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What is GERD (acid reflux)?
Gastroesophageal reflux disease, commonly referred to as GERD or acid reflux, is a condition in which the liquid content of the stomach regurgitates (backs up or refluxes) into the esophagus. The liquid can inflame and damage the lining (cause esophagitis) of the esophagus although visible signs of inflammation occur in a minority of patients. The regurgitated liquid usually contains acid and pepsin that are produced by the stomach. (Pepsin is an enzyme that begins the digestion of proteins in the stomach.) The refluxed liquid also may contain bile that has backed-up into the stomach from the duodenum. (The duodenum is the first part of the small intestine that attaches to the stomach.) Acid is believed to be the most injurious component of the refluxed liquid. Pepsin and bile also may injure the esophagus, but their role in the production of esophageal inflammation and damage is not as clear as the role of acid. GERD is a chronic condition. Once it begins, it usually is life-long. If there is injury to the lining of the esophagus (esophagitis), this also is a chronic condition. Moreover, after the esophagus has healed with treatment and treatment is stopped, the injury will return in most patients within a few months. Once treatment for GERD is begun, therefore, it usually will need to be continued indefinitely although it is argued that in some patients with intermittent symptoms and no esophagitis, treatment can be intermittent and done only during symptomatic periods. In fact, the reflux of the stomach's liquid contents into the esophagus occurs in most normal individuals. One study found that reflux occurs as frequently in normal individuals as in patients with GERD. In patients with GERD, however, the refluxed liquid contains acid more often, and the acid remains in the esophagus longer. It has also been found that liquid refluxes to a higher level in the esophagus in patients with GERD than normal individuals. As is often the case, the body has ways (mechanisms) to protect itself from the harmful effects of reflux and acid. For example, most reflux occurs during the day when individuals are upright. In the upright position, the refluxed liquid is more likely to flow back down into the stomach due to the effect of gravity. In addition, while individuals are awake, they repeatedly swallow, whether or not there is reflux. Each swallow carries any refluxed liquid back into the stomach. Finally, the salivary glands in the mouth produce saliva, which contains bicarbonate. With each swallow, bicarbonate-containing saliva travels down the esophagus. The bicarbonate neutralizes the small amount of acid that remains in the esophagus after gravity and swallowing have removed most of the liquid. Gravity, swallowing, and saliva are important protective mechanisms for the esophagus, but they are effective only when individuals are in the upright position. At night during sleep, gravity is not in effect, swallowing stops, and the secretion of saliva is reduced. Therefore, reflux that occurs at night is more likely to result in acid remaining in the esophagus longer and causing greater damage to the esophagus. Certain conditions make a person susceptible to GERD. For example, GERD can be a serious problem during pregnancy. The elevated hormone levels of pregnancy probably cause reflux by lowering the pressure in the lower esophageal sphincter (see below). At the same time, the growing fetus increases the pressure in the abdomen. Both of these effects would be expected to increase

and collection of fluid in the sinuses and middle ear. 24 hour esophageal acid testing. • • • • • . GERD may damage the lining of the esophagus. throat and laryngeal inflammation. thereby causing inflammation (esophagitis). patients with diseases that weaken the esophageal muscles (see below). hiatal hernia. although usually it does not. GERD may be diagnosed or evaluated by a trial of treatment. and esophageal acid perfusion. examination of the throat and larynx. Also. The causes of GERD include an abnormal lower esophageal sphincter. and slow emptying of the stomach. regurgitation. and nausea. inflammation and infection of the lungs. Barrett's esophagus is a pre-cancerous condition that requires periodic endoscopic surveillance for the development of cancer.Page 2 of 17 reflux. emptying studies of the stomach. endoscopy. are more prone to develop GERD. abnormal esophageal contractions. Complications of GERD include ulcers and strictures of the esophagus. X-ray. cough and asthma. The symptoms of uncomplicated GERD are heartburn. esophageal motility testing. biopsy. Barrett's esophagus. GERD Facts • • GERD is a condition in which the acidified liquid content of the stomach up into the esophagus. such as scleroderma or mixed connective tissue diseases.

