Multiple: Gastroesophageal Reflux Disease

Definition
Description
Demographics
Causes and Symptoms
Diagnosis
Treatment
Prognosis
Prevention
The Future
For more information

Definition

Gastroesophageal reflux disease, or GERD, is a chronic condition in which the backward flow (reflux) of stomach acid into the esophagus leads to heartburn, chest pain, and possible long-term health complications. The underlying cause is weakness in the sphincter (ring-shaped muscle) at the lower end of the esophagus where the esophagus joins the stomach.

Description

GERD could be described as a more serious or chronic form of gastroesophageal reflux (GER), a condition that occurs when the lower esophageal sphincter (LES) opens by itself for varying periods of time or does not close properly. When the LES is open, the contents of the stomach move upward into the esophagus. The acid in the digestive juices irritates the tissues that line the esophagus, causing a burning sensation behind the breastbone or at the back of the throat. If the stomach contents are regurgitated (brought back up without trying) as far as the mouth, the person will experience a sour or unpleasant taste in the mouth.

Most people have occasional episodes of heartburn (also called acid indigestion) because of emotional stress, something they ate, or eating too large a meal. The time to be concerned about GERD is when heart-burn occurs more than twice a week, is severe enough to wake the person from sleep, or is not helped by over-the-counter antacids.

GERD is not just a problem for adults; it can affect children as well. One major difference between children and adults with GERD, however, is that children are more likely to develop GERD without heart-burn. Instead, their symptoms are more likely to include a dry cough, bad breath, trouble swallowing, or wheezing. In babies, symptoms of GERD may include spitting up food repeatedly, failure to gain weight, burping, and refusing food.

Demographics

Heartburn is a very common digestive problem in the general population. According to the National Institutes of Health (NIH), more than

60 million Americans experience heartburn at least once a month. Some studies indicate that more than 15 million Americans experience heartburn symptoms every day.

About 35 percent of babies born in the United States develop GERD during their first few months of life, mostly because their digestive systems are not completely developed. Most of these infants, however, will outgrow GERD by the time of their first birthday.

Among adults, GERD is most common in people over forty. It appears to affect all races and ethnic groups equally. Uncomplicated GERD is equally common in men and women. Men, however, are three times more likely than women to develop a chronic inflammation of the esophagus, and ten times more likely to develop Barrett esophagus, a precancerous change in the cells of the tissues at the lower end of the esophagus.

Some people are at increased risk of developing GERD:

• Pregnant women.
• Obese people.
• Smokers.
• People with a hiatal hernia. A hiatal hernia is a condition in which the upper part of the stomach pushes upward through a weak spot in the diaphragm. The hernia weakens the ability of the lower esophageal sphincter to keep stomach acid from flowing into the esophagus.
• People who eat large amounts of foods known to increase the amount of acid in the stomach. These include citrus fruits, chocolate, tea, coffee, alcohol, fatty and fried foods, garlic and onions, mint flavorings, spicy foods, and tomato-based foods like spaghetti sauce, chili, and pizza.
• People who take certain types of prescription medications, most commonly tranquilizers, sleeping medicines, and medications for high blood pressure.

Causes and Symptoms

The basic cause of GERD is the inability of the LES to keep the contents of the stomach from moving backward into the lower end of the esophagus. The weakness of the lower esophageal sphincter may result from a structural disorder like hiatal hernia (a stomach abnormality); conditions that put pressure on the contents of the stomach, like pregnancy or obesity; a digestive tract that is still developing; or a disorder of the stomach that prevents it from emptying at a normal rate of speed.

Recurrent heartburn is the most common symptom of GERD, although most children and some adults with GERD do not have it. Other symptoms include:

• Belching or burping
• Regurgitating undigested food after meals
• Nausea and vomiting; vomiting blood
• Hoarseness, particularly in the morning
• Sore throat
• Coughing or wheezing
• Difficulty swallowing

Diagnosis

There is no single laboratory test that a doctor can use to diagnose GERD. In most cases the patient's history and description of symptoms are enough to suggest the diagnosis and begin treatment with medications and lifestyle changes.

