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Gastroesophageal Reflux Disease (GERD)
Gastroesophageal reflux disease (GERD) is a digestive disorder that
affects the lower esophageal sphincter (LES)--the muscle connecting
the esophagus with the stomach. Many people, including pregnant
women, suffer from heartburn or acid indigestion caused by GERD.
Doctors believe that some people suffer from GERD due to a condition
called hiatal hernia. In most cases, heartburn can be relieved through
diet and lifestyle changes; however, some people may require
medication or surgery. This fact sheet provides information on
GERD-its causes, symptoms, treatment, and long-term complications.
What Is Gastroesophageal Reflux?
Gastroesophageal refers to the stomach and esophagus. Reflux means
to flow back or return. Therefore, gastroesophageal reflux is the return
of the stomach's contents back up into the esophagus.
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FIGURE 1
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In normal digestion, the LES opens to allow food to pass into the
stomach and closes to prevent food and acidic stomach juices from
flowing back into the esophagus. Gastroesophageal reflux occurs
when the LES is weak or relaxes inappropriately allowing the
stomach's contents to flow up into the esophagus. Figure 1 shows the
location of the LES between the esophagus and the stomach.
The severity of GERD depends on LES dysfunction as well as the type
and amount of fluid brought up from the stomach and the neutralizing
effect of saliva.
What Is the Role of Hiatal Hernia?
Some doctors believe a hiatal hernia may weaken the LES and cause
reflux. Hiatal hernia occurs when the upper part of the stomach moves
up into the chest through a small opening in the diaphragm
(diaphragmatic hiatus). The diaphragm is the muscle separating the
stomach from the chest. Recent studies show that the opening in the
diaphragm acts as an additional sphincter around the lower end of the
esophagus. Studies also show that hiatal hernia results in retention of
acid and other contents above this opening. These substances can
reflux easily into the esophagus.
Coughing, vomiting, straining, or sudden physical exertion can cause
increased pressure in the abdomen resulting in hiatal hernia. Obesity
and pregnancy also contribute to this condition. Many otherwise healthy
people age 50 and over have a small hiatal hernia. Although considered
a condition of middle age, hiatal hernias affect people of all ages.
Hiatal hernias usually do not require treatment. However, treatment
may be necessary if the hernia is in danger of becoming strangulated
(twisted in a way that cuts off blood supply, i.e., paraesophageal
hernia) or is complicated by severe GERD or esophagitis (inflammation
of the esophagus). The doctor may perform surgery to reduce the size
of the hernia or to prevent strangulation.
What Other Factors Contribute to GERD?
Dietary and lifestyle choices may contribute to GERD. Certain foods
and beverages, including chocolate, peppermint, fried or fatty foods,
coffee, or alcoholic beverages, may weaken the LES causing reflux and
heartburn. Studies show that cigarette smoking relaxes the LES.
Obesity and pregnancy can also cause GERD.
What Does Heartburn Feel Like?
Heartburn, also called acid indigestion, is the most common symptom
of GERD and usually feels like a burning chest pain beginning behind
the breastbone and moving upward to the neck and throat. Many
people say it feels like food is coming back into the mouth leaving an
acid or bitter taste.
The burning, pressure, or pain of heartburn can last as long as 2 hours
and is often worse after eating. Lying down or bending over can also
result in heartburn. Many people obtain relief by standing upright or by
taking an antacid that clears acid out of the esophagus.
Heartburn pain can be mistaken for the pain associated with heart
disease or a heart attack, but there are differences. Exercise may
aggravate pain resulting from heart disease, and rest may relieve the
pain. Heartburn pain is less likely to be associated with physical activity.
How Common Is Heartburn?
More than 60 million American adults experience Gerd and heartburn
at least once a month, and about 25 million adults suffer daily from
heartburn. Twenty-five percent of pregnant women experience daily
heartburn, and more than 50 percent have occasional distress. Recent
studies show that GERD in infants and children is more common than
previously recognized and may produce recurrent vomiting, coughing
and other respiratory problems, or failure to thrive.
What Is the Treatment for GERD?
Doctors recommend lifestyle and dietary changes for most people with
GERD. Treatment aims at decreasing the amount of reflux or reducing
damage to the lining of the esophagus from refluxed materials.
Avoiding foods and beverages that can weaken the LES is
recommended. These foods include chocolate, peppermint, fatty foods,
coffee, and alcoholic beverages. Foods and beverages that can irritate
a damaged esophageal lining, such as citrus fruits and juices, tomato
products, and pepper, should also be avoided.
Decreasing the size of portions at mealtime may also help control
symptoms. Eating meals at least 2 to 3 hours before bedtime may
lessen reflux by allowing the acid in the stomach to decrease and the
stomach to empty partially. In addition, being overweight often worsens
symptoms. Many overweight people find relief when they lose weight.
Cigarette smoking weakens the LES. Therefore, stopping smoking is
important to reduce GERD symptoms.
Elevating the head of the bed on 6-inch blocks or sleeping on a
specially designed wedge reduces heartburn by allowing gravity to
minimize reflux of stomach contents into the esophagus.
Antacids taken regularly can neutralize acid in the esophagus and
stomach and stop heartburn. Many people find that nonprescription
antacids provide temporary or partial relief. An antacid combined with
a foaming agent such as alginic acid helps some people. These
compounds are believed to form a foam barrier on top of the stomach
that prevents acid reflux from occuring.