In some patients. frequent or prolonged regurgitation can lead to acid-induced erosions of the teeth. usually only small quantities of liquid reach the esophagus. however. and then they become less frequent or severe or even absent for several weeks or months. surgery. and acid is returned to the stomach more slowly. Episodes of heartburn may occur infrequently or frequently. rather than burning. The UES is a circular ring of muscle that is very similar in its actions to the LES. are refluxed and reach the upper esophagus. and the liquid remains in the lower esophagus. This means that the episodes are more frequent or severe for a period of several weeks or months. reflux occurs more easily. Many patients with GERD are awakened from sleep by heartburn. larger quantities of liquid. This nerve stimulation results most commonly in heartburn. Heartburn usually is described as a burning pain in the middle of the chest. patients may suddenly find their mouths filled with the liquid or food. regurgitation. and nausea. That is. In most patients with GERD. but episodes tend to happen periodically.Page 3 of 17 • GERD is treated with life-style changes. At the upper end of the esophagus is the upper esophageal sphincter (UES). nerve fibers in the esophagus are stimulated. What's more. It may start high in the abdomen or may extend up into the neck. Other symptoms occur when there are complications of GERD and will be discussed with the complications. histamine antagonists (H2 blockers). the pain may extend to the back. the UES prevents esophageal contents from backing up into the throat. Regurgitation Regurgitation is the appearance of refluxed liquid in the mouth. Heartburn When acid refluxes back into the esophagus in patients with GERD. Since acid reflux is more common after meals. Occasionally in some patients with GERD. This periodicity of symptoms provides the rationale for intermittent treatment in patients with GERD who do not have esophagitis. proton pump inhibitors (PPIs). foam barriers. pro-motility drugs. Such pain can mimic heart pain (angina). and endoscopy. the pain may be sharp or pressure-like. and it almost always returns. heartburn is a life-long problem. Heartburn is also more common when individuals lie down because without the effects of gravity. there may be an acid taste in the mouth. In other patients. sometimes containing food. the pain that is characteristic of GERD. . Nevertheless. If larger quantities breach the UES. What are the symptoms of uncomplicated GERD? The symptoms of uncomplicated GERD are primarily heartburn (sometimes interpreted as chest pain). antacids. When small amounts of refluxed liquid and/or foods breach (get through) the UES and enter the throat. heartburn is more common after meals.

• Strictures Ulcers of the esophagus heal with the formation of scars (fibrosis). however. The type of esophageal cancer associated with Barrett's esophagus (adenocarcinoma) is increasing in frequency. in patients with unexplained nausea and/or vomiting. What are the complications of GERD? Ulcers The liquid from the stomach that refluxes into the esophagus damages the cells lining the esophagus. This scarred narrowing is called a stricture. which is with inflammation (esophagitis). Then. it may be frequent or severe and may result in vomiting. or surgical treatment. Barrett's esophagus Long-standing and/or severe GERD causes changes in the cells that line the esophagus in some patients. The purpose of inflammation is to neutralize the damaging agent and begin the process of healing. GERD is one of the first conditions to be considered. to prevent food from sticking. Occasionally. In some patients. an endoscopic procedure (in which a tube is inserted through the mouth into the esophagus to visualize the site of bleeding and to stop the bleeding). the scar tissue shrinks and narrows the lumen (inner cavity) of the esophagus. If the damage goes deeply into the esophagus. Moreover. These cells are pre-cancerous and finally become cancerous. Ulcers and the additional inflammation they provoke may erode into the esophageal blood vessels and give rise to bleeding into the esophagus. Swallowed food may get stuck in the esophagus once the narrowing becomes severe enough (usually when it restricts the esophageal lumen to a diameter of one centimeter). to prevent a recurrence of the stricture. the narrowing must be stretched (widened). An ulcer is simply a break in the lining of the esophagus that occurs in an area of inflammation. The body responds in the way that it usually responds to damage. an ulcer forms.Page 4 of 17 Nausea Nausea is uncommon in GERD. This condition is referred to as Barrett's esophagus and occurs in approximately 10% of patients with GERD. but most do not. reflux also must be prevented. the bleeding is severe and may require: • • blood transfusions. It is not clear why some patients with GERD develop Barrett's esophagus. It is not clear why some patients with GERD develop mainly heartburn and others develop mainly nausea. In fact. patients with Barrett's esophagus may . Barrett's esophagus can be recognized visually at the time of an endoscopy and confirmed by microscopic examination of biopsies of the lining cells. Over time. This situation may necessitate endoscopic removal of the stuck food. Then.

Page 5 of 17 require periodic surveillance endoscopies with biopsies. As with coughing and asthma. resulting in an attack of asthma. Several endoscopic. The resulting inflammation can lead to a sore throat and hoarseness. It is also believed that patients with Barrett's esophagus should receive maximum treatment for GERD to prevent further damage to the esophagus. With or without these symptoms. aspiration may lead to infection of the lungs and result in pneumonia. however. progressive scarring of the lungs (pulmonary fibrosis) that can be seen on chest X-rays. Aspiration. The passages from the sinuses and the tubes from the middle ears (Eustachian tubes) open into the rear of the nasal passages near the adenoids. it is not clear just how often they are aggravated or caused by GERD. These techniques are attractive because they do not require surgery. and this stimulation results in pain (usually heartburn). called the adenoids. Procedures are being studied that remove the abnormal lining cells. When aspiration is unaccompanied by symptoms. Aspiration is more likely to occur at night because that is when the processes (mechanisms) that protect against reflux are not active and the coughing reflex that protects the lungs also is not active. Cough and asthma Many nerves are in the lower esophagus. and the long-term effectiveness of the treatments has not yet been determined. refluxed liquid can cause coughing without ever reaching the throat! In a similar manner. The reflux of liquid into the lungs (called aspiration) often results in coughing and choking. Some of these nerves are stimulated by the refluxed acid. there are associated complications. Refluxed liquid that enters the upper throat can inflame the . Inflammation and infection of the lungs Refluxed liquid that passes the larynx can enter the lungs. Other nerves that are stimulated do not produce pain. can also occur without producing these symptoms. reflux into the lower esophagus can stimulate esophageal nerves that connect to and can stimulate nerves going to the lungs. non-surgical techniques can be used to remove the cells. Surgical removal of the esophagus is always an option. it is not clear just how commonly GERD is responsible for otherwise unexplained inflammation of the throat and larynx. Fluid in the sinuses and middle ears The throat communicates with the nasal passages. are located where the upper part of the throat joins the nasal passages. Although GERD may cause cough. Although GERD also may be a cause of asthma. These nerves to the lungs then can cause the smaller breathing tubes to narrow. however. they stimulate yet other nerves that provoke coughing. Although chronic cough and asthma are common ailments. In this way. two patches of lymph tissue. In small children. it is not a common cause of unexplained coughing. it is more likely that it precipitates asthmatic attacks in patients who already have asthma. This type of pneumonia is a serious problem requiring immediate treatment. Inflammation of the throat and larynx If refluxed liquid gets past the upper esophageal sphincter. The purpose of surveillance is to detect precancerous changes so that cancer-preventing treatment can be started. Instead. it can enter the throat (pharynx) and even the voice box (larynx). it can result in a slow.

