What Is Heartburn And Gastroesophageal Reflux Disease?

Gastroesophageal Reflux Disease and Heartburn.

The esophagus, commonly called the food pipe, is a narrow muscular tube, about nine and a half inches long that begins below the tongue and ends at the stomach.  The esophagus is narrowest at the top and bottom; it also narrows to a lesser degree in the middle, where it passes the aorta. Wave-like muscle contractions, known as peristalsis, move food down through the esophagus and into the stomach. In the stomach, acid and various enzymes, notably hydrochloric acid and pepsin, break down and digest the starch, fat, and protein in food. Unlike the lining of the stomach, which has a thin layer of protective mucus, the lining of the esophagus offers only a weak defense against stomach acid and other harmful substances. Perhaps the most important structure in protecting the esophagus is the lower esophageal sphincter (LES), which is a band of muscle around the bottom of the esophagus where it meets the stomach. The LES opens after a person swallows to let food enter the stomach and then immediately closes to prevent regurgitation of the stomach contents, including gastric acid. It maintains this pressure barrier until food is swallowed again. If, in spite of LES pressure, there is some acid back-up (reflux), an additional defense mechanism, the peristaltic action of the esophagus, pushes the residue back down into the stomach.

If the LES or the peristaltic action is impaired or other protective mechanisms fail, then acid and other substances back up into the esophagus from the stomach, causing the condition known as gastroesophageal reflux disease (GERD). The most common symptoms of GERD are heartburn (a burning sensation in the chest and throat) and regurgitation (a sensation of acid backed up in the esophagus). In most people, the symptoms are short-lived and occur infrequently. In about 20% of cases, however, the condition becomes chronic. In such cases, the acid can cause irritation, inflammation, and even erosion of the esophagus (a condition called esophagitis). Although acid is a primary factor in damage caused by GERD, other products of the digestive tract, including pepsin and bile, can also be harmful. In a small percentage of chronic patients, a serious form of GERD called Barrett's esophagus may eventually develop, in which the erosion can lead to cancerous changes in the tissue lining of the esophagus.

It should be noted that symptoms of GERD may be present without any signs of injury to the esophagus, a condition now tentatively referred to as non-erosive esophageal reflux disease (NERD). In this condition, patients have no signs of inflammation or erosion in the esophagus, but they have similar symptoms, particularly burning sensations behind the breastbone, for at least three months. Some researchers suggest that, in such cases, nerves lying near the surface of the lining of the surface become exposed to acid that has penetrated the layers; in response the nerves trigger prolonged and painful symptoms. This condition rarely progresses to full-blown GERD.

What Causes Gastroesophageal Reflux Disease?

Mild temporary heartburn caused by overeating acidic foods can happen to anyone, particularly when bending over, taking a nap, or engaging in lifting after a large meal high in fatty, acidic foods. Persistent gastroesophageal reflux disease (GERD), however, may be due to abnormal biologic or structural factors, which include malfunction of the lower esophageal sphincter (LES) muscles, defects or injuries in the lining of the esophagus, peristalsis problems, over-acidic stomach contents, and other problems. Some people may be sensitive to digestive factors other than acid; such substances can cause GERD symptoms, but are likely to be missed during a medical examination.

Malfunction of the Lower Esophageal Sphincter (LES) Muscles

The band of muscle tissue called lower esophageal sphincter (LES) is responsible for closing and opening the lower end of the esophagus and is essential for maintaining a pressure barrier against contents from the stomach. If it loses tone, the LES cannot close up completely after food empties into the stomach; in such cases, acid from the stomach backs up into the esophagus. The LES is a complex area of smooth muscles and various hormones; dietary substances, drugs, and nervous system factors can impair its function.

Impaired Stomach Function

In one study, over half of GERD patients showed abnormal nerve or muscle function in the stomach, which caused impaired motility, an inability of the muscles to contract normally. This causes delays in stomach emptying, increasing the risk for acid back-up.

Hiatus Hernia

Until recent years, it was commonly believed that most cases of persistent heartburn were caused by hiatal, or hiatus, hernia, a protrusion of the stomach muscle from the abdomen up into the chest. Although hiatus hernia may impair LES function, studies have failed to find a close causal association between gastroesophageal reflux and hiatus hernia. Some studies indicate that people with both GERD and hiatal hernia do have more severe gastroesophageal reflux.

Medical Conditions that Contribute to GERD

Asthma. About half of asthmatic patients also have GERD. It is not entirely clear, however, whether asthma is a cause or effect of GERD. Some experts speculate that the coughing and sneezing accompanying asthmatic attacks cause changes in pressure in the chest that can trigger reflux. Exercise-induced asthma does not appear to be related to GERD. Certain asthmatic drugs that dilate the airways may relax the LES and contribute to GERD. 

Treatment for Helicobacter Pylori. Antibiotics used to eradicate the bacterium H. pylori are now accepted treatment for curing peptic ulcers. Of some concern, however, are studies indicating that H. pylori may actually protect against GERD by reducing stomach acid. Some experts estimate that 20% to 30% of patients cured of H. pylori infection will develop new-onset GERD. Some even suggest that widespread elimination of these bacteria may increase the incidence of GERD even to epidemic proportions. Other studies have not been as conclusive, however, and one showed no significant difference between the incidence of new-onset reflux symptoms in patients with and without persistent H. pylori infection.

 

Hypersensitive Esophagus

When the esophagus appears normal but GERD symptoms are present, the cause may be an exaggerated or hyper reactive response to irritants, which triggers the release of certain factors in the immune system that produce inflammation in the esophagus.

