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Gastroesophageal Reflux Disease
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As one of the National Institutes of Health, NIDDK conducts and supports research on many of the most serious diseases affecting public health. It also supports large-scale clinical trials of new treatments through contracts and offers free publications for the general public and patients. Their website is the first to turn to for general information on digestive diseases and disorders and specific information about GERD.
ACG represents more than 9,000 digestive health specialists and is committed to providing accurate, unbiased, and up-to-date information.. Organized by disease state and organ system, these educational materials, developed by ACG physician experts, span the broad range of digestive diseases and conditions, both common and not-so-common. Links to other respected GI health organizations are included as an additional resource.
AGA is dedicated to advancing the science and practice of gastroenterology. Founded in 1897, the AGA is the oldest medical-specialty society in the United States. Comprised of two non-profit organizations, the AGA and the AGA Institute, its 15,500 members include physicians and scientists who research, diagnose, and treat disorders of the gastrointestinal tract and liver.
This education and research organization is dedicated to informing, assisting, and supporting people affected by gastrointestinal (GI) disorders. Founded in 1991, it works with patients (both adults and children), families, physicians, practitioners, investigators, employers, regulators, and others to broaden understanding about gastrointestinal disorders and support or encourage research. Its website is one of the best for detailed information about GERD.
This society consists of more than 1100 pediatric gastroenterologists, predominantly in 46 states, the District of Columbia, Puerto Rico and 8 provinces in Canada. NASPGHAN strives to improve the care of infants, children and adolescents with digestive disorders by promoting advances in clinical care, research and education.
This association provides information and support to parents, patients and doctors about GER and promotes research into the causes, treatments and eventual cure for pediatric GER. One of its goals is to produce parent-friendly written, video, and electronic information on various aspects of caring for children with GERD and medical issues that are of concern to parents.
Episode number: 
404
Transcript: 
GERD (transcript)

Heartburn is nothing to take lightly. For many people, heartburn can interrupt daily life and be the precursor to serious illnesses. Our panel of experts on gastroesophageal reflux disease (GERD) will discuss the diagnosis and treatment of it, as well as the symptoms you should not ignore.

Heartburn and gastroesophageal reflux disease (GERD)

About ten to twenty percent of American adults have heartburn at least once a week. About one third have it at least once a month. The statistics are even higher among pregnant women and the elderly.

Something so common can't be serious, right? Wrong. An occasional attack of heartburn is, in fact, nothing to worry about.  Heartburn is not a disease. But frequent and persistent heartburn could be a symptom of a more serious condition that is a disease: gastroesophageal reflux disease, known as GERD. GERD can be diagnosed and treated – and should be, or it could lead to even more serious conditions.

Let's begin with some definitions. Gastroesophageal refers to the stomach and the esophagus. The esophagus (also called the gullet) is the tube that connects the throat to the stomach; when you eat, food goes from your mouth into the esophagus and then down to the stomach. Around the bottom of the esophagus, where it enters the stomach, is a band of muscle called the lower esophageal sphincter (LES). 

Normally, the LES tightens to prevent the contents of the stomach (including food, fluids, and digestive juices called "acids") from leaking back into the esophagus. This process of leaking back is called reflux. Reflux happens when the LES relaxes or opens at the wrong time.

"Heartburn" has nothing to do with the heart. It's actually simple reflux - acid and fluids from the stomach backing up into the esophagus. Heartburn's main symptom is a pain or burning sensation in the center of the chest, usually in the lower part of the mid-chest, behind the breastbone, in the solar plexus or mid-abdomen.

The stomach acids irritating the esophagus cause the pain. Sometimes the burning sensation can be felt in the throat; sometimes the bitter, sour, unpleasant taste of digested food and fluids can be tasted in the back of the mouth; and sometimes the acids end up being regurgitated (spat out). That's why heartburn is also known as acid indigestion and, more technically – and accurately – as acid reflux and gastroesophageal reflux (GER). 

GER is not the same as GERD. GER is simple heartburn. But frequent (more than twice a week), persistent, and severe heartburn can be a symptom of GERD. Among other things, tissue in the esophagus can be damaged by the repeated contact with stomach acids.  When this happens, the condition is known as esophagitis or erosive GERD. (When symptoms are present but there is no tissue damage, the condition is called non-erosive GERD.)

People of any age, including children and infants, can have GERD. The symptoms vary from case to case, and sometimes there are no obvious symptoms. The disease is discovered only because of complications that lead to a thorough medical exam. On the other hand, most people with GERD have very mild symptoms with no tissue damage and little chance of serious complications.  