the diagnosis of GERD is considered confirmed. Therefore. the true cause of their symptoms will not be pursued further. there is perhaps a 20% placebo effect. For example. For instance. This approach of making a diagnosis on the basis of a response of the symptoms to treatment is commonly called a therapeutic trial. on the basis of their response to treatment (the therapeutic trial). This accumulation of fluid can lead to discomfort in the sinuses and ears. and not in adults. heartburn. What's more. these patients then will continue to be treated for GERD. physicians often treat patients with medications to suppress the production of acid by the stomach. endoscopy will not help in the diagnosis of GERD. the lining of the esophagus. as with any treatment. a diagnosis of GERD can be made confidently. which means that 20% of patients will respond to a placebo (inactive) pill or. The swollen adenoids then can block the passages from the sinuses and the Eustachian tubes.Page 6 of 17 adenoids and cause them to swell. if the physician assumes that the problem is GERD. To confirm the diagnosis. If the heartburn then is diminished to a large extent. however. thisfluid accumulation in the ears and sinuses is seen in children and not adults. also can actually respond to such treatment. a type of infection called Helicobacter pylori. can also cause ulcers and these conditions would be treated differently from GERD. in most patients. The esophagus of most patients with symptoms of reflux looks normal. As the tube progresses down the gastrointestinal tract. or non-steroidal antiinflammatory drugs (for example. primarily because it does not include diagnostic tests. How is GERD diagnosed and evaluated? Symptoms and response to treatment (therapeutic trial) The usual way that GERD is diagnosed—or at least suspected—is by its characteristic symptom. even though they do not have GERD. ibuprofen). patients who have conditions that can mimic GERD. Endoscopy Upper gastrointestinal endoscopy (also known as esophago-gastro-duodenoscopy or EGD) is a common way of diagnosing GERD. Thus. In this situation. There are problems with this approach. However. he or she will not look for the cause of the ulcer disease. indeed. to any treatment. sometimes the lining of the esophagus appears inflamed (esophagitis). Moreover. Since the adenoids are prominent in young children. When the sinuses and middle ears are closed off from the nasal passages by the swelling of the adenoids. . EGD is a procedure in which a tube containing an optical system for visualization is swallowed. if erosions (superficial breaks in the esophageal lining) or ulcers (deeper breaks in the lining) are seen. specifically duodenal or gastric (stomach) ulcers. stomach. fluid accumulates within them. This means that 20% of patients who have causes of their symptoms other than GERD (or ulcers) will have a decrease in their symptoms after receiving the treatment for GERD. Moreover. and duodenum can be examined. Heartburn is most frequently described as a sub-sternal (under the middle of the chest) burning that occurs after meals and often worsens when lying down.

Page 7 of 17 Endoscopy will also identify several of the complications of GERD. However. As discussed previously. it has been suggested that even in patients with GERD whose esophagi appear normal to the eye. That is. sometimes GERD can be the cause. a . particularly infections. or cancers of the stomach or duodenum) with EGD. normal individuals and patients with GERD can be distinguished moderately well from each other by the amount of time that the esophagus contains acid. It is too early to conclude. other common problems that may be causing GERD like symptoms can be diagnosed (for example ulcers. ulcers and strictures. The amount of time that the esophagus contains acid is determined by a test called a 24-hour esophageal pH test. as discussed above. patients with the symptoms or complications of GERD have reflux of more acid than individuals without the symptoms or complications of GERD. specifically. The problem with the esophagram was that it was an insensitive test for diagnosing GERD. result from using the response to treatment to confirm GERD. Biopsies Biopsies of the esophagus that are obtained through the endoscope are not considered very useful for diagnosing GERD. however. in diagnosing cancers or causes of esophageal inflammation other than acid reflux. that seeing widening is specific enough to conclude confidently that GERD is present. inflammation. however. has the same problems that. and throat (ENT) specialist. biopsies are the only means of diagnosing the cellular changes of Barrett's esophagus. however. (pH is a mathematical way of expressing the amount of acidity. Finally. it failed to find signs of GERD in many patients who had GERD because the patients had little or no damage to the lining of the esophagus. Accordingly. ENT specialists often try acid-suppressing treatment to confirm the diagnosis of GERD. Moreover. biopsies will show widening of the spaces between the lining cells. Examination of the throat and larynx When GERD affects the throat or larynx and causes symptoms of cough. hoarseness. More recently. Although diseases of the throat or larynx usually are the cause of the inflammation. Biopsies also may be obtained. although they still can be useful along with endoscopy in the evaluation of complications. ulcers. possibly an indication of damage.) For this test. and Barrett's esophagus. The X-rays were able to show only the infrequent complications of GERD. Esophageal acid testing Esophageal acid testing is considered a "gold standard" for diagnosing GERD. They are useful. for example. Xrays have been abandoned as a means of diagnosing GERD. This approach. the reflux of acid is common in the general population. Patients swallowed barium (contrast material). Moreover. and X-rays of the barium-filled esophagus were then taken. patients often visit an ear. an X-ray of the esophagus (called an esophagram) was the only means of diagnosing GERD. nose. or sore throat. The ENT specialist frequently finds signs of inflammation of the throat or larynx. X-rays Before the introduction of endoscopy. strictures.

