Gastroesophageal Reflux Disease (GERD)

Heartburn isn't unusual. The National Institutes of Health (NIH) estimate that 60 million Americans a month have heartburn. (Read about "Heartburn") Twenty-five million people suffer once a day. Twenty-five percent of pregnant woman will get heartburn every day and 50 percent occasionally. It's a big problem. Heartburn can also be one of the main symptoms of a serious condition called Gastroesophageal Reflux Disease or GERD.

GERD is the result of problems where the stomach and the esophagus meet. The muscle there is called the lower esophagus sphincter, (LES) and is designed to let food pass through to the stomach and keep it there. When the muscle is weakened or relaxed, it can let the contents of the stomach flow back into the esophagus. This results in the burning sensation we call heartburn. Heartburn pain is sometimes mistaken for a heart attack. (Read about "Heart Attack") NIH says one thing that can help people tell the difference is the fact that exercise may aggravate pain from heart disease, whereas heartburn pain is less likely to be affected by physical activity.

Although the main symptoms are persistent heartburn and acid regurgitation, some people have GERD without heartburn. According to the National Institute of Diabetes and Digestive and Kidney Disorders (NIDDK), these people may experience pain in the chest, hoarseness in the morning, or trouble swallowing. NIDDK says GERD can also cause a dry cough and bad breath.

Causes

No one knows the exact cause of GERD. The National Digestive Diseases Information Clearinghouse (NDDIC) says many doctors believe that hiatal hernias are a major cause of GERD. (Read about "Hernia") A hiatal hernia happens when a portion of the upper part of the stomach slips by the diaphragm into the chest cavity. The diaphragm separates the stomach from the chest and helps the LES keep things in the stomach. With a hiatal hernia that extra help is lost. NDDIC says obesity and pregnancy (Read about "Obesity" "Healthy Pregnancy") can result in a hiatal hernia. Many people over the age of 50 have one even though they are otherwise healthy. Most of the time, the condition does not require treatment.

Diet and lifestyle are also believed to contribute to GERD. Reflux can happen when the LES is weakened by things such as:

• chocolate
• peppermint
• fried or fatty foods
• coffee
• alcohol

NIH studies show that smoking also relaxes the LES. And once again, obesity and pregnancy can cause GERD all by themselves.

Treatment

Most of the time doctors will recommend lifestyle changes first, including changes in diet, to try to cut back the amount of reflux and the damage caused by the acid to the esophagus. Some of the things you can do to control heartburn from GERD according to the American College of Gastroenterology (ACG) include:

• Avoid foods and drinks that affect LES pressure or irritate the esophagus such as fried or fatty food, alcohol, coffee, citrus fruit and juices and tomato products.
• Lose weight if you are overweight. (Read about "Losing Weight")
• Stop smoking. (Read about "Quit Smoking")
• Elevate the head of your bed by 6 inches to help keep the contents of your stomach in place.
• Avoid lying down for 2 to 3 hours after eating, giving the stomach a chance to clear things out.

Many times the above actions can help relieve the heartburn. If the problem persists, it is imperative that you consult with your doctor.

Medications

Your doctor may recommend 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. They can include any of the following:

• Antacids are usually the first drugs recommended to relieve heartburn and other mild GERD symptoms, according to NDDIC. Many brands on the market use different combinations of three basic salts - magnesium, calcium and aluminum - with hydroxide or bicarbonate ions to neutralize the acid in your stomach. (Read about "Vitamins & Minerals") Antacids, however, have side effects. Magnesium salt can lead to diarrhea (Read about "Diarrhea"), and aluminum salts can cause constipation. (Read about "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. (Read about "Calcium") They can cause constipation as well.
• Foaming agents 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, famotidine, nizatidine and ranitidine, 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, according to NDDIC. They are effective for about half of those who have GERD symptoms. Many people benefit from taking H2 blockers at bedtime in combination with a proton pump inhibitor.
• Proton pump inhibitors include omeprazole, lansoprazole, pantoprazole, rabeprazole and esomeprazole, which are all available by prescription. NDDIC says proton pump inhibitors are more effective than H2 blockers and can relieve symptoms in almost everyone who has GERD.
• Prokinetics are another group of drugs. They help strengthen the sphincter and make the stomach empty faster. This group includes bethanechol and metoclopramide. Metoclopramide also improves muscle action in the digestive tract, but these drugs have frequent side effects that limit their usefulness.

