Gastroesophageal reflux disease (GERD)

Gastroesophageal reflux disease (GERD) is a common condition in which acidic stomach contents flow back up into the esophagus, causing irritation and, sometimes, damage to the lining of the esophagus.


Anatomy
The esophagus is the tube that connects the throat and stomach. It passes through the diaphragm (the muscle that separates the chest cavity from the abdominal cavity) through an opening called the hiatus. A ring of muscle called the lower esophageal sphincter (LES) regulates the passage of solids and liquids from the esophagus into the stomach. Normally, the lower esophageal sphincter prevents acidic stomach contents from returning to the esophagus. In the stomach, the gastric mucosa (the lining of the stomach) releases acidic secretions that aid digestion and kill the germs sometimes ingested with food.

Causes/associated factors
GERD develops when the lower esophageal sphincter doesn't close properly. This allows acidic stomach contents to flow back up or reflux into the esophagus, causing irritation and in some cases damage to the lining of the esophagus. GERD is a common disorder, affecting as many as 25 percent of American adults. GERD can develop at any age, but it's less common in infants and children.
The exact cause of GERD is unknown. For infants, GERD is most often caused by an immature digestive system. By age 1, most children have outgrown the problem. For adults, risk factors -- which mainly affect the LES by weakening or relaxing the muscle tissue or increasing the pressure exerted on it by the stomach or abdomen -- include:

hiatal hernia (a protrusion of part of the stomach from its normal position in the abdomen through the diaphragm)
pregnancy
being overweight
overeating
delayed stomach emptying
drinking alcohol
eating foods such as chocolate, mint and onions, as well as foods that contain caffeine and are high in fat
smoking
taking certain medications, such as nonsteroidal anti-inflammatory drugs (ibuprofen or naproxen, for example), aspirin, potassium, iron, tetracycline, progesterone and others

Signs/symptoms
The most common symptom of GERD is heartburn, a burning sensation in the middle of the chest behind the breastbone that may move toward the throat. It often occurs after meals, especially if you're exercising, bending or lying down. Heartburn may awaken you at night and get worse after drinking alcohol or eating spicy or acidic foods, such as citrus fruits and tomatoes. You may also experience acid regurgitation, in which stomach acid and food particles reflux into your mouth, producing a sour or acidic taste.
More serious symptoms of GERD include:

difficulty or pain with swallowing
weight loss
gastrointestinal bleeding
Other symptoms that may be attributed to GERD after other conditions have been ruled out include:

chest pain
coughing or wheezing
sore throat or hoarseness
For infants and children, symptoms may include repeated spitting up or vomiting, irritability, poor feeding, slow weight gain, or respiratory problems such as coughing or wheezing.


Diagnosis
An occasional episode of heartburn doesn't necessarily mean that you have GERD. Initially, diagnosis is often based on symptoms -- such as experiencing heartburn twice a week or more -- and a physical exam. The diagnosis may be confirmed if your symptoms improve with medication.
If you have less typical symptoms, such as chest pain, wheezing or hoarseness, areas other than the gastrointestinal tract are typically investigated first. For example, if you have chest pain, your heart will likely be checked before the pain is attributed to GERD. If your symptoms are severe or not well controlled with treatment, you may be referred to a gastroenterologist (a doctor who specializes in digestive tract problems). Further tests may include:

Upper gastrointestinal endoscopy or esophagogastroduodenoscopy (EGD): Using an instrument called a fiberoptic endoscope (a tube equipped with a camera lens and light), the doctor will examine the lining of your esophagus and stomach. He or she will be able to see areas of irritation or abnormal tissue, as well as remove small tissue samples to check for Barrett's esophagus (a change in the esophageal cells that can occur with chronic exposure to stomach acid).

Bernstein test: The doctor will drip a mild acid into your esophagus through a tube in your throat. If heartburn symptoms appear quickly, a salt solution will be placed in your lower esophagus to stop the symptoms. The test confirms acid reflux if symptoms appear and disappear as expected during the test.

Esophageal manometric test: The doctor will take pressure measurements near the lower esophageal sphincter. The measurements will help the doctor decide if the muscular ring is working properly.

24-hour esophageal pH testing: If the diagnosis is still uncertain, the doctor may use pH testing to measure the acid levels inside your esophagus during meals, activity and sleep.

Barium esophagram: With this special X-ray, barium (a contrast material) is used to outline the esophagus. The doctor may be able to identify areas of narrowing or constriction in the esophagus, as well as a condition known as hiatal hernia (the protrusion of part of the stomach from its normal position in the abdomen through the diaphragm). This test may be useful if it's not possible to do an upper gastrointestinal endoscopy.

Upper gastrointestinal (GI) series or barium esophagram: This special X-ray uses a contrast material (usually barium) to outline the esophagus, stomach and upper part of the small intestine. The doctor won't be able to diagnose GERD with this X-ray, but he or she may be able to identify other problems that may contribute to GERD, such as hiatal hernia.

Treatment
If your symptoms are mild, lifestyle adjustments may be sufficient treatment. For many people, over-the-counter medications are also needed to keep symptoms under control. For more serious cases of GERD, prescription medications or even surgery may be needed to control symptoms and prevent complications.

Lifestyle adjustments
Your doctor may recommend various lifestyle adjustments, although their effectiveness may vary from person to person. For example:
Avoid anything that causes or worsens heartburn, such as chocolate, caffeinated or carbonated drinks (including coffee, tea and cola), alcohol, mints, fried or fatty foods, onions, garlic, spicy foods, citrus fruits and tomato products.