The other end of the catheter exits from the nose. pH testing has uses in the management of GERD other than just diagnosing GERD. it stimulates the sensor and the recorder records the episode of reflux. The capsule measures the acid refluxing into the esophagus and transmits this information to a receiver that is worn at the waist. where it is attached to a recorder. typical symptoms. and travels down to the waist. the pH test can be very useful. the catheter is removed and the record of reflux from the recorder is analyzed. For example. then reflux is unlikely to be the cause of the symptoms. the diagnosis of GERD is likely to be wrong and other causes for the symptoms need to be sought. some 20% of patients will have a decrease in their symptoms even though they don't have GERD (the placebo effect). On the tip of the catheter is a sensor that senses acid. If testing reveals substantial reflux of acid while medication is continued. Then. the lack of response can be explained by a wrong diagnosis of GERD. This means that the medication is not adequately suppressing the production of acid by the stomach and is not reducing acid reflux. After a 20 to 24 hour period of time. If there was no reflux at the time of symptoms. Despite the fact that normal individuals and patients with GERD can be separated fairly well on the basis of pH studies. pH testing can be used to evaluate patients prior to endoscopic or surgical treatment for GERD. wireless capsule that is attached to the esophagus just above the LES. The capsule is passed to the lower esophagus by a tube inserted through either the mouth or the nose. usually after 48 hours. the test can help determine why GERD symptoms do not respond to treatment. then reflux is likely to be the cause of the symptoms. A newer method for prolonged measurement (48 hours) of acid exposure in the esophagus utilizes a small. patients record each time they have symptoms. Lastly. It requires something other than the pH test to confirm the presence of GERD. some patients with GERD will have normal amounts of acid reflux and some patients without GERD will have abnormal amounts of acid reflux. or the presence of complications of GERD. After the capsule is attached to the esophagus. If reflux did occur at the same time as the symptoms. GERD also may be confidently diagnosed when episodes of heartburn correlate with acid reflux as shown by acid testing. response to treatment. it can be determined whether or not acid reflux occurred at the time of the symptoms. If testing reveals good acid suppression with minimal reflux of acid. To make this evaluation. the separation is not perfect. After the study. Alternatively. pH testing also can be used to help evaluate whether reflux is the cause of symptoms (usually heartburn). Therefore. Prior to endoscopic or surgical treatment. then the treatment is ineffective and will need to be changed. the information from the receiver is downloaded into a computer and . the tube is removed. There are problems with using pH testing for diagnosing GERD. while the 24-hour ph testing is being done. Perhaps 10 to 20 percent of patients will not have their symptoms substantially improved by treatment for GERD. wraps back over the ear. The pH study can be used to identify these patients because they will have normal amounts of acid reflux.Page 8 of 17 small tube (catheter) is passed through the nose and positioned in the esophagus. This lack of response to treatment could be caused by ineffective treatment. As discussed above. it is important to identify these patients because they are not likely to benefit from the treatments. when the test is being analyzed. In both of these situations. Each time acid refluxes back into the esophagus from the stomach. for example.

