Gastroesophageal reflux disease

Signs and Symptoms

Heartburn, a burning sensation under the sternum in the chest, is the primary symptom of GERD. Heartburn often happens after a meal and gets worse at when you are lying down. It is more likely to happen after a heavy meal, or if you bend, lift, or lie down after eating.

Other symptoms of GERD include:

• Regurgitating food
• Belching
• Nausea and vomiting
• Chronic cough, wheezing
• Sore throat, hoarseness or change in voice, difficulty swallowing
• Chest pain
• Sour taste

GERD is common in infants and young children, but is usually mild. If an infant has the following symptoms, call a doctor as soon as possible:

• Ongoing coughing
• Wheezing, gasping
• Severe vomiting
• Frequent burping

Causes

Normally when you swallow, the muscles in the esophagus move in waves to push food down into your stomach. Just after the food enters the stomach, a band of muscle (the lower esophageal sphincter, or LES) closes off the esophagus. If the muscle does not close tightly enough or gets weak over time, stomach contents can back up into the esophagus, causing heartburn and other symptoms.

Substances in the digestive juices from the stomach (such as acid, pepsin, and bile) can damage the inner lining of the esophagus. That can lead to ulcers (open sores), and, possibly, precancerous changes to cells (called Barrett's esophagus).

Any of the following may weaken the LES:

• Pregnancy
• Obesity
• Hiatal hernia, where a portion of the stomach protrudes through an opening in the diaphragm where the esophagus normally fits snugly
• Frequent vomiting
• Nasogastric tubes, which are inserted through the nose and into the stomach for a variety of medical reasons
• Smoking cigarettes
• Alcohol and coffee
• Certain foods, such as chocolate, yellow onions, and peppermint

Some medicines can also weaken the LES. Among them are:

Calcium channel blockers

Used to control high blood pressure:

• Amlodipine (Norvasc)
• Diltiazem (Cardizem, Dilacor, Tiazac)
• Felodipine (Plendil)
• Nifedipine (Procardia, Adalat)
• Nisoldipine (Sular)
• Verapamil (Verelan, Calan)

Anticholinergic drugs

• Benztropine (Cogentin)
• Dicyclomine (Bentyl)
• Hyoscyamine (Levsin)
• Isopropamide
• Scopolamine

Iron pills. Given for anemia.

Non steroidal anti-inflammatory drugs (NSAIDs)

• Aspirin
• Ibuprofen (Advil, Motrin)
• Naproxen (Aleve)

Potassium

Dopamine. Given for Parkinson disease.

Sedatives

Bisphosphonates

Used to treat osteoporosis:

• Alendronate (Fosamax)
• Risedronate (Actonel)

Beta blockers

Used to treat high blood pressure:

• Atenolol (Tenormin)
• Bisoprolol (Zebeta)
• Metoprolol (Lopressor, Toprol XL)
• Nadolol (Corgard)
• Propranolol (Inderal)

Risk Factors

• Eating heavy meals
• Lying down or bending after a meal
• Eating right before exercise
• Prior esophageal surgery
• Esophageal stricture (narrowing of the esophagus)
• Cigarette smoking
• Drinking alcohol
• Stress
• Chronic obstructive pulmonary disease
• Celiac disease
• Sleep disorders
• Having GERD as a child

Children with the following conditions are at particular risk for GERD:

• Neurologic impairment (such as cerebral palsy, epilepsy)
• Food allergies
• Scoliosis
• Frequent vomiting
• Cystic fibrosis
• Digestive disorders

Diagnosis

GERD is usually not hard to diagnose. Your symptoms, what you eat and drink, medications you are taking, and your lifestyle are usually enough to make a clear diagnosis. If your doctor is not sure, one or more tests may be performed:

• Ph Testing. Determines the amount of acid in your system.
• Upper endoscopy, called esophageal gastroduodenoscopy (EGD). A tube with a tiny camera is inserted down your throat into the esophagus to look for signs of reflux, inflammation, ulcers, or other changes in the esophagus.
• A barium swallow. After drinking a barium "shake," you have a series of x-rays taken of your esophagus. The x-rays look at the movement of the esophagus and whether any fluid comes back from the stomach into the esophagus.
• Manometry. Measures the pressure of the sphincter muscle. In people with GERD, the pressure is often low.

