Gastroesophageal reflux disease
Gastroesophageal reflux disease (GERD) is a condition in which contents of the stomach or small intestine repeatedly move back up into the esophagus (the tube connecting the throat to the stomach). This backwards movement is called reflux. Reflux causes heartburn. Although most people have heartburn at some point in their lives, persistent reflux and severe heartburn may mean you have GERD. GERD is one of the most common gastrointestinal disorders.
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 night, 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
- 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
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 doesn’t close tightly enough or gets weak over time, the stomach contents can back up into the esophagus, causing heartburn and other symptoms of GERD.
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:
- 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)
- Iron pills, given for anemia
- Non steroidal anti-inflammatory drugs (NSAIDs)
- Ibuprofen (Advil, Motrin)
- Naproxen (Aleve)
- Dopamine, given for Parkinson's disease
- 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)
- 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
- 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
- Frequent vomiting
- Cystic fibrosis
- Digestive disorders
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 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 recommend herbs, such as DGL-licorice (Glycyrrhiza glabra), for their soothing properties. Prescription medicines may be recommended also.
For moderate-to-severe cases, prescription medication may be needed. Your doctor will monitor you closely. In some cases surgery may be needed.
Changing certain habits can go a long way to relieving or preventing symptoms of GERD:
- Don't 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.
- Don't 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.
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 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 or vegetable 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, 1 to 2 capsules or 1 tablespoonful oil, 2 to 3 times daily -- 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), 5 to 10 billion CFUs (colony forming units) a day -- 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 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. You may use herbs as dried extracts (capsules, powders, 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) standardized extract, 250 to 500 mg, 3 times daily, 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) 400 mg, twice daily -- Some 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, 1,000 to 2,000 mg daily in divided doses -- 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.
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.
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.
Austin GL, Thiny MT, Westman EC, Yancy WS Jr, Shaheen NJ.A very low-carbohydrate diet improves gastroesophageal reflux and its symptoms. Dig Dis Sci. 2006;51(8):1307-12.
Berardi RR. Proton pump inhibition. An effective, safe approach to GERD management. Postgrad Med. 2001;Spec No:24-35.
Borrelli F, Izzo AA. The plant kingdom as a source of anti-ulcer remedies. [Review]. Phytother Res. 2000;14(8):581-591.
Bujanda L. The effects of alcohol consumption upon the gastrointestinal tract. Am J Gastroenterol. 2000;95(12):3374-3382.
Burger O, Ofek I, Tabak M, Weiss EI, Sharon N, Neeman I. A high molecular mass constituent of cranberry juice inhibits helicobacter pylori adhesion to human gastric mucus. FEMS Immunol Med Microbiol. 2000 Dec;29(4):295-301.
Burger O, Weiss E, Sharon N, Tabak M, Neeman I, Ofek I. Inhibition of Helicobacter pylori adhesion to human gastric mucus by a high-molecular-weight constituent of cranberry juice. Crit Rev Food Sci Nutr. 2002;42(3 Suppl):279-284.
Coron E, Hatlebakk JG, Galmiche JP.Medical therapy of gastroesophageal reflux disease. Curr Opin Gastroenterol. 2007;23(4):434-9.
Dickman R, Schiff E, Holland A, Wright C, Sarela SR, Han B, Fass R. Clinical trial: acupuncture vs. doubling the proton pump inhibitor dose in refractory heartburn. Aliment Pharmacol Ther. 2007 Nov 15;26(10):1333-44.
El-Serag HB, Satia JA, Rabeneck L. Dietary intake and the risk of gastro-esophageal reflux disease: a cross sectional study in volunteers. Gut. 2005;54(1):11-7.
Farup PG, Heibert M, Høeg V. Alternative vs. conventional treatment given on-demand for gastroesophageal reflux disease: a randomised controlled trial. BMC Complement Altern Med. 2009 Feb 24;9:3.
Ferri. Ferri's Clinical Advisor 2013. 1st ed. Philadelphia, PA: Mosby, An Imprint of Elsevier; 2012.
