Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a more serious form of gastroesophageal reflux (GER), which is common. GER is also called acid reflux, acid regurgitation, acid indigestion or "heartburn" because digestive juices—called acids—rise up into the esophagus causing a burning sensation. The esophagus is the tube that carries food from the mouth to the stomach. Normally, the esophagus is protected from stomach acids by the lower esophageal sphincter (LES). The LES is at the end of the esophagus where the muscles maintain a higher pressure which prevents reflux of acids from the stomach. It normally only relaxes when we swallow, allowing food and liquids to pass by into the stomach, acting like a one-way valve between the esophagus and stomach.

Occasional GER is common and does not necessarily mean one has GERD. Persistent reflux that occurs more than twice a week is considered GERD, and it can eventually lead to more serious health problems. People of all ages can have GERD.

Other Names

 * Acid reflux
 * Acid regurgitation
 * Acid indigestion
 * Heartburn

Symptoms
The main symptom of GERD in adults is frequent heartburn, also called acid indigestion—burning-type pain in the mid to lower part of the chest, behind the breast bone, and in the mid-abdomen. Most children under 12 years with GERD, and some adults, have GERD without heartburn. Instead, they may experience a dry cough, asthma symptoms, or trouble swallowing.

Causes of GERD
The reason some people develop GERD is still unclear. However, research shows that in people with GERD, the LES pressure is abnormally low, allowing acid reflux from the stomach to occur. One of the more common causes of GERD is a hiatal hernia. There are several types of hiatal hernias, but the most common type contributing to GERD is a Type I hiatal hernia. A Type I hernia, or a "sliding" hernia, occurs when the LES can move (or "slide") above the diaphragm. The diaphragm is the muscle that separates the abdomen from the chest and is the main muscle controlling our breathing. Normally, the LES is positioned below the diaphragm helping to maintain the function of the LES and keep acid from rising up into the esophagus. When a hiatal hernia is present, acid reflux can occur more easily. A hiatal hernia can occur in people of any age and is a common finding in otherwise healthy people over age 50. Most of the time, a hiatal hernia produces no symptoms.

Other factors that may contribute to GERD include:


 * Obesity
 * Pregnancy
 * Smoking

Common foods that can worsen reflux symptoms include:


 * Citrus fruits
 * Chocolate
 * Drinks with caffeine or alcohol
 * Fatty and fried foods
 * Garlic and onions
 * Mint flavorings
 * Spicy foods
 * Tomato-based foods, like spaghetti sauce, salsa, chili, and pizza

GERD in Children
Distinguishing between normal, physiologic reflux and GERD in children is important. Most infants with GERD are happy and healthy even if they frequently spit up or vomit. Babies usually outgrow GERD by their first birthday. Reflux that continues past one year of age may be GERD. Studies show GERD is common and may be overlooked in infants and children. For example, GERD can present as repeated regurgitation, nausea, heartburn, coughing, laryngitis, or respiratory problems like wheezing, asthma, or pneumonia. Infants and young children may appear irritable by arching the back, often during or immediately after feedings. Infants with GERD may refuse to feed and experience poor growth.

Children with reflux-related symptoms should be seen and evaluated by a doctor. He or she may recommend simple strategies for avoiding reflux, such as burping the infant several times during feeding or keeping the infant in an upright position for 30 minutes after feeding. In an older child, a health care provider may recommend that they eat small, frequent meals and avoid the following foods:


 * Sodas that contain caffeine
 * Chocolate
 * Peppermint
 * Spicy foods
 * Acidic foods like oranges, tomatoes, and pizza
 * Fried and fatty foods

Avoiding food two to three hours before bed may also help. The health care provider may recommend raising the head of the child's bed with wood blocks secured under the bedposts. Just using extra pillows will not help. If these changes do not work, the health care provider may prescribe medicine. In very rare cases, a child may need surgery.

Treatment
Symptoms of GERD that last for more than two weeks may need medical attention. A primary care physician may make the diagnosis, or provide a referral to a gastroenterologist, who treats diseases of the stomach and intestines. Depending on the severity of symptoms, treatment may involve one or more of the following lifestyle changes, medications, or surgery.

Lifestyle Changes

 * Quitting smoking
 * Avoiding foods and beverages that worsen symptoms
 * Losing weight if needed
 * Eating small, frequent meals
 * Wearing loose-fitting clothes
 * Avoiding lying down for three hours after a meal.
 * Raising the head of the bed six to eight inches by securing wood blocks under the bedposts. Just using extra pillows will not help since they are compressible.

Medications
The doctor may recommend over-the-counter antacids or medications that stop acid production or aid in emptying the stomach. Many of these medications can be bought without a prescription.

Antacids, 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. They also include hydroxide or bicarbonate ions to neutralize the acid in the stomach. Antacids, however, can have side effects. Magnesium salt can lead to diarrhea, and aluminum salt may cause constipation. Aluminum and magnesium salts are often combined in a single product to balance these effects.