Long-term use of antacids, however, can result in side effects, including
diarrhea, altered calcium metabolism (a change in the way the body
breaks down and uses calcium), and buildup of magnesium in the body.
Too much magnesium can be serious for patients with kidney disease. If
antacids are needed for more than 3 weeks, a doctor should be
consulted.
For chronic reflux and heartburn, the doctor may prescribe medications
to reduce acid in the stomach. These medicines include H2 blockers,
which inhibit acid secretion in the stomach. Currently, four H2 blockers
are available: cimetidine, famotidine, nizatidine, and ranitidine. Another
type of drug, the proton pump (or acid pump) inhibitor omeprazole
inhibits an enzyme (a protein in the acid-producing cells of the stomach)
necessary for acid secretion. The acid pump inhibitor lansoprazole is
currently under investigation as a new treatment for GERD.
Other approaches to therapy will increase the strength of the LES and
quicken emptying of stomach contents with motility drugs that act on
the upper gastrointestinal (GI) tract. These drugs include bethanechol
and metoclopramide.
Tips To Control Heartburn
- Avoid foods and beverages that affect LES pressure or
irritate the esophagus lining, including fried and fatty foods,
peppermint, chocolate, alcohol, coffee, citrus fruit and juices,
and tomato products.
- Lose weight if overweight.
- Stop smoking.
- Elevate the head of the bed 6 inches.
- Avoid lying down 2 to 3 hours after eating.
- Take an antacid.
What If Symptoms Persist?
People with severe, chronic esophageal reflux or with symptoms not
relieved by the treatment described above may need more complete
diagnostic evaluation. Doctors use a variety of tests and procedures to
examine a patient with chronic heartburn.
An upper GI series may be performed during the early phase of
testing. This test is a special x-ray that shows the esophagus, stomach,
and duodenum (the upper part of the small intestine). While an upper
GI series provides limited information about possible reflux, it is used to
rule out other diagnoses, such as peptic ulcers.
Endoscopy is an important procedure for individuals with chronic
GERD. By placing a small lighted tube with a tiny video camera on the
end (endoscope) into the esophagus, the doctor may see inflammation
or irritation of the tissue lining the esophagus (esophagitis). If the
findings of the endoscopy are abnormal or questionable, biopsy
(removing a small sample of tissue) from the lining of the esophagus
may be helpful.
The Bernstein test (dripping a mild acid through a tube placed in the
mid-esophagus) is often performed as part of a complete evaluation.
This test attempts to confirm that the symptoms result from acid in the
esophagus. Esophageal manometric studies-pressure measurements
of the esophagus-occasionally help identify critically low pressure in the
LES or abnormalities in esophageal muscle contraction.
For patients in whom diagnosis is difficult, doctors may measure the
acid levels inside the esophagus through pH testing. Testing pH
monitors the acidity level of the esophagus and symptoms during meals,
activity, and sleep. Newer techniques of long-term pH monitoring are
improving diagnostic capability in this area.
Does GERD Require Surgery?
A small number of people with GERD may need surgery because of
severe reflux and poor response to medical treatment. Fundoplication is
a surgical procedure that increases pressure in the lower esophagus.
However, surgery should not be considered until all other measures
have been tried.
What Are the Complications of Long-Term GERD?
Sometimes GERD results in serious complications. Esophagitis can
occur as a result of too much stomach acid in the esophagus.
Esophagitis may cause esophageal bleeding or ulcers. In addition, a
narrowing or stricture of the esophagus may occur from chronic
scarring. Some people develop a condition known as Barrett's
esophagus, which is severe damage to the skin-like lining of the
esophagus. Doctors believe this condition may be a precursor to
esophageal cancer.
Conclusion
Although GERD can limit daily activities and productivity, it is rarely
life-threatening. With an understanding of the causes and proper
treatment most people will find relief.
Additional Readings
Cramer T. A burning question: When do you need an antacid? FDA
Consumer 1992; 26(1): 19-22. This article for consumers provides
general information about antacids.
Larson D.E, Editor-in-chief. Mayo Clinic Family Health Book. New
York: William Morrow and Company, Inc., 1990. This general medical
guide includes sections about esophageal reflux and hiatal hernia.
Richter J.E. Why does surgery work for GERD? Practical
Gastroenterology 1993; XVII(10): 10-18. This article for physicians
describes antireflux surgery.
Sutherland J.E. Gastroesophageal reflux disease: when antacids aren't
enough. Postgraduate Medicine 1991; 89(7): 45-53. This article for
primary care physicians provides guidelines to determine if a patient has
reflux disease and offers treatment methods.
National Digestive Diseases Information Clearinghouse
The National Digestive Diseases Information Clearinghouse (NDDIC)
is a service of the National Institute of Diabetes and Digestive and
Kidney Diseases (NIDDK). The NIDDK is part of the National
Institutes of Health under the U.S. Public Health Service. Established in
1980, the clearinghouse provides information about digestive diseases
to people with digestive disorders and to their families, health care
professionals, and the public. NDDIC answers inquiries; develops,
reviews, and distributes publications; and works closely with
professional and patient organizations and Government agencies to
coordinate resources about digestive diseases.
The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Reprinted with permission.
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