Gastroesophageal reflux disease, commonly called GERD, is a digestive disorder in which the stomach's juices (acid and digestive enzymes) flow backward, or reflux, into the esophagus. The esophagus is the tube that carries food from your mouth to your stomach. The lining of the esophagus can't handle these caustic substances, so the esophagus becomes inflamed. This causes heartburn and other symptoms. If GERD is not treated, it can cause permanent damage to the esophagus.

A muscular ring seals the esophagus from the stomach. This valve is called the esophageal sphincter. Normally, this muscular ring opens when you swallow to let food into your stomach. In between swallows or belches, it squeezes tight to prevent food and acid in the stomach from backing up into the esophagus.

In most people with GERD, the esophageal sphincter does not seal tightly. It remains relaxed between swallows, allowing digestive juices to move up into the esophagus and irritate the esophageal lining. Certain foods, smoking, alcohol, pregnancy and many medications can weaken or loosen the lower esophageal sphincter. Increased abdominal pressure, because of obesity or pregnancy, can push against the sphincter, forcing it open. It is also possible for the sphincter to loosen if a bulge in the stomach, called a hiatal hernia, protrudes above the diaphragm.

Prolonged exposure to acid can cause the esophagus to become inflamed (esophagitis), to become more narrow (strictured) or to develop an open sore (ulcer) in the esophagus. Long-term exposure to acid also can lead to a condition called Barrett's esophagus, in which the normal gray-pink tissue of the esophagus is replaced by salmon-colored tissue that looks more like the lining of the stomach. Barrett's esophagus leads to cancer of the esophagus in 2% to 5% of people with the condition.

About 17 million people in the United States have heartburn and other symptoms of GERD. For many of these people, heartburn is not merely an occasional discomfort that follows a rich meal but is a frequent, even daily, ordeal.

Symptoms of GERD may include:

• Sharp or burning chest pain behind the breastbone (also known as heartburn, the most common symptom of GERD), which may be worse when you eat, bend over or lie down
• Tightness in your chest or upper abdomen, especially pain that wakes you up in the middle of the night
• Regurgitation (backflow of stomach fluids into your mouth)
• Nausea
• A recurring sour or bitter taste in the mouth
• Difficulty swallowing
• Hoarseness, especially in the morning
• Sore throat
• Coughing, wheezing or repeatedly needing to clear your throat

Your doctor will ask you to estimate how often you have heartburn or other symptoms of GERD, whether your symptoms are worse when you lie down or bend over, and whether they are relieved by over-the-counter heartburn remedies. Your doctor also will review your current medications, because some medications can loosen the esophageal sphincter. These include the asthma medicines theophylline or albuterol (both sold under several brand names), blood pressure or heart medications such as calcium channel blockers and different forms of nitroglycerin, muscle relaxants, anxiety medicines, medicines for an overactive bladder, migraine medicines, and medicines to treat diarrhea. Medicines that reduce the amount of saliva you produce cause your esophagus to be rinsed less frequently, so they also cause symptoms of GERD to be worse. Antihistamines and many antidepressants can have this effect.

Pain that feels like heartburn also can be a symptom of coronary artery disease, so your doctor may ask whether you have any symptoms of heart problems, including shortness of breath, palpitations and dizziness. Your doctor may test for heart problems.

If your only complaint is mild heartburn and your physical examination is normal, then your doctor may suggest that you try lifestyle changes and over-the-counter medications before beginning any special diagnostic testing or prescription treatment.

If you have more serious symptoms � such as severe, long-lasting heartburn; difficulty swallowing; or weight loss � or if your heartburn is not relieved by medications, then you will need further testing. The best test is for a doctor to look directly at your esophagus with an instrument called an endoscope. This test is called endoscopy or esophogogastroduodenoscopy, and it usually is done by a gastroenterology specialist. If necessary, during endoscopy, your doctor can take a small sample of tissue (biopsy) to be examined in a laboratory. To check for other possible causes of your symptoms, your doctor also may look at your stomach and first part of the small intestines by using the endoscope. You also may need one or more of the following tests:

• Barium swallow � This is an X-ray test that outlines the esophagus.
• Cardiac evaluation � People who have chest pain may also need an electrocardiogram and an exercise stress test to check for heart disease.
• Esophageal manometry or motility studies � These tests can check the squeezing motion of your esophagus when you are swallowing.
• Esophageal pH monitoring � This test uses electrodes to measure the pH (acid level) in the esophagus, usually over a 24-hour period.

Without treatment, GERD is typically a long-term problem. In fact, studies have shown that the average person with GERD has symptoms for one to three years before seeing a doctor. Symptoms may be relieved within the first day of treatment, but for many patients, several weeks of treatment are needed before symptoms lessen noticeably or go away.

Treatment often has to continue for a long period. Four or more years from the start of symptoms, more than three out of four people with reflux continue to have symptoms, and most of these people take medication daily.