Foods that Contribute to GERD

Foods that can weaken LES tone include garlic, onions, chocolate, fat, peppermint, spearmint, and coffee. Caffeinated drinks and decaffeinated coffee increase acid content in the stomach. Other acidic foods include citrus and tomato products. All carbonated beverages increase the risk for symptoms of GERD by bloating the abdomen and causing pressure that forces acid to back up into the esophagus. Food allergies may be responsible for some cases of gastroesophageal reflux disease in children.

Smoking and Alcohol

Alcohol relaxes the LES muscles and also may irritate the mucous membrane of the esophagus. On the other hand, some studies have shown that small amounts of alcohol may actually protect the mucosal layer. Smoking can also reduce muscle function, increase acid secretion, reduce prostaglandins and bicarbonate production, and decrease mucosal blood flow.

Obesity

Study findings have suggested that obesity increases acid in the esophagus, thereby significantly increasing the risk of GERD. (In severely obese individuals, gastric bypass surgery, which shrinks the stomach, not only produces weight loss but also reduces the amount of acid and protects against GERD.)

Drugs that Increase the Risk for GERD

A number of drugs can cause the LES to relax and function poorly including calcium channel blockers, anti-cholinergics, beta- and alpha-adrenergic agonists, dopamine, sedatives, and common pain relievers. Calcium channel blockers and anti-cholinergics also weaken the peristaltic action of the esophagus and slow stomach emptying. The anti-osteoporosis drug alendronate can cause damage to the esophagus. Patients should take this drug with six to eight ounces of water (not juice or carbonated or mineral water) on an empty stomach in the morning and should remain upright for 30 minutes afterward.

Antibiotics can also affect the mucous membrane, making it more vulnerable to acids. Potassium and iron pills are corrosive and can cause ulcers (erosions) in the esophagus.

Nonsteroidal anti-inflammatory drugs (NSAIDs), common causes of peptic ulcers, may also cause GERD. There are dozens of NSAIDs including aspirin, ibuprofen, naproxen, piroxicam, Indomethacin, flurbiprofen, ketorolac, ketoprofen and diclofenac. Most likely, taking an occasional aspirin or other NSAID will not harm someone who has GERD and no other risk factors for or indications of ulcers. Paracetamol (acetaminophen) is usually a good alternative for those who want to relieve mild pain and avoid NSAIDs.

Other Causes of GERD

Weakened peristaltic movement in the esophagus may contribute to GERD. If the mucous membrane is impaired, even a normal amount of acid can harm the esophagus. Pressure on the abdomen caused by factors such as obesity or tight clothing can contribute to acid backing up into the esophagus.

Who Gets Gastroesophageal Reflux Disease?

It is estimated that 60 million have heartburn or other symptoms of GERD at least once a month, and 25 million experience them on a daily basis. Interestingly, a random survey of 2,000 who reported having heartburn at least once in the last 6 months indicated that most didn't know the risk factors for it, and when they were told most made no behavior or lifestyle changes to avoid or prevent heartburn. People at all ages are susceptible to GERD. Elderly people with GERD tend to have a more serious condition than younger people with the problem.

Eating-Pattern Risk Factors

Anyone who eats a heavy meal, particularly if one subsequently lies on the back or bends over from the waist is at risk for an attack of heartburn. Anyone who snacks at bedtime is at high risk for GERD.

Children at Risk

About half of all infants up to three months regurgitate milk at least once a day. Some simply spit up; others vomit large amounts after feedings. When babies cry they often swallow a lot of air, which leads to gas if babies are not burped. Some mothers may even suspect their babies have GERD when they only need to be burped frequently during and after feeding. Even severe vomiting, however, is not necessarily a sign of GERD. Heartburn has been reported in 1.8% of three-year-olds and in 5.2% of young people between 10 and 17 years old. A physician should examine children who vomit frequently and have prolonged symptoms with or without complications, such as anemia, failure to gain weight, or respiratory problems, as soon as possible. Children at highest risk for GERD are those with neurologic impairments or problems in the lungs, ear, nose, or throat. Symptoms of such conditions may include, among others, chronic coughing, frequent infections, wheezing, and disturbed breathing while asleep. Other risk factors for GERD in children include food allergies, scoliosis, cyclic vomiting, cystic fibrosis, and medical conditions that affect the digestive tract. One study suggested that food allergies might be responsible for gastroesophageal reflux disease in children.

Pregnant Women

Pregnant women are particularly vulnerable to GERD in their third trimester as the growing uterus puts increasing pressure on the stomach. Heartburn in such cases is often resistant to dietary interventions and even antacids.

People with Asthma

People with asthma are at very high risk for GERD.

What Are The Symptoms Of Gastroesophageal Reflux Disease?

Typical Symptoms

The primary symptoms of gastroesophageal reflux are heartburn, a burning sensation that radiates up from the stomach to the chest and throat, and regurgitation, in which the patient can feel the acid backing up. Sometimes acid regurgitates as far as the mouth and may come out forcefully as vomit or be experienced as a "wet burp." Up to half of GERD patients have dyspepsia, which is a syndrome consisting of heartburn, fullness in the stomach, and nausea after eating. The symptoms are most likely to occur after a heavy meal, while bending over, lifting, or lying down, particularly on one's back. It should be noted that the severity of symptoms does not necessarily reflect actual injury in the esophagus. For example, Barrett's esophagus, which causes precancerous changes in the esophagus, may cause few symptoms, particularly in elderly people. On the other hand, people can suffer severe heartburn without actual damage to the esophagus.