Treatment

Treatment is intended to reduce the reflux, stop the harmful effect by reducing stomach acid, improve the way food gets through to the stomach, and protect the walls of the esophagus.

For mild cases, lifestyle changes (such as avoiding certain foods), elevating the head of your bed, and taking over-the-counter medication may be enough to reduce symptoms. Health care professionals may prescribe medications or recommend herbs, such as DGL-licorice (Deglychyrrhizinated Glycyrrhiza glabra), for their soothing properties.

For moderate-to-severe cases, prescription medication may be needed. Your doctor will monitor you closely. In some cases surgery may be needed.

Lifestyle

Changing certain habits can go a long way to relieving or preventing symptoms of GERD:

• DO NOT do anything that might stop food from moving easily down the esophagus into the stomach. This includes bending, lying down, or doing intense exercise soon after a meal.
• DO NOT eat heavy meals.
• Avoid acidic foods and drinks, such as caffeinated drinks, decaffeinated coffee, and orange juice.
• Avoid alcohol, chocolate, spearmint, and peppermint. They can relax the lower esophageal sphincter.
• Avoid carbonated beverages.
• Avoid eating fatty foods, including full-fat milk, which also may relax the lower esophageal sphincter. Take any medication with plenty of water.
• Lose weight if you are overweight.
• Quit smoking.
• If possible, avoid medications that cause symptoms. If your doctor has prescribed one of these medications, ask about other options.
• Practice relaxation techniques. Stress may make symptoms worse, so forms of relaxation, such as yoga, tai chi, or meditation, are worth considering as part of your treatment plan.

If you have more symptoms at night, these steps may help:

• Raising the head of your bed about 6 inches.
• Avoiding bedtime snacks.

Medications

The main aim of drug treatment is to reduce stomach acid. Both prescription and over-the-counter drugs that reduce stomach acid are available. Your doctor will determine which medicine is best for you.

There are several types of medications used for GERD, and each works in a different way.

Over-the-counter antacids, neutralize stomach acids. They include:

• Aluminum hydroxide (Amphojel, AlternaGEL)
• Magnesium hydroxide (Phillips' Milk of Magnesia)
• Aluminum hydroxide and magnesium hydroxide (Maalox, Mylanta)
• Calcium carbonate (Rolaids, Titralac, Tums)
• Sodium bicarbonate (Alka Seltzer)

Antacids may block medications from being absorbed and thereby decrease the medicine's effectiveness. It is recommended to take antacids at least 1 hour before or 2 hours after taking medications. Ask your pharmacist or doctor for more information.

Histamine H2 blockers. Block the production of stomach acid. They include:

• Cimetidine (Tagamet)
• Ranitidine (Zantac)
• Nizatidine (Axid)
• Famotidine (Pepcid)

Proton pump inhibitors. Work by suppressing molecules responsible for the release of stomach acid. They include:

• Esomeprazole (Nexium)
• Lansoprazole (Prevacid)
• Omeprazole (Prilosec)
• Pantoprazole (Protonix)
• Rabeprazole (Aciphex)

Sucralfate (Carafate). Makes a coating over an ulcer, protecting it from further damage.

Metoclopramide (Reglan). Promotes movement of stomach acids along the gastrointestinal tract, rather than backing up into the esophagus.

Surgery and Other Procedures

For a small number of people, diet, medication, and lifestyle changes are not enough to relieve symptoms of GERD. In such cases, a surgical procedure called fundoplication may be done to prevent reflux and repair a hiatal hernia. Up to 90% of people who have had this operation report no longer having heartburn.

Nutrition and Dietary Supplements

Following these nutritional tips may help reduce symptoms:

• Eat antioxidant-rich foods, including fruits (such as blueberries, cherries, and tomatoes), and vegetables (such as squash and bell peppers).
• Eat foods high in B vitamins and calcium, such as almonds, beans, whole grains (if no allergy), dark leafy greens (such as spinach and kale), and sea vegetables.
• Avoid refined foods, such as white breads, pastas, and especially sugar.
• Eat fewer red meats and more lean meats, cold-water fish, tofu (soy, if no allergy) or beans for protein.
• Use healthy oils, such as olive oil.
• Reduce or eliminate trans fatty acids, found in commercially-baked goods, such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
• Avoid beverages that can irritate the lining of the stomach or increase acid production including coffee (with or without caffeine), alcohol, and carbonated beverages.
• Drink 6 to 8 glasses of filtered water daily.
• Exercise at least 30 minutes daily, 5 days a week.