Fox M, Barr C, Nolan S, et al. The effects of dietary fat and calorie density on esophageal acid exposure and reflux symptoms. Clin Gastroenterol Hepatol. 2007;5(4):439-44.
Fox M, Barr C, Nolan S, Lomer M, Anggiansah A, Wong T. The effects of dietary fat and calorie density on esophageal acid exposure and reflux symptoms. Clin Gastroenterol Hepatol. 2007;5(4):439-44.
Gorbach SL. Probiotics in the third millennium. Dig Liver Dis. 2002;34(Suppl 2):S2-S7.
Han KS. The effect of an integrated stress management program on the psychologic and physiologic stress reactions of peptic ulcer in Korea . J Holist Nurs. 2002;20(1):61-80.
Ihde GM, Basancon K, Deljkich E. Short-term safety and symptomatic outcomes of transoral incisionless fundoplication with or without hiatal hernia repair in patients with chronic gastroensophageal reflux disease. Am J Surg. 2011; 202(6):740-6.
Jansson C, Nordenstedt H, Wallander MA, et al. A population-based study showing an association between gastroesophageal reflux disease and sleep problems. Clin Gastroenterol Hepatol. 2009; 7(9):960-5.
Junghard O, Wiklund IK. Effect of baseline symptom severity on patient-reported outcomes in gastroesophageal reflux disease. Eur J Gastroenterol Hepatol. 2007;19(7):555-60.
Kaltenbach T, Crockett S, Gerson LB. Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach. Arch Intern Med. 2006;166(9):965-71.
Kamolz T, Granderath FA, Bammer T, Pasiut M, Pointner R. Psychological intervention influences the outcome of laparoscopic antireflux surgery in patients with stress-related symptoms of gastroesophageal reflux disease. Scand J Gastroenterol. 2001;36(8):800-805.
KhayyalMT, el-Ghazaly MA, Kenawy SA, et al. Antiulcerogenic effect of some gastrointestinally acting plant extracts and their combination. Arzneimittelforschung 2001;51(7):545-553.
Klausz G, Tiszai A, Lenart Z, et al., Helicobacter pylori-induced immunological responses in patients with duodenal ulcer and in patients with cardiomyopathies. Acta Microbiol Immunol Hung. 2004;51(3):311-20.
Lacy BE, Weiser K, Chertoff J, et al. The diagnosis of gastroesophageal reflux disease. Am J Med. 2010;123(7):583-92.
Marteau P, Boutron-Ruault MC. Nutritional advantages of probiotics and prebiotics. Br J Nutr. 2002;87(Suppl 2):S153-S157.
Marteau PR. Probiotics in clinical conditions. Clin Rev Allergy Immunol. 2002;22(3):255-273.
Martin B. Prevention of gastrointestinal complications in the critically ill patient. AACN Adv CritCare. 2007;18(2):158-66.
Matsushima M, Suzuki T, Masui A, Kasai K, Kouchi T, Takagi A, Shirai T, Mine T. Growth inhibitory action of cranberry on Helicobacter pylori. J Gastroenterol Hepatol. 2008 Dec;23(Suppl 2):S175-80.
McManus TJ. Helicobacter pylori: an emerging infectious disease. Nurs Pract. 2000;25(8):42-46.
Michelfelder A, Lee K, Bading E. Integrative Medicine and Gastrointestinal Disease. Primary Care: Clinics in Office Pediatrics. 2010;37(2).
Moe GL, Kristal AR, Levine DS, Vaughan TL, Reid BJ. Waist-to-hip ratio, weight gain, and dietary and serum selenium are associated with DNA content flow cytometry in Barrett's esophagus. Nutr Cancer.2000;36(1):7-13.
Nachman F, Vazquex H, Gonzalez A, et al. Gastroesophageal reflux symptoms in patients with celiac disease and the effects of a gluten-free diet. Clin Gastroenterol Hepatol. 2011;9(3):214-9.
Nocon M, Labenz J, Willich SN.Lifestyle factors and symptoms of gastro-oesophageal reflux -- a population-based study. Aliment Pharmacol Ther. 2006;23(1):169-74.
