regurgitation onto the mucosa of the esophagus. Some patients experience chest pain, hoarseness in the morning, or dysphagia. GERD can also cause a dry cough and bad breath.

The clinical picture makes the diagnosis clear. In cases where the diagnosis is not clear or the symptoms persistent despite therapy additional tests may be needed including, barium studies, endoscopy and a 24 hour pH monitor to confirm the diagnosis (see below).

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.

Treatment

Depending on how severe your GERD is, treatment may involve one or more of the following lifestyle changes and medications or surgery.

Lifestyle Changes

  • Smoking and alcohol drinking cessation.
  • Weight loss in overweight/obese patients.
  • Eating small meals.
  • Avoid lying down for 3 hours after a meal.
  • Raising the head of the bed 6 to 8 inches.

Medications

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.

Over the counter 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. These use different combinations of three basic salts--magnesium, calcium, and aluminum--with hydroxide or bicarbonate ions to neutralize the acid in your stomach. Antacids 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.

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. H2 blockers can be given at bedtime in combination with a proton pump inhibitor.

Proton pump inhibitors include omeprazole (Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex), and esomeprazole (Nexium). 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.

In patients that complain of heartburn after eating taking both antacids and H2 blockers could help. The antacids work first to neutralize the acid in the stomach, while the H2 blockers reduce further acid production.

Persistent symptoms

Additional tests may be needed and include:

  • A barium swallow radiograph uses x rays to help spot abnormalities such as a hiatal hernia, ulcers or strictures (narrowing of the esophagus).
  • Upper endoscopy is more accurate than a barium swallow radiograph and allows a biopsy to be performed in order to rule out malignancy or infection.
  • A 24 hour ambulatory pH monitor is rarely needed except in cases that are not clear. It involves measuring the amount and quantity of acid reflux into the 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. This includes laparoscopic Nissen fundoplication or a circular purse-string suture in the LES to tighten it.

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.

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.


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