The following supplements may help with digestive health:

• A multivitamin daily, containing the antioxidant vitamins A, C, E, the B vitamins, and trace minerals, such as magnesium, calcium, zinc, and selenium.
• Omega-3 fatty acids, such as fish oil, may help decrease inflammation. Omega-3 fatty acids may increase the risk of bleeding, as ask your doctor before taking omega-3 fatty acids if you take blood-thinning medications. To avoid a potentially toxic build up of vitamin A, choose omega-3 fatty acid products where the bulk of vitamin A has been removed.
• Probiotic supplement (containing Lactobacillus acidophilus). Probiotics or "friendly" bacteria may help maintain a balance in the digestive system between good and harmful bacteria. Some probiotic supplements may need to be refrigerated for best results. People who have weakened immune systems, or who are on immune suppressive drugs, should take probiotics only under the direction of their physician.

Herbs

Herbs are one way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider to diagnose your problem before starting treatment. Herbs can interact with medications and/or other supplements, and may not be appropriate for people with certain medical conditions. Tell all of your medical providers about any supplements you are using or considering using before starting a regimen. You may use herbs as dried extracts (capsules, powders, or teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, make teas with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups per day. You may use tinctures alone or in combination as noted.

• DGL-licorice (Glycyrrhiza glabra), chewed either 1 hour before or 2 hours after meals, may help protect against stomach damage from NSAIDs. Glycyrrhizin is a chemical found in licorice that causes side effects and drug interactions. DGL is deglycyrrhizinated licorice, or licorice with the glycyrrhizin removed. The duration of use for DGL depends on many factors; speak with your physician.
• Cranberry (Vaccinium macrocarpon). Preliminary research suggests cranberry may inhibit H. pylori growth in the stomach. Cranberry may increase the length of time that medications, including warfarin (Coumadin), may stay in your body. And your doctor may need to change the dose of your medication. Cranberry contains high levels of salicylic acid, which is similar to aspirin. Therefore, people who have aspirin allergies may want to avoid cranberry supplements. People who have a history of kidney stones should speak with their doctors before using cranberry supplements.
• Mastic (Pistacia lentiscus) standardized extract. Mastic is a traditional treatment for peptic ulcers and inhibits H. pylori in test tubes. More studies are needed to see whether it works in humans.

Homeopathy

Although few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider the following remedies for the treatment of GERD symptoms based on their knowledge and experience. Before prescribing a remedy, homeopaths take into account your constitutional type to your physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each individual.

• Pulsatilla. For heartburn, queasiness, a bad taste in the mouth brought on by eating rich foods and fats (especially ice cream); symptoms may include vomiting partly digested food. This remedy is most appropriate for an individual whose tongue is coated with a white or yellow substance.
• Ipecacuahna. For persistent and severe nausea, with or without vomiting and diarrhea, caused by an excess of rich or fatty foods.
• Carbo vegetabilis. For bloating and indigestion, especially with flatulence and fatigue.
• Nux vomica. For heartburn, nausea, retching without vomiting, and sour burps caused by overeating, alcohol use, or coffee drinking. This remedy is most appropriate for individuals who also feel irritable and sensitive to noise and light.

Other Considerations

Pregnancy

GERD is common during pregnancy, particularly in the third trimester. In fact, the incidence in pregnant women exceeds 80 percent.

Warnings and Precautions

Contact your health care provider if the medication recommended does not help or if you experience side effects, such as cramping or diarrhea.

Prognosis and Complications

The acidic contents of the stomach can damage the esophagus, causing narrowing, ulcers, erosion, and precancerous changes to cells known as Barrett's esophagus. GERD can also result in respiratory diseases, ear, nose, throat conditions, and tooth decay. Most people can manage their symptoms with lifestyle modifications and medications.

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