Calcium carbonate antacids can also be a supplemental source of calcium. They can cause constipation as well.

Foaming agents, work by covering the stomach contents with a coating to prevent reflux.

H2 blockers, decrease acid production. They are available in prescription and over-the-counter strength. These drugs provide short-term relief and are effective for about half of those who have GERD symptoms.

Proton pump inhibitors are more effective than H2 blockers and can relieve symptoms and heal the esophageal lining in almost everyone who has GERD.

Prokinetics help make the stomach empty faster. This group includes bethanechol and metoclopramide. Metoclopramide also increases muscle action in the digestive tract. Prokinetics have frequent side effects that limit their usefulness—fatigue, sleepiness, depression, anxiety, and problems with physical movement.

Because drugs work in different ways, combinations of medications 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. Afterwards, the H2 blockers act on acid production. By the time the antacid stops working, the H2 blocker will have stopped acid production. However, taking multiple medications for GER should be discouraged, and in almost all cases is unnecessary and possibly dangerous. Use of any of these medications should be done under the supervision of a qualified doctor.

Diagnostic tests
If symptoms do not improve with lifestyle changes or medications, additional tests may be necessary.

The doctor may also perform a biopsy. Tiny tweezers, called forceps, are passed through the endoscope and allow the doctor to remove small pieces of tissue from the esophagus. The tissue is then viewed with a microscope to look for damage caused by acid reflux and to rule out other problems if the diagnosis is still unclear.
 * An upper GI series uses x rays to help spot abnormalities such as a hiatal hernia and other structural or anatomical problems of the esophagus and stomach. With this test, a barium solution is swallowed and then x rays are taken. The test will not detect mild irritation, although strictures (narrowing of the esophagus) and ulcers can be observed.
 * Upper endoscopy can be more accurate than an upper GI series and may be performed in a hospital or a doctor's office. The doctor will spray the throat to numb it and then will slide a thin, flexible plastic tube with a light and lens on the end (called an endoscope) down the throat. Acting as a tiny camera, the endoscope allows the doctor to see the surface of the esophagus and search for abnormalities. If symptoms were moderate to severe and this procedure reveals injury to the esophagus, usually no other tests are needed to confirm GERD.
 * pH monitoring examination the doctor either inserts a small tube into the esophagus or clips a tiny device to the esophagus that will stay there for 24 to 48 hours. The device allows a person to go about normal activities while it measures when and how much acid comes up into the esophagus. This test can be useful if combined with a carefully completed diary—recording when, what, and how much the person eats. This allows the doctor to see correlations between symptoms and reflux episodes. The procedure is sometimes helpful in detecting whether respiratory symptoms, including wheezing and coughing, are triggered by reflux.

A completely accurate diagnostic test for GERD does not exist.

Surgery
Surgery is an option when medicine and lifestyle changes do not improve GERD symptoms. Surgery may also be a reasonable alternative to a lifetime of drugs and discomfort.

Fundoplication is the standard surgical treatment for GERD. Usually a specific type of procedure, called Nissen fundoplication, is performed. During this operation, the upper part of the stomach is wrapped around the last part of the esophagus, below the diaphragm, to effectively recreate the function of the LES. Additionally, during this operation, the diaphragm is repaired, narrowing its opening where the esophagus comes through it.

The Nissen fundoplication is now almost always performed laparoscopically. Laparoscopic operations use a video camera and small instruments inserted through tiny incisions in the abdomen. When performed by experienced surgeons, laparoscopic fundoplication is safe and effective in people of all ages, including infants. People can leave the hospital in one to three days and return to work in two to three weeks.

Endoscopic techniques used to treat chronic heartburn include the Bard EndoCinch system, NDO Plicator, and the Stretta system. These techniques require the use of an endoscope to perform the anti-reflux procedure. The EndoCinch and NDO Plicator systems involve putting stitches in the lower esophagus to create pleats that help recreate the LES. The Stretta system uses electrodes to create tiny burns on the LES. When the burns heal, the scar tissue helps tighten the muscle. The longterm effects of these three procedures are still under investigation.

Complications
Chronic, untreated GERD can cause serious complications. Inflammation of the esophagus from refluxed stomach acid can damage the lining and cause bleeding or ulcers—also called esophagitis. Scars from tissue damage can lead to strictures—narrowing of the esophagus—that make swallowing difficult. Some people develop Barrett's esophagus, in which cells in the esophageal lining take on an abnormal shape and color. Over time, these cells can change into esophageal cancer, which if left untreated, is fatal. Physicians often advise that people with GERD and its complications receive close monitoring.

Studies have shown that GERD may worsen or contribute to asthma, chronic cough, and pulmonary fibrosis.

Research
The reasons certain people develop GERD and others do not remain unknown. Several factors may be involved. Research is under way to explore risk factors for developing GERD and the role of GERD in other conditions such as asthma and laryngitis.