Because drugs work in different ways, combinations of drugs 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, while the H2 blockers act on acid production. By the time the antacid stops working, the H2 blocker will have stopped acid production. Your doctor is the best source of information on how to use medications for GERD.

Complications

GERD can result in serious conditions if it isn't treated. Esophagitis results from too much stomach acid in the esophagus and can mean bleeding and ulcers there. (Read about "Gastrointestinal Bleeding") The chronic damage and scaring of the esophagus can result in a narrowing. A condition called Barrett's esophagus can also result. It is severe damage to the skin-like lining of the esophagus. It is sometimes seen as a precursor to cancer. (Read about "Esophagus Cancer)

Testing

If the heartburn goes on, according to NIDDK and ACG, there are tests that can be used to look at the area, including the following:

• Barium swallow radiograph or upper GI x-ray uses x-rays to help spot abnormalities such as a hiatal hernia and severe inflammation of the esophagus. With this test, you drink a solution and then x-rays are taken. Mild irritation will not appear on this test, although narrowing of the esophagus - called stricture - ulcers, hiatal hernia, and other problems will. (Read about "X-rays" "Ulcers" and "Hernias")
• Upper endoscopy can be more accurate than a barium swallow radiograph and may be performed in a hospital or a doctor's office. The doctor will spray your throat to numb it and slide down a thin, flexible plastic tube called an endoscope. A tiny camera in the endoscope allows the doctor to see the surface of the esophagus and to search for abnormalities. If you have had moderate to severe symptoms and this procedure reveals injury to the esophagus, usually no other tests are needed to confirm GERD. The doctor may use tiny tweezers (forceps) in the endoscope to remove a small piece of tissue for biopsy. A biopsy viewed under a microscope can reveal damage caused by acid reflux and rule out other problems if no infecting organisms or abnormal growths are found. (Read about "Endoscopy" "Biopsy")
• Ambulatory pH monitoring involves putting a tiny tube into the esophagus that will stay there for 24 hours. While you go about your normal activities, it measures when and how much acid comes up into your esophagus. This test is useful in people with GERD symptoms but no esophageal damage, according to NIDDC. The procedure is also helpful in detecting whether respiratory symptoms (Read about "Respiratory System"), including wheezing and coughing, are triggered by reflux

There are other tests that put small amounts of acid into the esophagus to make sure the symptoms are caused by acid there, as well as other tests that check the strength of the LES.

Surgery

Surgery is an option when medicine and lifestyle changes do not work.

Fundoplication, usually a specific variation called Nissen fundoplication, is the standard surgical treatment for GERD, according to NIDDC. 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.

This fundoplication procedure may be done using a laparoscope and requires only tiny incisions in the abdomen. (Read about "Endoscopy" "Robotic Surgery") To perform the fundoplication, surgeons use small instruments that hold a tiny camera. AGC says laparoscopic fundoplication has been used safely and effectively in people of all ages, even babies. When performed by experienced surgeons, the procedure is reported to be as good as standard fundoplication. Furthermore, people can leave the hospital in 1 to 3 days and return to work in 2 to 3 weeks.

In 2000, the U.S. Food and Drug Administration (FDA) approved two endoscopic devices to treat chronic heartburn. One puts stitches in the LES to create little pleats that help strengthen the muscle. The second 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, according to NIDDC.

Recently the FDA approved an implant that may help people with GERD who wish to avoid surgery. It involves 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. Once again, NIDDC says the long-term effects of the implant are unknown.

GERD and the heartburn that comes with it are certainly uncomfortable. Surgery is almost always a last resort for GERD. There are also many new drugs coming into play to help heartburn sufferers. Many of them are over-the-counter, but it is still important that you discuss the situation with your doctor before self-medicating.

Related Information:

    Medicine & Digestion

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    Digestive System