The capsule falls off of the esophagus after 3-5 days and is passed in the stool. Nevertheless. Information from the emptying study can be useful for managing patients with GERD. Moreover. On the part of the catheter that is inside the esophagus are sensors that sense pressure. The second use is evaluation prior to surgical or endoscopic treatment for GERD. patients look normal (they don't have a catheter protruding from their noses) and are more likely to go about their daily activities. a thin tube (catheter) is passed through a nostril. and into the esophagus. A pressure is generated within the esophagus that is detected by the sensors on the catheter when the muscle of the esophagus contracts. Sometimes the capsule does not attach to the esophagus or falls off prematurely. the purpose is to identify patients who also have motility disorders of the esophageal muscle. some surgeons will modify the type of surgery they perform for GERD. Capsule pH testing is expensive. the pressure at rest and the relaxation of the lower esophageal sphincter are evaluated. if a patient with GERD continues to have symptoms despite treatment with the usual medications. go to work. The first is in evaluating symptoms that do not respond to treatment for GERD. Alternatively. In this situation. for example. For gastric emptying studies. Use of the capsule is an exciting use of new technology although it has its own specific problems. doctors might prescribe other medications that speed-up emptying of the stomach. it is not clear whether obtaining additional information is important. in . As discussed above. The reason for this is that in patients with motility disorders. For periods of time the receiver may not receive signals from the capsule. For motility testing. During the test. For example. The end of the catheter that protrudes from the nostril is attached to a recorder that records the pressure. Occasionally there is pain with swallowing after the capsule has been placed. (The capsule is not reused. more data on acid reflux and symptoms are obtained. Gastric emptying studies Gastric emptying studies are studies that determine how well food empties from the stomach. Because the capsule records for a longer period than the catheter (48 versus 24 hours). Esophageal motility testing Esophageal motility testing determines how well the muscles of the esophagus are working. Motility testing can identify some of these abnormalities and lead to a diagnosis of an esophageal motility disorder. The patient then swallows sips of water to evaluate the contractions of the esophagus. without feeling self-conscious. and some of the information about reflux of acid may be lost. with the capsule. down the back of the throat.Page 9 of 17 analyzed. the patient eats a meal that is labeled with a radioactive substance. Esophageal motility testing has two important uses in evaluating GERD.) The advantage of the capsule over standard pH testing is that there is no discomfort from a catheter that passes through the throat and nose. The abnormal function of the esophageal muscle sometimes causes symptoms that resemble the symptoms of GERD. A sensor that is similar to a Geiger counter is placed over the stomach to measure how quickly the radioactive substance in the meal empties from the stomach. about 20 % of patients with GERD have slow emptying of the stomach that may be contributing to the reflux of acid.

At night. particularly related to eating. and regurgitation may be due either to abnormal gastric emptying or GERD. as it does in the upright position during the day. An evaluation of gastric emptying. patients who have heartburn. A dilute. This is the preferable way of deciding if acid reflux is causing a patient's pain. however. for patients who have infrequent pain. when individuals are lying down. If the perfusion with acid provokes the patient's usual pain and perfusion of the salt solution produces no pain. The patient is unaware of which solution is being infused. Acid perfusion test The acid perfusion (Bernstein) test is used to determine if chest pain is caused by acid reflux. vomiting. How is GERD treated? Life-style changes One of the simplest treatments for GERD is referred to as life-style changes. It then can be determined from the pH recording if there was an episode of acid reflux at the time of the pain. down the back of the throat. Elevation of the upper body at night generally is recommended for all patients with GERD. The elevation is accomplished either by putting blocks under the bed's feet at the head of the bed or. reflux of acid is more injurious at night than during the day. they might do a surgical procedure that promotes a more rapid emptying of the stomach. however. by sleeping with the upper body on a foam rubber wedge. more conveniently. it is likely that the patient's pain is caused by acid reflux. For the test. therefore. is used only rarely.Page 10 of 17 conjunction with GERD surgery. it is easier for reflux to occur. an acid perfusion test may be reasonable. However. and into the middle of the esophagus. The acid perfusion test. As discussed above. It is not possible to know for certain which patients will benefit from elevation at night unless acid testing clearly demonstrates night reflux. These problems can be overcome partially by elevating the upper body in bed. These maneuvers raise the esophagus above the stomach and partially restore the effects of gravity. The reason that it is easier is because gravity is not opposing the reflux. Symptoms of nausea. Elevating only the head does not raise the esophagus and fails to restore the effects of gravity. a combination of several changes in habit. It does not work well. may be useful in identifying patients whose symptoms are due to abnormal emptying of the stomach rather than to GERD. which may be missed by a one or two day pH study. for example every two-three days. the lack of an effect of gravity allows the refluxed liquid to travel further up the esophagus and remain in the esophagus longer. it is still debated whether a finding of reduced gastric emptying should prompt changes in the surgical treatment of GERD. most patients with GERD have reflux only during the day and elevation at night is of little benefit for them. In addition. acid solution and a physiologic (normal) salt solution are alternately poured (perfused) through the catheter and into the esophagus. a thin tube is passed through one nostril. Nevertheless. . A better test for correlating pain and acid reflux is a 24-hour esophageal pH or pH capsule study during which patients note when they are having pain. Nevertheless. It is important that the upper body and not just the head be elevated. In these cases.