 Quick Facts

  • Heartburn has nothing to do with the heart. Heartburn is the burning, painful sensation felt when acid and fluids from the stomach back up into the esophagus.
  • Other names for heartburn are acid indigestion, acid reflux, and gastroesophageal reflux or GER.
  • Although statistics vary a bit, we can say that every week about 40 million Americans have heartburn and forty percent of all Americans have had it at least once.
  • "Ordinary" heartburn is not the same thing as gastroesophageal reflux disease. But frequent, persistent, severe heartburn is the most common symptom of GERD in adults. Anyone experiencing heartburn twice a week or more may have GERD.
  • You can also have GERD with no heartburn. Other symptoms could be difficulty swallowing, a dry cough, or asthma symptoms.
  • Over-the-counter (non-prescription) antacids can be very effective in eliminating heartburn symptoms.
  • Lifestyle changes (including changes in what, when, and how much you eat, as well eliminating smoking and alcohol) are also very effective in eliminating GER symptoms.
  • If you have heartburn more than twice a week, or have been using antacids for two weeks in a row, you may have GERD and should see your doctor.
  • GERD should be treated and monitored because, if ignored, it can lead to serious complications. Currently available treatments are very effective.
  • Your regular doctor can probably treat GERD, though you may need to see a specialist called a gastroenterologist, a doctor who treats diseases of the stomach and intestines.
  • Standard treatments for GERD include prescription medication and, when needed, a surgery that can now be done laparoscopically (i.e. using minimally invasive techniques).
  • Children and even infants can have both GER and GERD. Most infants with GER are healthy even though they may spit up or vomit often, and they usually outgrow it by their first birthday. If they show symptoms beyond then, they may have GERD.

Ask Your Doctor

This list of questions is a good starting point for discussion with your doctor. However, it is not a comprehensive list.

  • Are my chest pains caused by GERD or something else?
  • I've noticed these symptoms: list them
  • What medical tests should I take to get an accurate diagnosis?

About the tests:

  •  What kinds of tests will I have?
    • What do you expect to find out from these tests?
    • When will I know the results?
    • Do I have to do anything special to prepare for any of the tests?
    • Do these tests have any side effects or risks?
    • Will I need more tests later?
  • How severe is my GERD?
  • How dangerous is my GERD?
  • What life-style changes (such as diet, exercise, etc.) should I make to treat my GERD?
  • What medications should I take for long-term control of my GERD?
  • What medications should I take when I need immediate relief from GERD symptoms?

About this medicine:

  •  What is the name and purpose of the medication?
    • What time of day do I take it, with food or without, and for how long?
    • How successful is this medicine?
    • What are the potential side effects and what should I do if they occur?
    • What should I do if I miss a dose?
    • Should I swallow it whole or can it be crushed?
    • Will this drug interact with any other medications I am currently taking – prescription, over-the-counter, or herbal?
    • While taking this medication, should I avoid certain foods, alcohol, or dietary supplements?
    • How long will I have to take this medicine?
  • Are other treatments available for GERD?  Do I need them?
  • Do I need to see a specialist (a gastroenterologist)? If so, can you recommend a few?

Key Point 1

Chest pain is a symptom, not a diagnosis, and heart disease always needs to be ruled out. You need an accurate diagnosis to determine what is causing your symptoms.

It's important to know about GERD not only because the disease itself can and should be treated, but also because other conditions and diseases can cause its major symptom, chest pain. The most serious, of course, are heart (cardiac) problems. That's why, if you have frequent or persistent chest pain, it's absolutely essential to have a through medical examination. 

Given the seriousness of heart problems, it makes sense for your doctor to run some routine cardiac diagnostic tests. These might include:

  • Blood tests
  • Electrocardiogram (EKG, ECG, or cardiogram) to measure the heart's electrical activity
  • Stress EKG (stress test) - an electrocardiogram made while the person is exercising
  • Echocardiogram - sound waves are bounced off the heart to produce still and moving images of it (similar to ultrasound imaging).

Cardiac catheterization is a less routine, more invasive test in which a small tube (catheter) is inserted through a blood vessel and threaded up into the heart, to measure blood flow and pressure.