There are a lot of things you can do to prevent the symptoms of GERD. Some simple lifestyle changes include:

• Elevate the head of your bed at least 6 inches. If possible, put wooden blocks under the legs at the head of the bed or use a solid foam wedge under the head portion of the mattress. Simply using extra pillows may not help.
• Certain foods cause the esophageal sphincter to relax for an hour or more while they are being digested. Avoid these foods, especially coffee, chocolate, fatty foods, whole milk, peppermint and spearmint.
• Limit acidic foods that make the irritation worse when they are regurgitated, including citrus fruits and tomatoes.
• Avoid carbonated beverages. Burps of gas force the esophageal sphincter to open and can promote reflux.
• Eat smaller, more frequent meals.
• Do not lie down after eating.
• Do not eat for three to four hours before going to bed.
• If you smoke, quit. Smoking loosens the lower esophageal sphincter and reduces the amount of saliva you produce, so your esophagus is less well rinsed.
• Avoid drinking alcohol, since it loosens the esophageal sphincter.
• Lose weight if you are obese. Obesity can make it harder for the esophageal sphincter to stay closed.
• Avoid wearing tight-fitting garments. They increase pressure on the abdomen, which can open the esophageal sphincter when it should be shut.
• To keep producing saliva so that your esophagus continues to be rinsed, it may be useful to use lozenges or gum.

People who have had symptoms of GERD or have been treated for GERD for more than five years should have an endoscopy test to look for Barrett's esophagus. If Barrett's esophagus is found, it's a good idea to have endoscopy at regular intervals so that cancerous changes can be identified and treated when the cancer is in its earliest stages.

Treatment for most people with GERD includes lifestyle changes as described above and medication. If symptoms persist, surgery or endoscopy treatments are other options.

There are several medications that can be used to treat GERD. They include:

• Over-the-counter acid buffers � Buffers that neutralize acid include Mylanta, Maalox, Tums, Rolaids, Gaviscon and others. The liquid forms of these medications work faster, but the tablets may seem more convenient to you. Because antacids that contain magnesium can cause diarrhea and antacids that contain aluminum can cause constipation, your doctor may advise you to alternate antacids to avoid these problems. These medicines work for a short time, and they do not heal the inflammation of the esophagus.



• Over-the-counter H2 blockers � These drugs work by causing the stomach to make less acid, and they are effective in patients with mild to moderate symptoms. They include famotidine (Pepcid AC), cimetidine (Tagamet HB) and ranitidine (Zantac 75).



• Over-the-counter proton pump inhibitors � An over-the-counter form of omeprazole (Prilosec OTC) is one of several medicines that block the pump mechanism in the stomach's acid-making cells, shutting off the stomach's acid production. Proton pump inhibitors are very effective medications that can be especially helpful in patients who do not respond to H2 blockers and antacids. These drugs are more potent acid-blockers than are H2 blockers, but they take longer to begin to take effect. They should not be combined with an H2 blocker because the H2 blocker can prevent them from working.



• Prescription medications � Prescription medications include:
  • H2 blockers � These are prescribed at higher doses than those available in over-the-counter forms.
  • Proton pump inhibitors � A variety of proton pump inhibitors are available by prescription, including omeprazole (Prilosec), esomeprazole (Nexium), lansoprazole (Prevacid), pantoprazole (Protonix) and rabeprazole (Aciphex).
  • Motility drugs � These medications may help to decrease esophageal reflux, but usually are not used as the only treatment for GERD. They help the stomach to empty faster, which decreases the amount of time during which reflux can occur. The most commonly prescribed motility drug is metoclopramide (Reglan).
  • Mucosal protectors � These medications coat, soothe and protect the irritated esophageal lining. One example is sucralfate (Carafate).

Surgery is an option for people with severe, difficult-to-control GERD symptoms or people who have complications such as asthma or pneumonia, or strictures (blockages) of the esophagus from scar tissue. Some people who do not want to take medications for a long time may choose surgery.

Surgery for GERD can be done using camera-guided instruments, a technique called laparoscopic surgery. Laparoscopic surgery requires smaller incisions than conventional surgery. In a procedure called Nissen fundoplication, excess stomach tissue is folded around the esophagus and sewn in place hold extra pressure around the weakened esophageal sphincter. This operation appears to relieve symptoms about as much as prescription acid-blocking medicines. The success rates of surgery might be lower for people whose symptoms are not relieved by antacid medicines. Following surgery, about one out of five people will have a lasting bothersome side effect, but most people who have surgery are very satisfied with the results. These potential side effects include swallowing difficulty, diarrhea, and the inability to belch or vomit to relieve bloating or nausea.

Endoscopy treatments
Three new treatments have been developed to tighten the lower esophageal sphincter using an endoscope. An endoscope is a flexible tube that can be passed through the mouth and throat to examine the interior of the esophagus. The three treatments are stitching (plication), heating (the Stretta procedure) and injection of the sphincter with a bulking material (the Enteryx procedure). All three endoscopic treatments were developed recently, so their long-term success rates are unknown and little is known about their potential complications. They are not yet widely available, but they are being offered at an increasing number of medical centers.

Eighty percent to 90% of patients improve after treatment with medication, but it can take weeks of treatment before symptoms begin to be relieved. For example, with proton pump inhibitor treatment, only about 10% of people will be symptom-free after 1 week, but about 80% will be relieved of symptoms after 8 weeks of daily treatment.

National Digestive Diseases Information Clearinghouse (NDDIC)
2 Information Way
Bethesda, MD 20892-3570
Toll-Free: 1-800-891-5389
Phone: 301-654-3810
Fax: 301-907-8906
Email: nddic@info.niddk.nih.gov
http://digestive.niddk.nih.gov/

American College of Gastroenterology (ACG)
P.O. Box 342260
Bethesda, MD 20827-2260
Phone: 301-263-9000
http://www.acg.gi.org/