Since the food from meals slows the emptying from the stomach. a second dose of . One novel approach to the treatment of GERD is chewing gum. the smaller meal results in lesser distention of the stomach. patients with GERD may find that other foods aggravate their symptoms. which is just before the symptoms of reflux begin after a meal. Antacids Despite the development of potent medications for the treatment of GERD. or other symptoms of GERD at night are probably experiencing reflux at night and definitely should elevate their upper body when sleeping. Examples are spicy or acid-containing foods. These foods should also be avoided. an antacid taken after a meal stays in the stomach longer and is effective longer. It is not clear. Reflux also occurs less frequently when patients lie on their left rather than their right sides. therefore. how effective chewing gum actually is in treating heartburn. They are emptied from the empty stomach quickly. Fatty foods (which should be decreased) and smoking (which should be stopped) also reduce the pressure in the sphincter and promote reflux. peppermint. and tomato juice. and caffeinated drinks. Nevertheless. Second. After the saliva is swallowed. Reflux is worse following meals. antacids remain a mainstay of treatment. The best way to take antacids. carbonated beverages. GERD Diet Several changes in eating habits can be beneficial in treating GERD. As a result. by bedtime. smaller and earlier evening meals may reduce the amount of reflux for two reasons. In addition. Therefore. Certain foods are known to reduce the pressure in the lower esophageal sphincter and thereby promote reflux. reflux is less likely to occur when patients with GERD lie down to sleep. chewing gum after meals is certainly worth a try. The problem with antacids is that their action is brief.Page 11 of 17 regurgitation. and the acid then re-accumulates. like citrus juices. in less than an hour. a smaller and earlier meal is more likely to have emptied from the stomach than is a larger one. however. is approximately one hour after meals. In effect. it neutralizes acid in the esophagus. alcohol. For the same reason. These foods should be avoided and include: • • • • chocolate. This probably is so because the stomach is distended with food at that time and transient relaxations of the lower esophageal sphincter are more frequent. Antacids neutralize the acid in the stomach so that there is no acid to reflux. First. chewing gum exaggerates one of the normal processes that neutralize acid in the esophagus. Chewing gum stimulates the production of more bicarbonate-containing saliva and increases the rate of swallowing.

the phenomenon of acid rebound is theoretically harmful. However. the secretion of acid rebounds after the direct acid-neutralizing effect of the calcium carbonate is exhausted. specifically cimetidine (Tagamet). unlike other antacids. at least every hour. it may be necessary to switch antacids or alternately use antacids containing aluminum and magnesium. this increased acid is not good for GERD. is not believed to be harmful. magnesium. the calcium they add to the diet. Therefore. (Histamine antagonists are referred to as H2 antagonists because the specific receptor they block is the histamine type 2 receptor. The rebound is due to the release of gastrin. particularly heartburn. they do so for only a short period of time. H2 antagonists also can be taken at bedtime to suppress nighttime production of acid. or Barrett's esophagus. H2 antagonists are very good for relieving the symptoms of GERD. For substantial neutralization of acid throughout the day. or calcium based. The advantages of calcium carbonate-containing antacids are their low cost . was a histamine antagonist. therefore. . Histamine antagonists work by blocking the receptor for histamine and thereby preventing histamine from stimulating the acid-producing cells. they are not very good for healing the inflammation (esophagitis) that may accompany GERD. The first medication developed for more effective and convenient treatment of acid-related diseases. treatment with calcium carbonate has not been shown to be less effective or safe than treatment with antacids not containing calcium carbonate. Histamine is an important chemical because it stimulates acid production by the stomach. The reason for this timing is so that the H2 antagonists will be at peak levels in the body after the meal when the stomach is actively producing acid. Acid rebound. histamine attaches to receptors (binders) on the stomach's acid-producing cells and stimulates the cells to produce acid. H2 antagonists are best taken 30 minutes before meals. while magnesium-containing antacids tend to cause diarrhea. has not been shown to be clinically important. however. Calcium-based antacids (usually calcium carbonate).Page 12 of 17 antacids approximately two hours after a meal takes advantage of the continuing post-meal slower emptying of the stomach and replenishes the acid-neutralizing capacity within the stomach. including GERD. In practice. Histamine antagonists Although antacids can neutralize acid. however. In fact. That is. Antacids may be aluminum. such as erosions or ulcers. Nevertheless.) Because histamine is particularly important for the stimulation of acid after meals. and their convenience as compared to liquids. calcium-containing antacids such as Tums and Rolaids are not recommended. Theoretically at least. stimulate the release of gastrin from the stomach and duodenum. they are used primarily for the treatment of heartburn in GERD that is not associated with inflammation or complications. strictures. Aluminum-containing antacids have a tendency to cause constipation. The occasional use of these calcium carbonate-containing antacids. antacids would need to be given frequently. Released within the wall of the stomach. which results in an overproduction of acid. Gastrin is the hormone that is primarily responsible for the stimulation of acid secretion by the stomach. If diarrhea or constipation becomes a problem.