Several earlier episodes of Second Opinion explored various aspects of heart disease, including the diagnostic tests and preventative medications mentioned in this episode.  You'll find lots of valuable information about these topics at:

    • Second Opinion, Heart Failure (Cardiomyopathy) Episode 102
    • Second Opinion, Heart Rhythm Disorder (Arrhythmia), Episode 110
    • Second Opinion, Heart Attack, Episode 113
    • Second Opinion, Women's Cardiac Health, Episode 209

It makes sense for you to give your doctor as open, honest, accurate, and complete a report of your symptoms and your lifestyle as possible. Make sure you tell your doctor about your eating habits, sleeping habits, lifestyle choices (such as whether and how much you smoke). Never be afraid to discuss the "little details." They may be very important to helping your doctor arrive at an accurate diagnosis. 

The main symptom of GERD in adults is frequent heartburn (two or more times per week), especially:

  • Heartburn that doesn't respond to the standard over-the-counter (OTC) anti-heartburn medications (often called antacids because they fight the effects of stomach acids)
  • Heartburn that returns soon after the OTC medications wear off
  • Heartburn that causes you to awaken during the night. 

But there are other symptoms that could point to the condition, including:

  • Heartburn that doesn't respond to prescription medications
  • Difficulty swallowing
  • Spitting up or throwing up blood or black material
  • Black stools
  • Weight loss
  • Belching
  • Waterbrash (sudden excess of saliva)
  • Chronic sore throat
  • Laryngitis
  • Inflammation of the gums
  • Erosion of tooth enamel
  • Chronic throat irritation
  • Morning hoarseness
  • Sour, bitter, or bad taste in the mouth
  • Bad breath

Some adults and most children under 12 who have GERD do not have heartburn.  Their symptoms may be:

  • Dry cough
  • Asthma symptoms  (For more information about asthma and its symptoms, go to Second Opinion, Asthma, Episode 213) 
  • Difficulty swallowing; food sticking in throat

If you have these symptoms, your doctor can do a number of diagnostic tests that can discover the presence of GERD.  For more information about diagnosing GERD, go to Key Point 2.) 

Although the causes of GERD remain uncertain, we do know what some of the major risk factors for heartburn are.  In general, they include:

  • Lying down too soon after eating (especially a large meal)
  • Conditions that relax or weaken the LES and the diaphragm (the wall of muscle that separates the stomach from the chest and helps the LES keep acid from backing up into the esophagus), such as:
    • Hiatal hernia, a condition in which the upper part of the stomach and the LES protrude into the chest by pressing against the diaphragm. This can weaken those muscles, increasing the chance of acid reflux.
    • Pregnancy, which puts pressure on the affected muscles and also produces a muscle relaxing hormone
    • Excess weight
    • Very large meals or high fat meals
  • Conditions that cause the stomach to take an abnormally long time to empty, so that its contents have the chance to flow back into the esophagus, such as:
    • Diabetes
    • Obstruction of the pylorus valve (which controls the flow of stomach contents into the small intestine)
    • Nerve, muscle, or connective tissue disorders
    • Certain drugs including narcotics, some antidepressants and antihistamines
  • Asthma
    • The exact connection between asthma and heartburn is not yet understood.
      • It may be that labored breathing and coughing in some way cause acid reflux
      • Asthma medications may relax the LES, causing acid reflux
      • The reverse may be true: acid reflux may increase asthma symptoms
  • Zollinger-Ellison syndrome (ZES)
    • This rare disorder causes tumors in the pancreas and duodenum (the first part of the small intestine) and ulcers in the stomach and duodenum that produce a hormone (gastrin) that causes the stomach to produce excess acid.
  • Some sedatives, antidepressants, and calcium channel blockers for high blood pressure
  • Smoking

In addition, certain foods and beverages are known to cause heartburn in some people, including:

  • Alcohol
  • Caffeinated drinks, including coffee, tea, and soft drinks
  • Non-caffeinated coffee
  • Carbonated soft drinks
  • Chocolate
  • Citrus fruits
  • Fatty and fried foods
  • Garlic and onions
  • Mint flavorings
  • Spicy foods
  • Tomato sauce and tomato-based spaghetti sauce, salsa, chili, pizza, etc.

Key Point 2

You may think heartburn is simple, but it is not. There are multiple causes and getting a professional diagnostic work up will result in better treatment.

When your doctor has a complete, accurate description of your symptoms, and other causes of chest pain have been ruled out, the diagnosis may be heartburn (GER).  Heartburn can be treated using over-the-counter (OTC) medicines, prescription medicines, and lifestyle changes.  You'll find information about these when you go to Key Point 3.