Atypical Symptoms

Between 10% and 15% of people with GERD have so-called atypical symptoms, which can occur with or without heartburn or acid regurgitation. These symptoms can resemble other serious conditions and may lead to an intensive diagnostic work-up.

Chest Pain. GERD is a common cause of chest pain. It is very important to differentiate chest pain caused by GERD from that caused by heart conditions, particularly angina and heart attack. In general, if the pain does not occur after exertion or is worse at night, then it is less likely to be due to a heart problem. Chest pain from either GERD or from severe angina, however, can occur after a heavy meal. It should be noted that the two conditions often coexist; some patients with coronary artery disease may develop anginal chest pain from acid reflux. Some experts believe that this is because the acid in the esophagus of such patients may activate nerves that temporarily impair blood flow to the heart.

Bleeding. Dark-colored, tarry stools (indicating the presence of blood) or vomiting blood may occur if ulcers have developed in the esophagus. This is a sign of severe damage and requires immediate attention.

Trouble Swallowing and Choking. Many GERD patients report having trouble swallowing (dysphagia). In severe cases patients may even choke or experience the sensation that food is trapped behind the breastbone. These are symptoms of serious esophageal damage or of a temporary spasm that narrows the tube. Choking may also occur because of spasm in the larynx.

Coughing and Asthmatic Symptoms. Asthmatic symptoms, including coughing and wheezing, may occur. GERD is, in fact, the second most common cause of persistent coughing, which can occur without other symptoms of asthma.

Chronic Nausea and Vomiting. Nausea that persists for weeks or even months that is not attributable to a common cause of stomach upset may be a symptom of acid reflux. Vomiting may also occur, in rare cases, as often as once a day. Other causes of chronic nausea and vomiting should be ruled out, including ulcers, stomach cancer, obstruction, or pancreas or gallbladder disorders.

Other Problems in the Throat. If stomach acid reaches the larynx (the voice box), it may cause a condition called acid laryngitis, which can produce hoarseness, a dry cough, the sensation of having a lump in the throat, and the need to repeatedly clear the throat. GERD is also a common cause of chronic sore throat and may also trigger persistent hiccups.

How Serious Is Gastroesophageal Reflux Disease?

General Outlook

Nearly everyone has an attack of heartburn at some point in their lives, and in the vast majority of cases, the condition is temporary and mild, causing only transient discomfort. If patients develop persistent gastroesophageal reflux disease with frequent relapses, however, and it remains untreated, serious problems can develop over time. These can include severe narrowing (called stricture) of the esophagus, erosion of the lining of the esophagus, ulcers, and precancerous changes in the cells of the esophagus. The risk for recurrent and serious GERD increases if the esophagus is very inflamed, if the initial symptoms are severe, if symptoms persist in spite of treatments that are successfully healing the esophagus, or if there are severe underlying muscular abnormalities. In addition to its effect on the esophagus, GERD can also cause complications in other areas, including the teeth, throat, and airways leading to the lungs. The condition is more severe in older people.

Barrett's Esophagus and Cancer of the Esophagus

Barrett's esophagus is caused by chronic and severe exposure to acid and bile reflux caused by GERD. In such cases, cellular changes can occur that, over time, may develop into cancer. Barrett's esophagus is a proven risk factor for cancer in the mucous lining of the esophagus, which is one of the most rapidly increasing cancers in North America. It occurs only in a small number of GERD patients; at risk are patients who develop GERD at an early age and whose symptoms last longer than average. Certain factors increase or reduce the risk for progression to precancerous changes in patients with Barrett's esophagus. The presence of a hiatal hernia that measures at least 3 cm (1.18 in.) poses a higher risk, for example, while the absence of a hiatal hernia or only a short segment of involved esophagus carries a lower risk for cancer. In fact, the absence of that hiatal hernia strongly suggests that Barrett's esophagus will clear up. To date, no treatments can reverse the cellular damage done after Barrett's esophagus has developed. Patients with this condition need to be monitored periodically with endoscopy and biopsy in order to detect cancer early. 

Also of concern was a study that reported a higher risk for esophageal cancer in GERD patients, regardless of whether they developed Barrett's esophagus. Some experts believe that bile, not acid, back up may be the culprit in this process. Standard GERD anti-drug treatments, then, may not be protective. Some experts stress the importance of Nissen fundoplication, a surgical procedure that is effective in suppressing both bile and acid reflux.

Bleeding

If ulcers (erosions) develop in the esophagus, they can cause bleeding. Persistent bleeding can result in iron deficiency anemia, and in some cases, may even require emergency transfusions. This condition may occur even without heartburn or other warning symptoms.

Respiratory Disorders

Asthma. There is a very high incidence of asthma and GERD occurring together, with the reflux disorder occurring in between 32% to 80% of asthma cases. The actual incidence may be on the high side, because, according to one study, about a third of asthma patients diagnosed with GERD had no active reflux symptoms. In fact, one group of researchers believes GERD should be suspected in all patients with asthma. There is also some evidence that GERD worsens asthma symptoms at night (although this effect may occur primarily in children). Some experts believe that GERD causes or exacerbates asthma when the acid leaking from the lower esophagus in GERD stimulates the vagus nerves that are located nearby. These stimulated nerves, in turn, trigger the airways in the lung to constrict, causing asthmatic symptoms. Asthma attacks may be triggered by fluid back-up from the esophagus that is inhaled into the airways (aspirated). The hypothesis that GERD causes asthma is supported by several clinical trials that demonstrated an improvement in asthma symptoms, lung function, or both after therapy for GERD using omeprazole, an anti-GERD drug known as a proton-pump inhibitor. In one study, however, asthma symptoms were relieved by this treatment primarily at night and only in 35% of patients who had both conditions. This study suggests that the effect of GERD on asthma may be significant only in a subset of patients.