the pro-motility agents are reserved either for patients who do not respond to other treatments or are added to enhance other treatments for GERD. However. omeprazole(Prilosec). which also would be expected to reduce reflux. or Barrett's esophagus exist. including the esophagus. lansoprazole (Prevacid). If the PPI is taken before the meal. Foam barriers are tablets that are composed of an antacid and a foaming agent. One pro-motility drug. Not only is the PPI good for treating the symptom of heartburn. Therefore. Foam barriers are . They are not very effective for treating either the symptoms or complications of GERD. both times when reflux is more likely to occur.rabeprazole (Aciphex). and/or colon. Proton pump inhibitors The second type of drug developed specifically for acid-related diseases. ranitidine (Zantac). The advantage of a PPI over an H2 antagonist is that the PPI shuts off acid production more completely and for a longer period of time. The reason for this timing is that the PPIs work best when the stomach is most actively producing acid. nizatidine (Axid). and esomeprazole (Nexium). is approved for GERD. Therefore. without the need for a prescription. including omeprazole (Prilosec. A sixth PPI product consists of a combination of omeprazole and sodium bicarbonate (Zegerid). PPIs (except for Zegarid) are best taken an hour before meals. the OTC dosages are lower than those available by prescription. Pro-motility drugs are most effective when taken 30 minutes before meals and again at bedtime. it is believed that the primary effect of metoclopramide may be to speed up emptying of the stomach. Dexilant). However. All four are also available over-the-counter (OTC). stomach. Pro-motility drugs increase the pressure in the lower esophageal sphincter and strengthen the contractions (peristalsis) of the esophagus. The foam forms a physical barrier to the reflux of liquid. the antacid bound to the foam neutralizes acid that comes in contact with the foam. these effects on the sphincter and esophagus are small. metoclopramide (Reglan). but it also is good for protecting the esophagus from acid so that esophageal inflammation can heal. pantoprazole (Protonix).Page 13 of 17 Four different H2 antagonists are available by prescription. As the tablet disintegrates and reaches the stomach. specifically. strictures. it is at peak levels in the body after the meal when the acid is being made. PPIs are used when H2 antagonists do not relieve symptoms adequately or when complications of GERD such as erosions or ulcers. The tablets are best taken after meals (when the stomach is distended) and when lying down. and famotidine. Pro-motility drugs Pro-motility drugs work by stimulating the muscles of the gastrointestinal tract. such as GERD. it turns into foam that floats on the top of the liquid contents of the stomach. Both effects would be expected to reduce reflux of acid. Foam barriers Foam barriers provide a unique form of treatment for GERD. which occurs after meals. (Pepcid). small intestine. includingcimetidine (Tagamet). was a proton pump inhibitor (PPI). At the same time. Five different PPIs are approved for the treatment of GERD. A PPI blocks the secretion of acid into the stomach by the acid-secreting cells.

All of this surgery can be done through an incision in the abdomen (laparotomy) or using a technique called laparoscopy. If it is not transient. Moreover. Nevertheless. Rather. any hiatal hernial sac is pulled below the diaphragm and stitched there. the sticking usually is temporary. regurgitation. Nevertheless. Surgery The drugs described above usually are effective in treating the symptoms and complications of GERD. and alginate (Gaviscon). a small viewing device and surgical instruments are passed through several small puncture sites in the abdomen. It is not clear whether they take the drugs because they continue to have reflux and symptoms of reflux or if they take them for symptoms that are being caused by problems other than GERD. magnesium trisilicate. For example. The surgical procedure that is done to prevent reflux is technically known asfundoplication and is called reflux surgery or anti-reflux surgery. One type of endoscopic treatment involves suturing (stitching) the area of the lower esophageal sphincter. endoscopic techniques for the treatment of GERD have been developed and tested. they are added to other drugs for GERD when the other drugs are not adequately effective in relieving symptoms. The most common complication of fundoplication is swallowed food that sticks at the artificial sphincter. A second type involves the application of radio-frequency waves to the lower part of the esophagus just above the sphincter. Endoscopy Very recently. Surgery is very effective at relieving symptoms and treating the complications of GERD. the amounts and/or numbers of drugs that are required for satisfactory treatment are sometimes so great that drug treatment is unreasonable. may still occur. despite adequate suppression of acid and relief from heartburn. which is a combination of aluminum hydroxide gel. A third type of endoscopic treatment involves the injection of materials into the esophageal wall in the area of the LES. with its potential for complications in the lungs.Page 14 of 17 not often used as the first or only treatment for GERD. The scar shrinks and pulls on the surrounding tissue. Only occasionally is it necessary to re-operate to revise the prior surgery. Approximately 80% of patients will have good or excellent relief of their symptoms for at least 5 to 10 years. thereby tightening the sphincter and the area above it. In addition. Fortunately. Finally. In such situations. sometimes they are not. the upper part of the stomach next to the opening of the esophagus into the stomach is wrapped around the lower esophagus to make an artificial lower esophageal sphincter. During laparoscopy. many patients who have had surgery—perhaps as many as half—will continue to take drugs for reflux. This procedure avoids the need for a major abdominal incision. endoscopic treatment to stretch (dilate) the artificial sphincter usually will relieve the problem. the opening in the diaphragm through which the esophagus passes is tightened around the esophagus. surgery can effectively stop reflux. During fundoplication. There is only one foam barrier. The injected material is intended to increase pressure in the LES and thereby . The waves cause damage to the tissue beneath the esophageal lining and a scar (fibrosis) forms. which essentially tightens the sphincter.