If the patient's symptoms are severe or are not helped by initial treatments, the doctor may refer the patient to a gastroenterologist, a doctor who specializes in disorders of the digestive tract.

When to See the Doctor about Heartburn

Occasional episodes of heartburn do not necessarily mean that someone has GERD. To tell whether a visit to the doctor for further evaluation might be a good idea, the American College of Gastroenterology (ACG) suggests the following checklist:

• Does the person have one or more of the following: pain behind the breast-bone moving upward from the stomach; burning sensation in the back of the throat; or a sour taste in the mouth?
• Do these symptoms usually appear after a meal?
• Does the person experience heartburn two or more times per week?
• Do antacids provide only temporary relief from the symptoms?
• Is the person still having heartburn in spite of taking prescription medication for it?
• Does the person wake up at night because of heartburn?
• Does the person have trouble swallowing food?
• Does the person notice blood in the stools? Are they regurgitating blood?
• Is the person losing weight without trying to?

If the person can answer yes to two or more of these questions, he or she should see a doctor to be tested for GERD.

A gastroenterologist may order one or more of the following tests:

• Barium swallow. In a barium swallow, the patient is given a chalky liquid containing barium, a chemical that coats the inside of the digestive tract and outlines its shape on an x ray. A barium swallow can help to detect hiatal hernias, abnormal narrowing of the esophagus, or a growth in the esophagus.
• Endoscopy. Endoscopy is a technique that allows a gastroenterolo-gist to look directly into the esophagus and stomach by inserting a long flexible tube (endoscope) attached to a light source and video camera down the patient's throat. Endoscopy allows the doctor to take tissue samples to check for a Barrett esophagus or cancer of the esophagus as well as to look at the structure of the esophagus and LES.
• Acid probe test. This test measures the acidity of the patient's stomach contents over a 24-hour period and the length of time that the lower esophagus is exposed to stomach acid. A probe is inserted through the patient's nose via a long, flexible catheter to a point just above the LES. The other end of the catheter is attached to a small computer that the patient wears around the waist during the test. The computer measures the length of time and frequency of acid reflux into the lower esophagus.
• Tests to measure the speed of stomach emptying. These tests are usually performed only when the doctor thinks that delayed emptying of the stomach is a factor in the patient's GERD.

Treatment

Most patients with GERD can be successfully treated by a combination of medications and lifestyle changes.

There are several types of medications that doctors may prescribe for GERD.

• Over-the-counter antacids, such as Alka-Seltzer, Maalox, Mylanta, Rolaids, and Riopan. Antacids can be purchased in any pharmacy in either tablet or liquid form and work well to control mild cases of GERD. They should be taken after each meal and at bedtime.
• Foaming agents. Gaviscon is the best-known of this type of medication. They work by coating the stomach contents with foam, which prevents reflux.
• H2 blockers. These are drugs like Tagamet, Zantac, and Pepcid; they work by decreasing the production of stomach acid. They are available in both over-the-counter and prescription strength.

• Proton pump inhibitors (PPIs). These drugs also work by decreasing stomach acid and are generally more effective than the H2 blockers. Most are available by prescription. PPIs include drugs like Prilosec, Protonix, Prevacid, and Nexium.
• Prokinetics. These are drugs that work by speeding up the rate of stomach emptying. Reglan and Urecholine are examples of drugs in this group.

People who are not helped by medications may need surgery to treat GERD. The operation that is usually done is called fundoplication. In this procedure, the surgeon wraps the upper part of the stomach around the lower end of the esophagus to strengthen the LES, prevent acid reflux, and repair a hiatal hernia. The operation is safe and can be done in infants as well as adults.

Prognosis

Most people diagnosed with GERD do very well with medications and lifestyle changes. Of those who require surgical treatment, 92 percent have no more symptoms of GERD.

Complications from GERD, such as narrowing of the esophagus or Barrett esophagus, develop in about 20 percent of patients. These patients should be treated with surgery as soon as their complication is diagnosed.