Other Respiratory and Airway Conditions. In one study, GERD alone accounted for 41.1% of cases of chronic cough in nonsmoking patients. The incidence is even higher when GERD and asthma are combined. In addition, people with GERD appear to have an above-average risk for a number of other respiratory disorders. These include chronic bronchitis, chronic sinusitis, emphysema, pulmonary fibrosis, and pneumonia. If a person inhales fluid from the esophagus (aspirates) into the lungs, serious pneumonia can occur. It is not yet known whether treatment of GERD would also reduce the risk for these respiratory conditions.

Sleep Apnea

Acid reflux can cause spasms of the vocal cords (larynx), thereby blocking the flow of air to the lungs. One study reported that such spasms may cause sleep apnea in adults. In sleep apnea, breathing stops repeatedly-but temporarily-during sleep. Patients often experience restless sleep, morning headaches, and afternoon drowsiness. In time, they are at higher risk for high blood pressure.

Dental Problems

Dental erosion is a very common problem in GERD patients due to the acid backing up into the mouth and eroding enamel in the teeth.

Chronic Throat Conditions

An estimated 20% to 60% of patients with GERD have "atypical" head and neck symptoms such as a the feeling of having a lump in the throat, without any significant heartburn. In such cases, a failure to diagnose and treat GERD can, in the long term, lead to chronic laryngitis, dysphonia, chronic sore throat, chronic cough, constant throat clearing, and granuloma (soft, pink bumps) on the vocal cords.

Severe Dysphagia

If the esophagus becomes severely injured, over time narrowed regions called strictures can develop, which may impair swallowing (dysphagia). Stretching procedures or surgery may be required to restore normal swallowing. Paradoxically, strictures may actually improve other GERD symptoms by helping to prevent acid from traveling up the esophagus.

GERD in Infants and Children

Gastroesophageal reflux disease in children, as in adults, is usually mild, causing only frequent spitting up. Feeding problems may, however, be more severe than previously thought. In one study, six-month old infants with GERD had problems swallowing, tended to refuse food, and were late in eating solids. They also cried more and reacted more negatively in general than non-GERD babies. Needless to say, such behaviors negatively effected the mothers as well. An earlier study supported these findings by reporting that at one year, children who had GERD in infancy were no longer spitting, but did still tend to have negative dining experiences ("too slow," "upsetting"). (They were at no greater risk for respiratory illnesses than other one-year olds, however.) In rare cases, GERD in infancy causes severe vomiting and increases susceptibility for impaired growth and anemia. It also may produce a syndrome of choking, coughing and gagging, and pneumonia. If acid reflux causes spasms in the larynx severe enough to block the airways, the infant's life may be in danger; in fact, some experts believe this action may contribute to sudden infant death syndrome (SIDS). More research is needed to determine whether this association is valid.

How Is Gastroesophageal Reflux Diagnosed?

In the great majority of cases, a diagnosis of gastroesophageal reflux disease is straightforward, particularly if heartburn and acid regurgitation are present and are lessened by taking antacids for short periods. About 600,000 people come to emergency rooms each year with chest pains. Over 100,000 of these people are believed to actually have GERD. Laboratory or invasive tests are required if heartburn is persistent or if atypical symptoms or complications, such as signs of bleeding or difficulty in swallowing, are present. Until recently, endoscopy, an invasive test, has been used to diagnose GERD and determine treatment. A simple drug trial is proving to be sufficient to identify patients with GERD, however, and endoscopy is increasingly being reserved for detecting evidence of Barrett's esophagus.

A Trial of Omeprazole

A simple noninvasive trial using omeprazole, a drug that blocks stomach acid secretion, may help avoid some invasive tests for identifying GERD, such as endoscopy and pH monitoring. The test involves administration of high-dose omeprazole for several weeks. Studies have found this simple and noninvasive test to be sensitive and fairly specific. In one small trial, the omeprazole test accurately detected 80% of people who had GERD; it missed 20% and inaccurately diagnosed 43% of patients with GERD who didn't have it.

Barium-Swallow Radiograph

A barium swallow radiograph (x-ray) is useful for identifying structural abnormalities and severe esophagitis (inflammation). When taking this test, the patient drinks a solution containing barium, then x-rays are taken, which can show stricture, active ulcer craters, hiatal hernia, erosion, or other abnormalities. This test cannot, however, reveal mild irritation.

