GERD

Gastro-Esophageal Reflux Disease

Definition
GERD — gastroesophageal reflux disease — is more than just chronic heartburn.
Although heartburn is the most common symptom of this disease, GERD is a
condition in which stomach acid or, occasionally, bile flows back (refluxes) into the
food pipe (esophagus). The constant backwash or acid reflux can irritate the lining of
your esophagus and cause inflammation. Such irritation can lead to complications
such as narrowing of the esophagus, ulcers and even a slightly increased risk of
esophageal cancer.

Most people can manage the discomfort of heartburn with lifestyle modifications and
over-the-counter medications. But if you have GERD, these remedies may offer only
temporary or partial relief. If you have GERD, you may need newer, more potent
medications, possibly even surgery, to reduce symptoms.

Symptoms
Common signs and symptoms of GERD include:

 Heartburn — burning sensation in the chest, sometimes spreading to the

throat, along with a sour taste in the mouth.
 Chest pain, especially at night while lying down
 Difficulty swallowing (dysphagia)
 Coughing, wheezing, asthma, hoarseness or sore throat
 Regurgitation of food or sour liquid
Causes

How heartburn and GERD occur

In heartburn, the sphincter muscle at the lower end of your esophagus relaxes at the wrong time,
allowing stomach acid to back up into your esophagus. Frequent or constant heartburn can lead
to GERD.

When you swallow, the lower esophageal sphincter — a circular band of muscle
around the bottom part of your esophagus — relaxes to allow food and liquid to flow
down into your stomach. Then it closes again.

However, if this valve relaxes abnormally or weakens, stomach acid can flow back up
into your esophagus, causing frequent heartburn and disrupting your daily life. The
acid backup is worse when you bend over or lie down.

This constant backwash of acid can irritate the lining of your esophagus, causing it to
become inflamed (esophagitis). Over time, the inflammation can erode the esophagus,
producing bleeding, or narrow the esophagus, causing difficulty swallowing or even
breathing problems. When there's evidence of esophageal irritation or inflammation,
you have GERD. However, many people with GERD will have a normal-appearing
esophagus despite symptoms.

GERD may be related to other conditions such as hiatal hernia. In this condition, also
called diaphragmatic hernia, part of your stomach protrudes into your lower chest. If
the protrusion is large, a hiatal hernia can worsen heartburn by further weakening the
lower esophageal sphincter muscle.

Some factors that can make GERD worse include:

 Certain foods, such as fatty foods, spicy foods, chocolate, caffeine, onions, tomato sauce,
carbonated beverages and mint
 Alcohol
 Large meals
 Lying down soon after eating
  Certain medications, including sedatives, tranquilizers and calcium channel blockers for
high blood pressure
 Cigarette smoking

Risk factors
Conditions that cause difficulty with digestion can increase the risk of GERD. These
include:

 Obesity. Excess weight puts extra pressure on your stomach and diaphragm
— the large muscle that separates your chest and abdomen — forcing open the
lower esophageal sphincter and allowing stomach acids to back up into your
esophagus. Eating very large meals or meals high in fat may cause similar
effects.
 Hiatal hernia. In this condition, also called diaphragmatic hernia, part of your
stomach protrudes into your lower chest. If the protrusion is large, a hiatal
hernia can worsen heartburn by further weakening the lower esophageal
sphincter muscle.
 Pregnancy. Pregnancy results in greater pressure on the stomach and a higher
production of the hormone progesterone. This hormone relaxes many of your
muscles, including the lower esophageal sphincter.
 Asthma. Doctors aren't certain of the exact relationship between asthma and
heartburn. It may be that coughing and difficulty exhaling lead to pressure
changes in your chest and abdomen, triggering regurgitation of stomach acid
into your esophagus. Some asthma medications that widen (dilate) airways
may also relax the lower esophageal sphincter and allow reflux. Or it's
possible that the acid reflux that causes heartburn may worsen asthma
symptoms. For example, you may inhale small amounts of the digestive juices
from your esophagus and pharynx, damaging lung airways.
 Diabetes. One of the many complications of diabetes is gastroparesis, a
disorder in which your stomach takes too long to empty. If left in your
stomach too long, stomach contents can regurgitate into your esophagus and
cause heartburn.
 Peptic ulcer. An open sore or scar near the valve (pylorus) in the stomach that
controls the flow of food into the small intestine can keep this valve from
working properly or can obstruct the release of food from the stomach. Food
doesn't empty from your stomach as fast as it should, causing stomach acid to
build up and back up into your esophagus.
 Delayed stomach emptying. In addition to diabetes or an ulcer, abnormal
nerve or muscle functions can delay emptying of your stomach, causing acid
backup into the esophagus.
 Connective tissue disorders. Diseases such as scleroderma that cause
muscular tissue to thicken and swell can keep digestive muscles from relaxing
and contracting as they should, allowing acid reflux.
 Zollinger-Ellison syndrome. One of the complications of this rare disorder is
that your stomach produces extremely large amounts of acid, increasing the
risk of acid reflux.