Olafsson S, Berstad A. Changes in food tolerance and lifestyle after eradication of Helicobacter pylori. Scand J Gastroenterol. 2003;38(3):268-76.
Pace F, Tonini M, Pallotta S, Molteni P, Porro GB. Systematic review: maintenance treatment of gastro-esophageal reflux disease with proton pump inhibitors taken 'on-demand'. Aliment Pharmacol Ther. 2007;26(2):195-204.
Paraschos S, Magiatis P, Mitakou S, et al. In vitro and in vivo activities of Chios mastic gum extracts and constituents against Helicobacter pylori. Antimicrob Agents Chemother. 2007 Feb;51(2):551-9.
Pereira Rde S.Regression of gastroesophageal reflux disease symptoms using dietary supplementation with melatonin, vitamins and aminoacids: comparison with omeprazole. J Pineal Res. 2006;41(3):195-200.
Qasim A, O'Morain CA. Review article: treatment of Helicobacter pylori infection and factors influencing eradication. Aliment Pharmacol Ther. 2002;16(Suppl 1):24-30.
Rogha M, Behravesh B, Pourmoghaddas Z. Disease symptoms with exacerbations of chronic obstructive pulmonary disease. J Gastrointestin Liver Dis. 2010;19(3):253-6.
Rosemurgy A, Donn N, Paul H, Luberice K, Ross S. Gastroesophageal Reflux disease. Surgical Clinics of North America. 2011; 91(5):1015-29.
Rosch W, Vinson B, Sassin I. A randomised clinical trial comparing the efficacy of a herbal preparation STW 5 with the prokinetic drug cisapride in patients with dysmotility type of functional dyspepsia. Z Gastroenterol. 2002;40(6):401-408.
Ryan SW. Management of dyspepsia and peptic ulcer disease. Altern Ther Health Med. 2005;11(5):26-9; quiz 30.
Salyers WJ Jr, Mansour A, El-Haddad B, Golbeck AL, Kallail KJ. Lifestyle modification counseling in patients with gastroesophageal reflux disease. Gastroenterol Nurs. 2007 Jul-Aug;30(4):302-4.
Shaheen N, Ransohoff DF. Gastroesophageal reflux, Barrett esophagus, and esophageal cancer, clinical applications. JAMA. 2002;287(15):1982-1986.
Simopoulos AP. Omega-3 fatty acids in inflammation and autoimmune diseases. J Am Coll Nutr. 2002;21(6):495-505.
Sugimoto N, Yoshida N, Nakamura Y, Ichikawa H, Naito Y, Okanoue T, Yoshikawa T. Influence of vitamin E on gastric mucosal injury induced by Helicobacter pylori infection. Biofactors. 2006;28(1):9-19.
Takada K, Matsumoto S, Hiramatsu T. Relationship between chronic obstructive pulmonary disease and gastroesphageal reflux disease defined by the Frequency Scale for the Symptoms of gastroesophageal reflux disease. Nihon Kokyuki Gakkai Zasshi. 2010;48(9):644-8.
van P, Numans ME, Bonis PA, Lau J. Short-term treatment with proton pump inhibitors, H2-receptor antagonists and prokinetics for gastro-esophageal reflux disease-like symptoms and endoscopy negative reflux disease. Cochrane Database Syst Rev. 2001;(4):CD002095.
Vonkeman HE, Fernandes RW, van de Laar MA. Under-utilization of gastroprotective drugs in patients with NSAID-related ulcers. Int J Clin Pharmacol Ther. 2007;45(5):281-8.
Winter HS, Illueca M, Henderson C, Vaezi M. Review of the persistence of gastroesophageal reflux disease in children, adolescents and adults: does gasroesophageal reflux disease in adults sometimes begin in childhood. Scan J Gastroenterol. 2011; 46(10):1157-68.
Woodward M, Tunstall-Pedo H, McColl K. Helicobacter pylori infection reduces systemic availability of dietary vitamin C. Eur J Gastroenterol Hepatol. 2001;13(3):233-237.