Upper Endoscopy

Upper endoscopy, also called esophagogastroduodenoscopy or panendoscopy, is more accurate than a barium-swallow radiograph, although it is more invasive and expensive. Endoscopy may be performed either in a hospital or in a doctor's office. The doctor first administers a local anesthetic using an oral spray and an intravenous sedative to suppress the gag reflex and to relax the patient. Next, the physician places an endoscope, a thin, flexible plastic tube, into the patient's mouth and down the esophagus. The procedure does not interfere with breathing. It may be slightly uncomfortable, but some patients even fall asleep through it. (A less invasive nasal tube administered without sedation may replace many of these procedures in the future.) A tiny camera in the endoscope allows the physician to see the surface of the esophagus and to search for abnormalities, including damage to the mucus lining and hiatal hernia. If a patient has moderate to severe symptoms and the procedure reveals injury in the esophagus, usually no further tests are needed to confirm a diagnosis of GERD. The test is not foolproof, however; a visual view misses about half of esophageal abnormalities. A biopsy (the removal and microscopic examination of small tissue sections) may detect tissue injury indicative of GERD and can rule out or confirm cancer or infective organisms, such as yeast (Candida albicans) or certain viruses (eg, herpes simplex and cytomegalovirus). Such organisms are more likely to occur in people with impaired immune systems. Periodic endoscopy is important for detecting early cancer in people with Barrett's esophagus. For such patients, it is recommended that endoscopy be performed every other year in those with normal cells and then annually if precancerous changes are detected. Complications of the procedure are uncommon, and if they occur, are almost always mild, including minor bleeding from the biopsy site or irritation where medications have been injected.

pH Monitor Examination

The (ambulatory) pH monitor examination uses a tubular probe that is inserted through the nose into the esophagus. The probe is left in place for 24 hours while the patient engages in normal activities. The probe measures the amount of acid backing up in the esophagus and the pattern of its occurrence during the day. This information is useful when GERD symptoms are present, but endoscopy has not detected damage to the mucous lining in the esophagus. It is particularly beneficial for determining if respiratory symptoms, including wheezing and coughing, are related to reflux episodes in patients with unexplained asthma. Because it is only a measure of acidic content, however, other digestive agents in the stomach content that can be causing harm may be overlooked.

Manometry

Manometry is a test that measures internal pressure. Such measurements of the pressure exerted by the lower esophagus sphincter muscles may help determine which patients need or are appropriate candidates for surgery. It is also useful for detecting muscle action abnormalities, including impaired stomach motility (an inability of the muscles to contract normally), which cannot be surgically corrected with standard procedures. Manometry may also be used to detect impaired peristalsis or other motor abnormalities in people with chest pain and GERD. To reproduce chest pain during manometry, the patient may be given acid and a drug to stimulate nerves that affect the heart.

What Are The General Guidelines For Preventing And Treating Gastroesophageal Reflux?

The American College of Gastroenterology (ACG) promulgated its original guidelines for the management of GERD in 1995; the guidelines have since been revised. For patients with mild forms of GERD and an uncomplicated history, the ACG says it is appropriate to treat with over-the-counter medications and antacids as the initial approach. Those who have long-standing symptoms or who require continuous therapy may need endoscopic screening for Barrett's esophagus. Acid suppression continues to be the mainstay of pharmacologic therapy. The guidelines also recommend that GERD should be considered in the differential diagnosis of unexplained causes of chronic chest pain, cough, hoarseness, and asthma.

The majority of cases of gastroesophageal reflux can be managed with lifestyle changes and the use of antacids for episodes of heartburn. Drug manufacturers have recently been aggressively promoting more powerful drug treatments for GERD that should be reserved for severe cases only. Only if conservative measures fail to relieve symptoms are more intensive treatments needed to prevent persistent acid reflux. In such cases, the aim of drug therapy is to reduce the amount of acid present and improve any abnormalities in muscle function of the lower esophagus sphincter (LES), the esophagus, or the stomach. If drugs fail to relieve symptoms, other conditions may be present. As examples, the drug may be unable to control acid reflux during the night. Or bile, rather than acid, may be backing up into the esophagus. Bile is a fluid composed mostly of water, bile salts, lecithin, and cholesterol that is present in the small intestine and gallbladder. Even when symptoms are completely relieved by medication, they usually return within a few months after drug treatment has stopped. Surgery may be indicated under certain circumstances: if lifestyle changes and drug treatments have failed, in patients with medical complications, or in younger people with chronic GERD who face a lifetime of expense and inconvenience with maintenance drug treatment. Because minimally invasive surgical procedures are becoming more widely available, some experts are recommending surgery as treatment for many patients with chronic GERD. They argue that acid-suppressing treatment does not heal the condition, while surgery offers a possible cure. Furthermore, persistent GERD appears to be much more serious than previously believed, and the long-term safety of acid suppression is still uncertain.

What Are The Lifestyle Changes For Managing Gastroesophageal Reflux?

Dietary Changes

People with heartburn should first try lifestyle and dietary changes. In one study, 44% of patients who experienced symptoms of GERD reported improvement after changing their diet. People with heartburn should avoid or reduce consumption of foods and beverages that contain caffeine, chocolate, peppermint, spearmint, and alcohol. Both caffeinated and decaffeinated coffee increase acid secretion. All carbonated drinks increase the risk for GERD. Although physicians often advise patients with GERD to cut down on fatty foods, one small study found no evidence that a low-fat or high-fat meal made any difference in symptom exacerbation. Still, better studies are needed to confirm this and, in any case, it is always wise to avoid high-fat meals.

Prevention of Nighttime GERD

After meals, chronic heartburn sufferers should take a walk or, at the very least, remain upright. Bedtime snacks should be avoided. When going to bed, some experts recommend lying on the left side rather than on the right, because the stomach lies higher than the esophagus when a person sleeps on the right side, which can put pressure on the lower esophageal sphincter, increasing the risk for fluid back-up. Lying flat, in any case, can produce intense acid reflux. To help keep acid in the stomach at night, a patient may need to raise the bed at an angle using four- to six-inch blocks at the head of the bed or a wedge-support that elevates the top half of the body so that the patient's body is tilted up. Extra pillows that only raise the head actually increase the risk for reflux.