If heartburn is frequent. life-style changes and an occasional antacid may be all that is necessary. unexplained lung infections. Prevention of transient LES relaxation Transient LES relaxations appear to be the most common way in which acid reflux occurs. the adequacy of the response to treatment. Endoscopic treatment has the advantage of not requiring surgery. and the material for injection is no longer available. . the most common symptom of GERD. it is time to see a physician for further evaluation and to consider prescription-strength drugs. The approach depends primarily on the frequency and severity of symptoms. In one treatment the injected material was a polymer. they have too many side effects to be generally useful. If life-style changes and antacids. Limited information is available about a third type of injection which uses gelatinous polymethylmethacrylate microspheres. daily non-prescription-strength (overthe-counter) H2 antagonists may be adequate. especially long-term. It is not clear how effective they are. It can be performed without hospitalization. Unfortunately. Another treatment involving injection of expandable pellets also was discontinued. the injection of polymer led to serious complications. Although there are available drugs that prevent relaxations. hoarseness. For infrequent heartburn. asthma. it is felt generally that endoscopic treatment should only be done as part of experimental trials. sore throat. The evaluation by the physician should include an assessment for possible complications of GERD based on the presence of such symptoms or findings as: • • • • • • • cough. Much attention is being directed at the development of drugs that prevent these relaxations without accompanying side effects. and the presence of complications. difficulty swallowing. non-prescription H2 antagonists. or anemia (due to bleeding from esophageal inflammation or ulceration). Experience with endoscopic techniques is limited. A foam barrier also can be used with the antacid or H2 antagonist. Because the effectiveness and the full extent of potential complications of endoscopic techniques are not clear. What is a reasonable approach to the management of GERD? There are several ways to approach the evaluation and management of GERD.Page 15 of 17 prevent reflux. and a foam barrier do not adequately relieve heartburn.

for example. treatment with PPIs also is more appropriate. If necessary. the effectiveness of the recently developed endoscopic treatments remains to be determined. The second option is to go ahead without 24 hour pH testing and to increase the dose of PPI. With Barrett's esophagus. an endoscopic treatment trial for GERD? (As mentioned previously. is continued. all three types of drugs can be used. If treatment relieves the symptoms completely. it is . can be given. If at the time of evaluation. it may still be abnormally high. Another alternative is to add another drug to the PPI that works in a way that is different from the PPI. In this case. Therefore. the H2 antagonist or PPI. a second trial. there are potential problems with this commonly used approach. should be sought.Page 16 of 17 Clues to the presence of diseases that may mimic GERD. prescription strength H2 antagonists or PPIs are appropriate. If there is not a satisfactory response to this maximal treatment. However. If the esophagus is normal and no other diseases are found. judging the adequacy of suppression of acid reflux by only the response of symptoms to treatment is not satisfactory. Sometimes. although the amount of acid reflux may be reduced enough to control symptoms. a trial of treatment begins with a PPI and skips the H2 antagonist. perhaps. no further evaluation may be necessary and the effective drug. a further evaluation by endoscopy (EGD) definitely should be done. Who should consider surgery or. If there are no symptoms or signs of complications and no suspicion of other diseases. If H2 antagonists are not adequately effective. there are symptoms or signs that suggest complicated GERD or a disease other than GERD or if the relief of symptoms with H2 antagonists or PPIs is not satisfactory. a higher dose of PPI may be tried. the adequacy of the PPI treatment probably should be evaluated with a 24-hour pH study during treatment with the PPI. PPIs are preferred over H2 antagonists because they are more effective for healing. The first is to perform 24-hour pH testing to determine whether the PPI is ineffective or if a disease other than GERD is likely to be present. a therapeutic trial of acid suppression with H2 antagonists often is used. however. periodic endoscopic examination should be done to identify pre-malignant changes in the esophagus. such as gastric or duodenal ulcers and esophageal motility disorders.) Strictures may also need to be treated by endoscopic dilatation (widening) of the esophageal narrowing. If damage to the esophagus (esophagitis or ulceration) is found. the goal of treatment simply is to relieve symptoms. and some physicians would recommend a further evaluation for almost all patients they see. Therefore. (With PPIs. Still. Patients also should consider surgery if they require large doses of PPI or multiple drugs to control their reflux. such as stricture or Barrett's esophagus are found. If the PPI is ineffective. 24 hour pH testing should be done.) Patients should consider surgery if they have regurgitation that cannot be controlled with drugs. As discussed previously. the goal of treatment is healing the damage. with the more potent PPIs. a pro-motility drug or a foam barrier. This recommendation is particularly important if the regurgitation results in infections in the lungs or occurs at night when aspiration into the lungs is more likely. there are two options for management. If complications of GERD. There are several possible results of endoscopy and each requires a different approach to treatment. If symptoms of GERD do not respond to maximum doses of PPI.

Page 17 of 17 debated whether or not a desire to be free of the need to take life-long drugs to prevent symptoms of GERD is by itself a satisfactory reason for having surgery. demonstrating the superiority of surgery over drugs for the treatment of GERD and its complications. . however. This recommendation is based on the belief that surgery is more effective than treatment with drugs in preventing both the reflux and the cancerous changes in the esophagus. Moreover. There are no studies. Some physicians—primarily surgeons—recommend that all patients with Barrett's esophagus should have surgery. the effectiveness of drug treatment can be monitored with 24 hour pH testing.