However, if these treatments don't relieve the symptoms, or your doctor suspects GERD, one or more of the following diagnostic tests may be ordered:

Barium x-ray (also known as a barium swallow radiograph or esophagram).  For this test, you drink a chalky fluid that coats your esophagus and digestive system, enabling the x-rays to present a better picture of any problems or abnormalities, such as a hiatal hernia, ulcers, or stricture (narrowing of the esophagus), that may be causing difficulties.

Endoscopy (or upper endoscopy).  For this test, the doctor numbs your throat, sedates you slightly, then slides a thin, flexible, plastic tube with a tiny camera and light at the end (an endoscope) down your esophagus.  This gives the doctor direct images of the area that are more accurate than x-rays.  They can show any abnormalities, including ulcers, inflammation, tissue damage in the esophagus and stomach, hiatal hernia, etc.  (The test is technically known as esophagogastroduodenoscopy or EGD).

Biopsy, a test in which tissue samples are removed and then examined under a microscope to look for damage, infection and abnormal growths.  A biopsy can also test for precancerous cells in the esophagus (a condition called Barrett's esophagus) and esophageal cancer. 

Acid monitoring (also called pH monitoring, ambulatory acid probe, and ambulatory 24-hour pH probe).  For this test, the doctor numbs your throat, sedates you slightly, then slides a small tube (catheter) into your esophagus through your nose or mouth, then slides a tiny acid measuring probe through the catheter and attaches it to your esophagus, where it remains for 24 to 48 hours. You continue with your normal life while the probe measures how often and how much stomach acid backs up into your esophagus.  The measurements are recorded on a tiny, portable computer worn around your waist, and are later compared with standards to diagnose and understand your symptoms.  Another version of this test eliminates the catheter. Instead, the probe is attached to your esophagus during endoscopy, transmits measurements for about two days, then falls off the esophagus and passes out of you in your stool.

Esophageal impedance. This is similar to the acid monitoring test, but it measures the reflux of gas and fluids other than acid (such as bile) into the esophagus. 

Esophageal manometry.  For this test, the doctor numbs your throat, then slides a tiny, pressure-sensitive tube into your esophagus through your nose or mouth. You'll be asked to swallow.  When you do so, the muscles in your throat contract and exert pressure that is measured by tube. These are called measurements of motility (muscle contractions); the motility of the LES can also be measured.  These measurements help diagnose problems that may be linked to GERD.

Key Point 3

Left untreated GERD can lead to serious, perhaps irreversible damage. Treatment can be very effective.

There are several possible complications or consequences from GERD, including esophagitis (an irritated and/or inflamed esophagus) and stricture (narrowing in the esophagus that can make swallowing difficult). Some studies suggest that GERD may worsen the symptoms of asthma, chronic cough, and pulmonary fibrosis.

However, the most serious complication is the slightly increased risk of esophageal cancer (cancer of the espophagus). Some people with GERD develop a condition called Barrett's esophagus, in which cells in the lining of the esophagus become abnormal in color and shape. These cells (called "specialized intestinal metaplasia") may become precancerous - that is, undergo further changes that increase the risk of eventually becoming cancerous. However, precancerous cells do not necessarily become cancer. 

The number of GERD sufferers who develop Barrett's esophagus is relatively small, and the number of those who develop precancerous cells and then esophageal cancer is smaller still. Nevertheless, esophageal cancer is often fatal. Therefore, anyone with GERD, and especially with Barrett's esophagus, should be checked regularly.

Despite these possible complications, treatment for heartburn and GERD is usually successful. Ordinary heartburn and GER can be treated with simple lifestyle changes and over-the-counter (OTC) medicines. 

Lifestyle changes include:

  • Stop smoking. Smoking relaxes the LES and increases production of stomach acid.
  • Avoid alcoholic drinks.  Alcohol relaxes the LES.
  • Lose weight if overweight. Extra weight adds pressure to the stomach, which can cause acid reflux.
  • Eat smart.  This means three things.
    • Avoid food and drink that relax the LES or have acids that can irritate the esophagus, such as:
      • Caffeinated drinks, including coffee, tea, and soft drinks
      • Non-caffeinated coffee
      • Carbonated soft drinks, especially colas
      • Chocolate
      • Citrus fruits
      • Fatty and fried foods
      • Garlic and onions
      • Mint flavorings
      • Spicy foods
      • Tomato sauce and tomato-based spaghetti sauce, salsa, chili, pizza
    • Eat small, frequent meals rather than fewer large ones. Large meals also put pressure on the stomach and LES.
    • Avoid eating habits that put pressure on the lower abdomen and LES.  In other words:
      • Don't lie down for 3 hours after a meal.
      • Don't eat close to bedtime.
      • Don't stoop or bend for long periods right after eating.
  • Raise the head of your bed 6 to 8 inches to give gravity the chance to keep food in your stomach. You can put wooden blocks under the bedposts or use a foam wedge under the mattress to raise yourself from the waist. 
  • Don't use piles of extra pillows. That actually increases pressure on the abdomen.
  • Wear loose belts and clothes. Tight clothing also adds pressure to the lower abdomen and LES.