Chewing Gum

Because saliva helps neutralize acid and contains a number of other factors that protect the esophagus, chewing gum 30 minutes after a meal has been found to help relieve heartburn and even protect against damage caused by GERD. In fact, chewing on anything at all can help, since it stimulates production of saliva.

Avoiding NSAIDs

Many physicians advise GERD patients to avoid nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Motrin, Advil), or naproxen (Aleve), among others. Tylenol (acetaminophen) is a good alternative.

Other Lifestyle Changes

Quitting smoking is, of course, essential. People who are overweight should try to reduce. People with GERD should avoid tight clothing, particularly around the abdomen.

Managing Infants and Children with GERD

During feeding, and for a while after, any infant should be positioned vertically and burped frequently. If a baby with GERD is fed formula, a mother should ask the doctor about making it thicker to help prevent splashing up from the stomach. Because food allergies may trigger GERD in children, parents may want to discuss with their physicians a dietary plan that starts with a formula using non-allergenic proteins and then adds other foods back one at a time until symptoms are triggered. Studies have found that infants with gastroesophageal reflux who spend prolonged periods of time in infant seats, including car seats, have more reflux than those who spend waking time on their stomachs. Parents of infants with GERD should discuss their baby's sleeping position with their pediatrician. Experts strongly recommend that all healthy infants sleep on their backs to help prevent sudden infant death syndrome. For babies with GERD, however, lying on the back may obstruct their airways. If the physician recommends that such babies sleep on their stomachs, parents should be sure that their infant's mattress is very firm and possibly tilted up at the head, that there are no pillows, and that the baby's head is turned so that the mouth and nose are completely unobstructed.

What Are The Drugs Used For Treating Gastroesophageal Reflux?

A number of drugs are effective in managing both episodic heartburn and persistent GERD. Over-the-counter antacids, which neutralize digestive acids, are the primary drugs for mild symptoms. Also available over the counter are the H ₂ blockers, which block acid production. These drugs provide relief for about half of people with chronic symptoms. Another important class of anti-acid drugs is proton-pump inhibitors (omeprazole or lansoprazole), which suppress acid production. They can relieve symptoms in almost all people with GERD, but are currently used only when symptoms are severe and there is damage to the esophagus lining. Cisapride is known as a prokinetic drug; it does not affect acid production but works on motor function, improving the muscle action of the esophagus, the LES, and stomach to enhance peristaltic action, LES pressure, and stomach emptying. (Unfortunately, the drug has been withdrawn from the market. See below.]

Experts argue about the best way to initiate treatment for GERD with typical symptoms (heartburn and regurgitation) that do not respond to lifestyle changes and or antacids. Using a so-called step-up approach, the physician first prescribes an H ₂ blocker drug. If the condition fails to improve, then therapy is "stepped up" to the more powerful proton pump inhibitor, usually omeprazole. Other physicians, however, advocate a step-down approach, in which the proton pump inhibitor is used first. Treatment is then "stepped down" to milder drugs as the patient improves. Some experts believe, however, that by using the more powerful drug first, symptoms of a peptic ulcer, if present, may be masked and persist undiagnosed. They argue that at this time the step-down approach should be reserved for patients who have complications.

Although studies have not found any cure or reversal of Barrett's esophagus using current drug therapies, one study suggested that profound suppression of acid secretion with omeprazole induced a small but significant regression of Barrett's esophagus. Even when drugs relieve symptoms completely, the condition usually recurs within months after drugs are discontinued. In chronic cases, drugs may need to be taken life-long.

Antacids

Many antacids are available without prescription and are the first drugs recommended to relieve heartburn and mild symptoms. They are best used alone for relief of occasional and unpredictable episodes of heartburn. Despite the many brands, they all rely on various combinations of three basic ingredients, and they all work by neutralizing the acid in the stomach. They may also stimulate the defensive systems in the stomach by increasing bicarbonate and mucous secretion.

 
It is generally believed that liquid antacids work faster and are more potent than tablets, although evidence suggests that they all work equally well. Antacids can interact with a number of drugs in the intestines by reducing their absorption. These drugs include tetracycline, ciprofloxacin , propranolol , captopril , and H ₂ blockers. Interactions can be avoided by taking the drugs one hour before or three hours after taking the antacid.

H2 Blockers

H₂ blockers block or antagonize the actions of histamine; a chemical found in the body that encourages acid secretion in the stomach. They provide symptom relief in about half of GERD patients. The drugs are usually taken at bedtime; some people may need to take them twice a day. Four H ₂ blockers are currently marketed in the US and are available over the counter: famotidine , ranitidine  and nizatidine . All have few side effects and good safety profiles. In spite of different marketing claims, they are all about equally effective. Famotidine is the most potent H2 blocker.

These drugs inhibit acid secretion for six to 24 hours and are very useful for people who need persistent acid suppression. They may also prevent heartburn episodes in people who are able to predict its occurrence. These drugs have few side effects. Headache is the most common; others include mild temporary diarrhea, dizziness, rash, and nausea.

Proton Pump Inhibitors

Proton pump or acid pump inhibitors work by inhibiting the so-called gastric acid pump that is required for the stomach's cells to secrete acid. Oral agents include omeprazole, lansoprazole, rabeprazole, and pantoprazole  (which is expected to be available in intravenous formulation as well). They are more effective than H ₂ blockers.

Proton pump inhibitors are currently recommended for patients with moderate symptoms that do not respond to H ₂ blockers, for those with severe symptoms, those who have respiratory complications, patients who have esophageal injury, and those who have persistent nausea. Some experts believe, however, that they should be the first drugs of choice even for patients with milder symptoms.