Eat smaller meals throughout the day, rather than two or three large meals. Don't eat anything for at least two to three hours before going to bed.

Eat slowly. This can help reduce the amount of air you swallow, as well as control your portion size.

Lose excess pounds. If you're overweight, your doctor can help you design an appropriate weight loss plan.

Don't smoke. If you're trying to quit, your doctor may suggest nicotine replacement products or other ways to make the process easier.

Raise the head of your bed about 6 inches. Place wooden blocks under the legs of your bed or use a full-length foam wedge on the mattress. (Using pillows alone to elevate your head isn't often helpful.)

Avoid tight clothing that puts pressure on your stomach.

Avoid over-the-counter medications that can make your symptoms worse, such as ibuprofen, naproxen and aspirin, unless prescribed by your doctor. Be sure any doctor who prescribes medication for you knows about your GERD.

Swallow pills or tablets with an adequate amount of water or other liquid.
If your baby has GERD, burp him or her several times during each feeding to help prevent reflux. It's also important to hold your baby upright for at least 30 minutes after each feeding.


Medication
Often, medication can help relieve symptoms, heal damaged esophageal tissue and prevent complications.
Various antacids can help neutralize stomach acid quickly and stop heartburn for up to two hours (such as Alka-Seltzer, Tums, Rolaids, Mylanta and Maalox). Antacids containing a foaming agent (such as Gaviscon) cover your stomach contents with a foam to prevent reflux. Keep in mind that antacids are intended for occasional use only. Long-term use may cause diarrhea, change the way your body breaks down calcium and create magnesium retention, which is risky if you have kidney disease. Don't take antacids for more than three weeks without consulting your doctor.

Over-the-counter H2 receptor antagonists (known as H2 blockers), which decrease stomach acid production for six to 10 hours, are also available for occasional relief. These include cimetidine (Tagamet), famatidine (Pepcid), nizatidine (Axid) and ranitidine (Zantac). If you have chronic acid reflux, your doctor may prescribe a stronger form of one of these H2 blockers.

Proton pump inhibitors (PPIs) may be recommended if H2 blockers don't provide relief. They inhibit the production of excess stomach acid for up to 24 hours with few side effects. Prescription options include esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix) and rabeprazole (Aciphex). An over-the-counter version of omeprazole is available at a lower dose.

Although your body still produces enough stomach acid to digest the food you eat when you take H2 blockers and PPIs, the long-term effects of reducing stomach acid are unknown. The risk of infectious diarrhea may increase slightly with less acid production.

As another option, promotility medications such as metoclopramide (Reglan) may be prescribed to help your stomach empty more quickly and prevent the acid contents from refluxing into the esophagus. These medications may be used with an acid-reducing medication, but the side effects often limit their usefulness.


Surgical repair
Nissen fundoplication is the most common surgery used to relieve severe GERD. It may also be done when complications develop or chronic medication therapy isn't desirable. Nissen fundoplication can be done at any age. For infants, however, it's only done when GERD prevents normal growth or causes breathing problems.
During the procedure, the upper part of the stomach is wrapped around the lower esophageal sphincter to strengthen it. This can be done through an incision in the abdomen or chest or through a laparoscope (a thin, flexible tube equipped with a camera lens and light) that's inserted through several small incisions. Both approaches have similar success rates, but the laparoscopic surgery usually takes less time and has a shorter, more comfortable recovery.

Although the procedure is highly effective, symptoms may return six to 20 years later for some people.


Endoscopic procedures
Within the last few years, the U.S. Food and Drug Administration has approved three endoscopic procedures to treat GERD. These procedures are done through the esophagus with an endoscope (a thin, flexible tube equipped with a camera lens and light). They're less invasive than traditional or laparoscopic surgery and may be used to treat uncomplicated cases of GERD.
During the stretta procedure, the doctor uses radiofrequency energy to make small cuts in the lower esophageal sphincter. The scar tissue that forms when the cuts heal appears to strengthen the LES muscle.
During the endocinch procedure, the doctor strengthens the lower esophageal sphincter with stitches.
With the enteryx implant, a special solution is injected around the lower esophageal sphincter. The solution becomes spongy and reinforces the LES.
Because these procedures are so new, the long-term effects are not yet known.


Complications
If you have chronic acid reflux, you may develop:
esophagitis (irritation, inflammation and swelling of the esophagus, which sometimes produces ulcers and scarring)
narrowing of the esophagus due to scarring, which may make swallowing difficult
bleeding from esophageal ulcers or irritation
pneumonia or asthma, if you inhale stomach contents into your lungs
Barrett's esophagus (This condition, which makes the cells that line the esophagus more like those that line the stomach after chronic exposure to stomach acid, develops in about 10 percent of people who have GERD. It's associated with a slightly increased risk of esophageal cancer. Treatment for Barrett's esophagus is usually the same as GERD, but researchers haven't determined whether treatment reduces the risk of cancer.)

Pregnancy-specific information
GERD is common during pregnancy. Often, hormonal changes and increased pressure from your expanding abdomen affect the lower esophageal sphincter. Report any symptoms to your doctor, and consult him or her before trying any home remedies or taking medication to relieve your symptoms -- even those available without a prescription.

Senior-specific information
The risk of developing GERD increases with age. Despite more severe damage to the esophagus, symptoms in older adults may be milder.

Prevention
To prevent GERD, make healthy lifestyle choices. Don't smoke, and avoid caffeine and alcohol. If you're overweight, lose the extra pounds.