What is GERD?
Gastroesophageal reflux disease (GERD) is a more serious form of gastroesophageal reflux (GER), which is common. GER occurs when the lower esophageal sphincter (LES) opens spontaneously, for varying periods of time, or does not close properly and stomach contents rise up into the esophagus. GER is also called acid reflux or acid regurgitation, because digestive juices—called acids—rise up with the food. The esophagus is the tube that carries food from the mouth to the stomach. The LES is a ring of muscle at the bottom of the esophagus that acts like a valve between the esophagus and stomach.
When acid reflux occurs, food or fluid can be tasted in the back of the mouth. When refluxed stomach acid touches the lining of the esophagus it may cause a burning sensation in the chest or throat called heartburn or acid indigestion. 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.
What are the symptoms of GERD?
The main symptom of GERD in adults is frequent heartburn, also called acid indigestion—burning-type pain in the lower part of the mid-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.
What causes GERD?
The reason some people develop GERD is still unclear. However, research shows that in people with GERD, the LES relaxes while the rest of the esophagus is working. Anatomical abnormalities such as a hiatal hernia may also contribute to GERD. A hiatal hernia occurs when the upper part of the stomach and the LES move above the diaphragm, the muscle wall that separates the stomach from the chest. Normally, the diaphragm helps the LES 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 most often a normal 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:
Common foods that can worsen reflux symptoms include:
- citrus fruits
- drinks with caffeine or alcohol
- garlic and onions
- spicy foods
- fatty and fried foods
- mint flavorings
- tomato-based foods - like spagetti sauce, chili, salsa and pizza
How is GERD treated?
See your health care provider if you have had symptoms of GERD and have been using antacids or other over-the-counter reflux medications for more than 2 weeks. Your health care provider may refer you to a gastroenterologist, a doctor who treats diseases of the stomach and intestines. Depending on the severity of your GERD, treatment may involve one or more of the following lifestyle changes, medications, or surgery.
- If you smoke, you should quit.
- Avoid foods and beverages that worsen symptoms.
- Eat small, frequent meals.
- Avoid lying down for 3 hours after a meal.
- Lose weight if needed
- Wear loose-fitting clothes
- Raise the head of your bed 6 to 8 inches by securing wood blocks under the bedposts. Just using extra pillows will not help.
Your health care provider may recommend over-the-counter antacids or medications that stop acid production or help the muscles that empty your stomach. You can buy many of these medications without a prescription. However, see your health care provider before starting or adding a medication.
Antacids, such as Alka-Seltzer, Maalox, Mylanta, Rolaids, and Riopan, 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—with hydroxide or bicarbonate ions to neutralize the acid in your 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, such as Tums, Titralac, and Alka-2, can also be a supplemental source of calcium. They can cause constipation as well.
Foaming agents, such as Gaviscon, work by covering your stomach contents with foam to prevent reflux.
H2 blockers, such as cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR), and ranitidine (Zantac 75), decrease acid production. They are available in prescription strength 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
Proton pump inhibitors include omeprazole (Prilosec, Zegerid), lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex), and esomeprazole (Nexium), which are available by prescription. Prilosec is also available in over-the-counter strength. 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 strengthen the LES and make the stomach empty faster. This group includes bethanechol (Urecholine) and metoclopramide (Reglan). Metoclopramide also improves 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, and then the H2 blockers act on acid production. By the time the antacid stops working, the H2 blocker will have stopped acid production. Your health care provider is the best source of information about how to use medications for GERD.
What are the long-term complications of GERD?
Chronic GERD that is untreated 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, the cells can lead to esophageal cancer, which is often fatal. Persons with GERD and its complications should be monitored closely by a physician.
Studies have shown that GERD may worsen or contribute to asthma, chronic cough, and pulmonary fibrosis.
Considerations for the Pharmacologic Management of Gastroesophageal Reflux Disease
- GERD is a common disorder; severity ranges from mild non-erosive disease to severe complicated
- Goals of treatment are to relieve patient symptoms, heal esophagitis, manage or prevent complications, avoid recurrence.
- Treatment should be based upon patient symptomology, although symptoms do not always reflect disease severity.
- Diagnostic evaluation is warranted in patients with atypical symptoms, at high risk for Barrett’s metaplasia, have failed pharmacologic therapy, or have signs or symptoms of complicated disease. Esophagogastroduodenoscopy (EGD) is the best test to evaluate mucosal damage.
- Lifestyle modifications are recommended in all patients with GERD throughout therapy.
- Pharmacologic therapy should be considered in patients who do not adequately respond to lifestyle modifications or have moderate to severe symptoms or evidence of esophageal damage.
- Options for pharmacotherapy include an antacid, histamine2 receptor antagonist, or a proton pump inhibitor (PPI). Prokinetic agents should be reserved for patients who fail other therapies due to their potential for serious and potentially life-threatening drug and disease interactions.
- Surgical intervention may be necessary in a minority of patients and is based on individual patient considerations and preferences. A gastroenterologist should be consulted to help determine the appropriateness of antireflux surgery in patients with severe esophagitis, intractable symptoms, recurrent symptoms despite maintenance antisecretory therapy, or in patients requiring maintenance therapy with a PPI. Surgery may be the preferred therapy in these patients, especially if they are young and otherwise healthy.