Patients with impaired esophageal motility who take proton pump inhibitors are still likely to experience acid breakthrough and reflux at night. Proton pump inhibitors may have little or no effect on regurgitation or asthmatic symptoms. Side effects are uncommon, but can include an allergic reaction, headache, stomach pain, diarrhea, and flatulence. Although studies suggest that they do not pose an increased risk of birth defects, pregnant or nursing mothers should avoid them if possible. These agents appear to be safe and effective for children with severe GERD and may help some avoid surgery.

Drugs to Improve Stomach Emptying and Muscle Action

Prokinetic Drugs. Prokinetic drugs, the most common of which was cisapride, increase s LES pressure, enhance s stomach emptying, and improve s peristaltic action (the wave-like muscular movement) in the esophagus. This type of agent is used when the esophagus is not injured or eroded by acid reflux. Because of continuing, although rare, reports of heart rhythm disorders and deaths linked to the use of cisapride, however, the drug has been withdrawn from the market. The dangerous side effects occurred most often in patients taking certain drugs or in those with certain underlying conditions. Such conditions include heart disease, a history or evidence of irregular heartbeats, kidney disease, lung disease (emphysema, chronic bronchitis), sleep apnea, or conditions, such as dehydration, persistent vomiting or eating disorders, that increase the risk for electrolyte disorders (imbalances in potassium, magnesium, sodium, or calcium). Cisapride should also be avoided by patients taking antibiotics, anti-fungal agents, protease inhibitors, potassium-sparing diuretics, or drugs for treating allergies, angina, arrhythmias, depression, psychosis, or nausea. People currently taking the drug should check with their physician for alternatives

Sucralfate

Sucralfate seems to work by adhering to an ulcer crater and protecting it from further damage by the stomach acid and pepsin. It may be used for maintenance therapy in people with mild to moderate GERD. Other than constipation, which occurs in 2.2% of patients, the drug has few side effects. Sucralfate interacts with a wide variety of drugs, including warfarin, phenytoin and tetracycline.

Investigative and Other Drugs Used for GERD

Foaming Agents. Foaming agents are available over the counter and work by forming a barrier that floats over the contents of the stomach, thereby preventing reflux. Such medications may be useful for patients who have GERD but no signs of injury to the esophagus.

Anti-Spasm Drugs. Baclofen, a gamma-amino butyric acid agonist, used to reduce muscle spasms, has been shown to decrease the number of reflux episodes by as much as 70% in one study and to reduce the episodes of lower esophageal sphincter relaxation, a major factor in GERD.

Other Drugs that Affect Muscle Tone. Another drug that helps muscle tone in the digestive tract is metoclopramide (Reglan); a few reports of neurologic side effects in children have also raised concern. It should be noted, however, that serious side effects are still very rare and these drugs may offer significant benefit for adults and children who have delayed stomach emptying. Erythromycin has also been used to improve stomach emptying.

Drug Combinations

A number of studies have investigated combinations of anti-GERD drugs. One study suggested that a combination of over-the-counter antacids and H ₂ blockers might be the best approach for many people who experience heartburn after eating. Both classes of drugs are effective in relieving GERD but have different timing. Antacids neutralize the acid already in the stomach and work within a few minutes, but their effects do not last more than an hour or so. H ₂ blockers suppress acid production, so it takes between a half hour to 90 minutes for them to work, but their benefits persist for hours. Because these drugs have different actions, they may be taken in combination without concern that the effects are additive, although some research indicates that antacids may slow down absorption of H2 blockers and therefore reduce their effectiveness.

For severe cases, some experts recommend a combination of one of the acid-reducing drugs (either an H ₂ blocker or a proton-pump inhibitor) with a prokinetic drug (usually cisapride), which works on muscle action. Some suggest that such combinations be considered under the following circumstances: when single drugs fail, when the primary symptom is acid regurgitation, when symptoms occur mostly at night, when respiratory problems accompany GERD, when reflux symptoms persist, but tests do not show abnormally high acid levels in the esophagus, or when patients are seriously ill and also have severe GERD. It should be noted that combination therapies are expensive and should not be used until other options have failed. For severe cases, some experts believe combination therapy has no benefit over high doses of a proton-pump inhibitor because symptom severity is most -likely due to injury to the esophagus from acid, against which the prokinetic drug has no effect.

What Are The Surgical Treatments For Gastroesophageal Reflux?

Evidence now strongly suggests that anti-reflux surgery is superior to medication for maintaining remission in patients with severe GERD. Moreover, only surgery improves regurgitation, and it is far more effective in improving asthmatic symptoms than drug treatment. Many experts, then, believe surgery should be considered as primary treatment in patients with server GERD, rather than long-term maintenance drug therapy, which cannot cure the reflux disorder and have unknown long-term effects on the stomach. One study reported that the life-time costs of surgical treatment are less than treatment using proton pump inhibitors, assuming a patient took the medication for one-third of a normal life-span. Complications, although uncommon, can still occur even with minimally invasive surgeries, and patients should always consider any elective surgery very carefully.

Fundoplication

The standard surgical treatment for GERD is fundoplication, usually a specific variation called Nissen fundoplication. The goal of fundoplication is to increase LES pressure so that acid reflux is prevented and to repair any present hiatal hernia. About 90% of patients are free of heartburn after the operation. It also cures GERD-induced asthmatic or respiratory symptoms in up to 85% of patients. The procedure may enhance stomach emptying, and it improves peristalsis in about half of patients. (It may actually cause abnormal peristalsis in about 14% of patients, although in such cases the problem does not appear to be very significant.) Although fundoplication is not thought to be very effective for Barrett's esophagus, it is the only treatment that suppresses both acid and bile reflux. (The latter is thought to play a role in the development of early cancer in Barrett's esophagus.)