Prevention

Lifestyle changes are the most effective form of prevention for GERD. The NIH recommends:

• Not smoking. Smoking increases the production of stomach acid.
• Keeping one's weight within the recommended guidelines for one's age, sex, and height.
• Avoiding foods and beverages that trigger acid indigestion.
• Eating small frequent meals rather than three large ones.
• Avoiding lying down for three hours after eating.
• Raising the head of the bed by 6–8 inches (15–20 centimeters). This should be done by using wooden blocks or foam wedges; just using extra pillows will not be effective.
• Wear clothing with loose waistlines. Tight belts or waistbands put pressure on the abdomen.

The Future

A surgical treatment for GERD that was approved by the Food and Drug Administration (FDA) in 2000 is the use of an endoscope to insert stitches into the LES to strengthen the muscle or to use radiofrequency energy to form scar tissue on the LES to tighten it. However, the long-term effectiveness of this type of surgery compared to fundoplication is not known.

SEE ALSO Alcoholism; Obesity; Smoking; Stress; Ulcers

WORDS TO KNOW

Diaphragm: The flat sheet of muscle that separates the abdomen from the chest cavity.

Esophagus: The muscular tube that carries food downward from the lower throat to the stomach.

Fundoplication: A surgical procedure in which the upper part of the stomach is wrapped around the lower end of the esophagus to prevent stomach acid from rising into the esophagus.

Gastroenterologist: A doctor who specializes in diagnosing and treating disorders of the digestive system.

Hiatal hernia: A condition in which the upper part of the stomach bulges upward into the chest cavity through a weak spot in the diaphragm.

Reflux: The medical term for the backward flow of stomach acid from the stomach into the esophagus.

Regurgitation: Throwing up; effortless flow of undigested stomach contents back up the esophagus into the mouth.

Sphincter: A ring-shaped muscle that can contract to close off a body opening.

For more information

BOOKS

Ballard, Carol. The Digestive System. Chicago, IL: Heinemann Library, 2003.

Burns, David L., and Neeral L. Shah. 100 Questions and Answers about Gastroesophageal Reflux Disease (GERD): a Lahey Clinic Guide. Sudbury, MA: Jones and Bartlett Publishers, 2007.

King, John, ed. Mayo Clinic on Digestive Health, 2nd ed. Rochester, MN: Mayo Clinic, 2004.

PERIODICALS

Brody, Jane. “Personal Health: When Swallowing Becomes a Problem.” New York Times, July 20, 2004. Available online at http://query.nytimes.com/gst/fullpage.html?res=9D01E3DD103AF933A15754C0A9629C8B63&sec=&spon=&pagewanted=all (accessed July 4, 2008).

Jaret, Peter. “A Sigh of Relief for Heartburn Sufferers.” New York Times, June 2, 2008. Available online at http://health.nytimes.com/ref/health/healthguide/esn-gerd-ess.html (accessed July 4, 2008).

WEB SITES

American Academy of Family Physicians (AAFP). Antacids and Acid Reducers: OTC Relief for Heartburn and Acid Reflux. Available online at http://familydoctor.org/online/famdocen/home/otc-center/otc-medicines/854.html (updated December 2006; accessed July 4, 2008).

American College of Gastroenterology (ACG). Common GI Problems: Volume 1. Available online at http://www.acg.gi.org/patients/cgp/cgpvol1.asp#gerd (accessed July 4, 2008).

KidsHealth. Have You Heard of GERD? Available online at http://kidshealth.org/kid/health_problems/stomach/gerd.html (updated April 2008; accessed July 4, 2008).

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Heartburn, Gastroesophageal Reflux (GER), and Gastroesophageal Reflux Disease (GERD). Available online at http://digestive.niddk.nih.gov/ddiseases/pubs/gerd/index.htm#3 (updated May 2007; accessed July 4, 2004).

National Library of Medicine (NLM). GERD. Available online at http://www.nlm.nih.gov/medlineplus/tutorials/gerd/htm/index.htm (accessed July 4, 2008). This is an online tutorial with voiceover; viewers have the option of a self-playing version, a text version, or an interactive version with questions.