When to seek medical advice

Most problems with heartburn are short-term and mild. But if you have severe or
frequent discomfort, or you experience any of the other symptoms of GERD for a
while, you may be developing complications that need more intensive medical
treatment and prescription medications. Talk to your doctor if you have:

 Heartburn several times a week

 Heartburn that returns soon after your antacid wears off
 Heartburn that wakes you up at night
 Difficulty swallowing

You may need further medical care, possibly even surgery, if you experience any of
these:

 Symptoms that persist even though you're taking prescription medications

 Difficulty swallowing
 Regurgitated blood
 Stool that's black
 Weight loss

Tests and diagnosis

Usually a description of your symptoms will be all your doctor needs to establish the
diagnosis of heartburn. However, if your symptoms are particularly severe or don't
respond to treatment, you may need to undergo other tests to check for GERD and
other conditions:

 Barium X-ray. This procedure requires you to drink a chalky liquid that coats
and fills the hollows of your digestive tract. The coating allows your doctor to
see a silhouette of the shape and condition of your esophagus, stomach and
upper intestine (duodenum). X-rays can also reveal whether a hiatal hernia
may be contributing to your heartburn. They can also reveal an esophageal
narrowing or stricture, or a growth, which may cause difficulty swallowing.
 Endoscopy. A more direct test for diagnosing the cause of heartburn is
esophagogastroduodenoscopy (EGD). In this test your doctor inserts a thin,
flexible tube equipped with a light and camera (endoscope) down your throat.
The endoscope allows your doctor to see if you have an ulcerated or inflamed
esophagus (esophagitis) or stomach (gastritis). It can also reveal a peptic ulcer.
During an EGD, your doctor can take tissue samples to test for Barrett's
esophagus — a condition in which precancerous changes occur in cells in your
esophagus — or esophageal cancer, two potential complications of severe
heartburn. Your doctor also may take biopsies of the stomach that may reveal
the presence of a bacterium that may cause peptic ulcers. Some of the reasons
you may need an endoscopy are if medications aren't working for you, you
have had GERD symptoms for a long time, you experience difficulty
swallowing, weight loss, regurgitation of blood or black material, or your
doctor is not sure whether you have GERD. Although endoscopy results often
appear normal despite GERD, sometimes endoscopy can reveal inflammation,
stricture, Barrett's esophagus or cancer.
  Ambulatory acid (pH) probe tests. These tests use an acid-measuring (pH)
probe to identify when, and for how long, stomach acid regurgitates into your
esophagus. This information can help your doctor determine how best to treat
your condition. In the standard tube test, a nurse or technician sprays your
throat with a numbing medication while you're seated. Then a thin, flexible
tube (catheter) is threaded through your nose into your esophagus to insert the
probe. The probe is positioned just above the lower esophageal sphincter. A
second probe may be placed in your upper esophagus. Attached to the other
end of the catheter is a small computer that you wear around your waist or
with a strap over your shoulder during the test. It records acid measurements.
After the probe is in place, you go about your business and then come back
one or two days later to have the device removed. Another ambulatory test
called a Bravo pH probe may be more comfortable than the standard test,
because it eliminates the need for a tube in your nose. In the Bravo test, the
probe is attached to the lower portion of your esophagus during endoscopy.
The probe transmits a signal to a small computer that you wear around your
waist for about two days, and then the probe falls off to be passed in your
stool. Another benefit of the Bravo test is that you can shower and sleep more
comfortably than with the standard test. Generally, if you have symptoms of
GERD your doctor will likely first treat you with medication. If the
medication doesn't work or you have side effects and can't tolerate it, your
doctor may order an ambulatory acid (pH) probe test.
 Esophageal impedance. Rather than measuring acid, this test can measure
whether gas or liquids reflux back into your esophagus. It's helpful for people
who have regurgitation or reflux of materials in the esophagus that aren't
acidic and wouldn't be detected by a pH probe. The test works by placing a
catheter through your nose and into your esophagus, similar to a standard pH
probe tube test. However, because the test is new, its role in helping people
with GERD hasn't been clearly defined.