Candidates for Fundoplication. Fundoplication is recommended for patients whose condition includes one or more of the following: esophagitis (inflamed esophagus), recurrent or persistent symptoms in spite of drug treatment, strictures, evidence of severe asthmatic symptoms caused by GERD, or in children who fail to gain or maintain weight. Surgery has, until recently, been the primary treatment for children with severe complications from GERD because drugs had severe side effects, were ineffective, or had not been optimized for children. With the introduction of omeprazole, some children may be able to avoid surgery. The procedure has little benefit for patients with impaired stomach motility (an inability for the muscles to move spontaneously).

The Procedures. Until recently the standard fundoplication procedure for GERD has been the 360 ° Nissen fundoplication, which is a so-called open procedure because it is an invasive technique that requires wide surgical incisions. With this procedure, the fundus (the upper part) of the stomach is wrapped completely around the esophagus in order to put pressure on the LES. ⁴² This open procedure has now been replaced in many cases by a less invasive fundoplication procedure that uses laparoscopy. In this operation, tiny incisions are made in the abdomen and small instruments and a tiny camera are inserted through tubes. Laparoscopic fundoplication appears to be safe and effective in people of all ages, even very small babies. When performed by experienced surgeons, the procedure is showing results that are equal to those from standard open fundoplication and recovery time is faster. In about 8% of laparoscopies, it is necessary to convert to open surgery during the procedure. The procedure is more difficult in certain patients, including those who are obese, who have a short esophagus, or who have a history of previous surgery in the upper abdominal area. Open fundoplication has failure rates of 9% to 30%, which require repeat procedures in most patients. Failure rates for laparoscopy are still uncertain, although one center reported the need for repeat procedures due to laparoscopy failure in only 3.5% of cases. Even with repeat surgery, results are excellent, and laparoscopy (rather than invasive procedures) may even be appropriate, particularly when performed by experienced surgeons.

A number of variants of the fundoplication procedure now employ only a partial wrap (such as one called Toupét fundoplication) or a very short and "floppy" Nissen full wrap. Many surgeons are reporting that the partial fundoplications result in earlier feeding and discharge from the hospital and a lower incidence of complications, particularly dysphagia (problems with swallowing), gas bloating, and gagging than the full Nissan fundoplication. These benefits appear to apply to children as well as adults. Partial fundoplications procedures, however, appear to be much more effective in patients with poor or no esophageal motility (spontaneous muscle contraction) than in those with normal motility, who may do better with the full-circle wrap.

Complications. After surgery, there may be a delay in intestinal functioning that causes bloating, gagging, and vomiting, which resolves in a few weeks. If symptoms persist or if they start weeks or months after surgery, particularly if vomiting is present, then surgical complications are likely. Complications include bowel obstruction, wound infection, and injury to nearby organs. If the fundus is wrapped too tightly, patients may have difficulty swallowing or experience gagging, gas, bloating, or inability to burp. Difficulty in swallowing appears to be much more common after laparoscopy than open fundoplication, and patients should be warned about this before the procedure. Respiratory complications can occur but are uncommon, particularly with laparoscopic fundoplication. In rare cases following surgery, muscle s spasms after swallowing food can cause intense pain, and patients may require a liquid diet, sometimes for weeks. The complication rate can be very high in children with neurologic abnormalities, who are, unfortunately, at very high risk for GERD in the first place. Hiatal herniation is the most common reason for surgical failure and the need for a repeat procedure. Other common reasons for re-operation are fundoplication problems, including breakdown, slippage, and excessive tightness of the wrap.

Esophagectomy

Esophagectomy is the surgical removal of all or part of the esophagus. Patients with Barrett's esophagus who are otherwise healthy are candidates for this procedure if endoscopy shows developing cancer.

Ablation Procedures

Procedures using laser or heat probes are being investigated for ablating (removing) injured tissue in the mucus lining of the esophagus. Researchers are hoping that such techniques will be successful in treating precancerous cells and small cancers that are detected in Barrett's esophagus. Studies on the use of ablation procedures along with aggressive standard anti-GERD drug or surgical treatments are encouraging.

Prosthetic Devices

The Angelchik prosthesis is a silicone collar that is placed around the LES. The procedure is generally not recommended because complications are very common, particularly difficulty in swallowing. GERD can also recur, and even more serious, the device can migrate and puncture organs. Under investigation is an inflatable cone that may allow pressure adjustment after implantation.

Procedures for Complications of GERD

Treatments for Bleeding. Endoscopic treatment of bleeding involves using a probe passed through the endoscopic tube that applies electricity or heat to coagulate blood and stop the bleeding.

Treatment of Strictures. Strictures (abnormally narrowed regions) may need to be dilated (opened) with endoscopy. Dilation may be performed by inflating a balloon in the passageway. About 30% of patients who need this procedure require a series of dilation treatments over a long duration in order to fully open the passageway. Long-term use of proton-pump inhibitors may reduce this duration.

Phototherapy for Barrett's Esophagus. An experimental procedure called photodynamic therapy is showing promise for removing local cancers and precancerous tissue found in patients with Barrett's esophagus. 

Newer Endoscopic Therapies 

1. Endoscopic Sewing
2. Radiofrequency Ablation