Most common over-the-counter antacids (such as Alka-Seltzer, Axid, Gaviscon, Gelusil, Maalox, Mylanta, Pepcid, Riopan, Rolaids, Tagamet, Tums, and Zantac, etc.) neutralize stomach acid and relieve most people's heartburn symptoms. But overusing some antacids (more than two or three times a week or for more than two weeks in a row) not only can cause side effects such as diarrhea or constipation but is also a sign of something more serious than heartburn. And antacids alone won't heal an esophagus damaged or inflamed by stomach acid.

If these treatments don't relieve the symptoms, or you have been diagnosed with GERD, then you will need stronger treatments, such as prescription medicines or possibly surgery.  Prescription medications include:

  • H2 blockers (also called H2-receptor antagonists). Unlike antacids that neutralize stomach acid, this class of drugs reduces acid production. This, in turn, reduces or eliminates reflux symptoms and helps heal esophagitis (irritated or inflamed esophagus).  The success rate for eliminating symptoms is about 50%; for healing esophagitis about 25%.  Some are also available in non-prescription strength.  They include cimetidine (trade name: Tagamet HB), famotidine (trade name: Pepcid AC), nizatidine (trade name: Axid AR), and ranitidine (trade name: Zantac 75).
  • Proton pump inhibitors (PPIs).  These drugs also reduce stomach acid production, but they are stronger, usually more effective, (and more expensive) that H2 blockers. Their success rate for eliminating symptoms and healing esophagitis is about 80 to 90%. They're also useful for managing stricture (narrowing of the esophagus). Proton pump inhibitors include omeprazole (trade names: Prilosec, Zegerid), lansoprazole (trade name: Prevacid), pantoprazole (trade name Protonix), rabeprazole (trade name Aciphex), and esomeprazole (trade name Nexium). Prilosec is also available in non-prescription strength.
  • Prokinetics (also known as promotility drugs.)  These drugs help strengthen the LES and make the stomach empty faster (increase motility).  This group includes bethanechol (trade name: Urecholine) and metoclopramide (trade name: Reglan). Metoclopramide also improves muscle action in the digestive tract. Unfortunately, these drugs have more frequent side effects (fatigue, sleepiness, depression, anxiety, and problems with physical movement) that make their success less certain.

GERD can be a chronic (long term) condition; its symptoms may be controlled, but the disease itself remains. Therefore, you may need to take a maintenance dose of a drug for a long time, perhaps the rest of your life. Anyone taking any medication for the long-term should be seen by their doctor at regular intervals.

If none of the medical and other options succeed in controlling GERD, then your doctor may suggest a surgical procedure, called fundoplication. This has been a standard surgical treatment for GERD for more that fifty years. 

In fundoplication, the upper part of the stomach is wrapped around the LES to strengthen it and repair any hiatal hernia. Today, this procedure can be done laparoscopically, that is, using the techniques of minimally invasive surgery. The surgeon makes tiny incisions through which tiny instruments with attached mini-cameras are inserted, then manipulates the instruments while watching a video monitor. Compared to traditional surgery, minimally invasive surgery leads to faster recovery, less post-operative pain, and smaller scars. The surgery has an extremely high success rate.

More recently, a number of non-surgical endoscopic techniques have been developed that are also designed to strengthen the LES.  However, they are so new that there is no long-term data about their success or side effects. 

Please note, we don't endorse or favor any other specific commercial products or companies. Any trade, proprietary, or company names seen here are used only because they're considered necessary in the context of the information provided. If a product isn't mentioned, the omission doesn't mean or imply that the product is unsatisfactory



 

Medline Plus

Medline Description: 

Conduct an off-site search for GERD information from MedlinePlus.  These up-to-date search results are based on search terms specific to Second Opinion Key Points.

GERD- main page

Heartburn- main page

Esophagus Disorders- main page

Hiatal Hernia- main page

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