Complications
In addition to irritation and inflammation of your esophagus (esophagitis), chronic
reflux of stomach acid into your esophagus can lead to one or more of the following
conditions if left untreated:

 Esophageal narrowing (stricture). Strictures occur in some people with

GERD. Damage to cells in the lower esophagus from acid exposure leads to
formation of scar tissue. The scar tissue narrows the food pathway, causing
large chunks of food to get caught up in the narrowing, and can interfere with
swallowing.
 Esophageal ulcer. Stomach acid can severely erode tissues in the esophagus,
causing an open sore to form. The esophageal ulcer may bleed, cause pain and
make swallowing difficult.
 Barrett's esophagus. This is a serious, though uncommon, complication of
GERD. In Barrett's esophagus, the color and composition of the tissue lining
the lower esophagus change. Instead of pink, the tissue turns a salmon color.
Under a microscope, the tissue resembles that of the small intestine. This
cellular change is called metaplasia. Metaplasia is brought on by repeated and
long-term exposure to stomach acid and is associated with an increased risk of
 esophageal cancer. The risk of cancer is low, but you'll need regular
endoscopies to look for early warning signs of cancer if you're diagnosed with
Barrett's esophagus.

Treatments and drugs

Whether you have mild, moderate or severe heartburn, many treatment options are
available. The most common treatments involve medications, but surgical and other
procedures also are available.

Over-the-counter remedies
If you experience only occasional, mild heartburn, you may get relief from an over-
the-counter (OTC) medication and self-care measures. OTC remedies include:

 Antacids. Antacids, such as Maalox, Mylanta, Gelusil, Rolaids and Tums,

neutralize stomach acid and can provide quick relief. But antacids alone won't
heal an inflamed esophagus damaged by stomach acid. Overuse of some
antacids can cause side effects such as diarrhea or constipation. A liquid
antacid will coat your esophagus and help reduce stomach acid.
 H-2-receptor blockers. Over-the-counter H-2-receptor blockers, such as
cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR) or
ranitidine (Zantac 75), are available at half the strength of their prescription
versions. Instead of neutralizing the acid, these medications reduce the
production of acid. They don't act as quickly as antacids, but they provide
longer relief. Take these medications before a meal that you think may cause
heartburn because it takes them about 30 minutes to work. They're also
effective in reducing reflux at night if taken at bedtime. H-2-receptor blockers
can cause infrequent side effects, including bowel changes, dry mouth,
dizziness or drowsiness. In rare instances they can also react dangerously with
other medications.
 Proton pump inhibitors. These medications block acid production and allow
time for damaged esophageal tissue to heal. Omeprazole (Prilosec) was
previously available only by prescription, but now is available in an over-the-
counter form for short-term treatment of heartburn. Do not use OTC
omeprazole long term unless prescribed by your doctor. See your doctor to
make sure that you don't have any complications of GERD.

Prescription-strength medications
If you have frequent and persistent heartburn leading to an inflamed esophagus, you'll
likely need prescription-strength medication. It's important that you take these
medications correctly, and generally 30 minutes before a meal. Prescription
medications can help reduce and eliminate GERD symptoms, as well as help heal an
inflamed esophagus — the result of continual exposure to stomach acid. The main
types of prescription drugs are:

 Prescription-strength H-2-receptor blockers. These significantly reduce

acid production and have few side effects. They include prescription-strength
Axid, Pepcid, Tagamet and Zantac.
  Prescription-strength proton pump inhibitors. These are long-acting and
are the most effective medications for suppressing acid production. They're
safe and have few side effects for long-term treatment. To prevent possible
side effects, such as diarrhea or headaches, your doctor will likely prescribe
the lowest effective dose. Prescription-strength proton pump inhibitors include
esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec),
pantoprazole (Protonix) and rabeprazole (Aciphex).
 Prokinetic agents. These don't reduce acid production. Instead, they help your
stomach empty more rapidly and may help tighten the valve between the
stomach and the esophagus. Because the prokinetic agents thus far sometimes
cause serious side effects, researchers are working to develop safer versions.

Surgical and other procedures

Because of the effectiveness of medications, surgery for GERD is uncommon.
However, it may be an option if you can't tolerate the medications, you can't afford
their long-term use or your doctor determines that the medications are ineffective.
Your doctor may also recommend surgery if you have any of these complications:

 Large hiatal hernia

 Severe esophagitis, especially with bleeding
 Recurrent narrowing (stricture) of the esophagus
 Severe pulmonary problems, such as bronchitis or pneumonia, due to acid
reflux
 GERD that is not controllable by medication

Before 1991, a procedure called open Nissen fundoplication was the surgery of choice
for severe GERD. Today, doctors are able to perform the same surgery with similar
success laparoscopically — through a few small abdominal incisions, instead of one
large one. The advantages of laparoscopic surgery are a shorter recovery time and less
discomfort.

Nissen fundoplication involves tightening the lower esophageal sphincter to prevent

reflux by wrapping the very top of the stomach around the outside of the lower
esophagus. During laparoscopic surgery, a surgeon makes three or four small
incisions in the abdomen and inserts instruments, including a flexible tube with a tiny
camera, through the incisions.

People who benefit most from a Nissen fundoplication are those who gained relief
from medications. If you have minimal or no relief from medications, your doctor
must be certain that you have GERD before recommending surgery, which may mean
additional testing. Most people who undergo Nissen fundoplication remain free of
GERD symptoms for at least two years. For the majority of people, this benefit
extends to five years or more. You may still require medications for GERD, but your
GERD will likely be easier to control.

Other surgical procedures include Toupet fundoplication, Hill repair and the Belsey
Mark IV operation. All involve restructuring the lower esophageal sphincter to
improve its strength and ability to prevent reflux. These surgeries are done less often,
and their success is often dependent on the skill of the surgeon.
Complications from surgery generally are mild, but may include difficulty
swallowing, bloating and diarrhea. These complications generally go away within one
year.

Newer, less-invasive procedures

Your doctor may suggest a procedure for tightening the lower esophageal sphincter.
These procedures generally take less time to perform, they don't require any incisions,
and you can go home the same day. The procedures are performed endoscopically
through a long, flexible tube that's inserted into your mouth and down your
esophagus. These procedures are recommended if you have a hiatal hernia or Barrett's
esophagus.

 EndoCinch endoluminal gastroplication. This procedure uses a tool that's

like a miniature sewing machine. It places pairs of stitches (sutures) in the
stomach near the weakened sphincter. The suturing material is then tied
together, creating barriers (plications) to prevent stomach acid from washing
into your esophagus. The barriers are located at and just below the junction of
the esophagus and stomach. The procedure may cause a sore throat or chest
pain. The long-term effectiveness of the procedure is still unknown.
 Stretta procedure. This approach uses controlled radiofrequency energy to
heat and melt (coagulate) tissues within the portion of the esophagus that
contains the malfunctioning valve and at the junction of the esophagus and
upper stomach. The procedure appears to work by creating scar tissue and
altering the sensory nerves that respond to refluxed acid. The procedure may
cause a sore throat or chest pain. The long-term effectiveness of the procedure
is still unknown.

Lifestyle and home remedies

You may eliminate or reduce the frequency of heartburn by making the following
lifestyle changes:

 Control your weight. Being overweight is a major risk factor for heartburn
and GERD. Excess pounds put pressure on your abdomen, pushing up your
stomach and causing acid to back up into your esophagus.
 Eat smaller meals. This reduces pressure on the lower esophageal sphincter,
helping to prevent the valve from opening and acid from washing back into
your esophagus.
 Loosen your belt. Clothes that fit tightly around your waist put pressure on
your abdomen and the lower esophageal sphincter.
 Eliminate heartburn triggers. Everyone has specific triggers. Common
triggers such as fatty or fried foods, alcohol, chocolate, peppermint, garlic,
onion, caffeine and nicotine may make heartburn worse.
 Avoid stooping or bending. Tying your shoes is OK. Bending over for longer
periods to weed your garden isn't, especially soon after eating.
 Don't lie down after a meal. Wait at least three to four hours after eating
before going to bed, and don't lie down right after eating.
 Raise the head of your bed. An elevation of about six to nine inches puts
gravity to work for you. You can do this by placing wooden or cement blocks
under the feet of your bed at the head end. If it's not possible to elevate your
 bed, you can insert a wedge between your mattress and box spring to elevate
your body from the waist up. Wedges are available at drugstores and medical
supply stores. Raising your head only by using pillows is not a good
alternative.
 Don't smoke. Smoking may increase stomach acid. The swallowing of air
during smoking may also aggravate belching and acid reflux. In addition,
smoking and alcohol increase your risk of esophageal cancer.

Alternative medicine
Several home remedies exist for treating GERD, but they provide only temporary
relief. They include drinking baking soda (sodium bicarbonate) added to water or
drinking other fluids such as baking soda mixed with cream of tartar and water.

Although these liquids create temporary relief by neutralizing, washing away or

buffering acids, eventually they aggravate the situation by adding gas and fluid to
your stomach, increasing pressure and causing more acid reflux. Further, adding more
sodium to your diet may increase your blood pressure and add stress to your heart,
and excessive bicarbonate ingestion can alter the acid-base balance in your body.