GERD TREATMENTS
TREATMENT S FOR GASTROESOPHAGEAL REFLUX DISEASE
(GERD)

Gastroesophageal reflux disease (GERD) occurs when the lower
esophageal sphincter (LES) does not close properly and stomach
contents leak back, or reflux, into the esophagus. The LES is a ring of
muscle at the bottom of the esophagus that acts like a valve between
the esophagus and stomach. The esophagus carries food from the
mouth to the stomach.

When refluxed stomach acid touches the lining of the esophagus, it
causes a burning sensation in the chest or throat called heartburn. The
fluid may even be tasted in the back of the mouth, and this is called acid
indigestion. Occasional heartburn is common but does not necessarily
mean one has gastroesophageal reflux disease. Heartburn that occurs
more than twice a week may be considered gastroesophageal reflux
disease (GERD).

The main symptoms are persistent heartburn and acid regurgitation.
Some people have gastroesophageal reflux disease (GERD) without
heartburn. Instead, they experience pain in the chest, hoarseness in the
morning, or trouble swallowing. You may feel like you have food stuck in
your throat or like you are choking or your throat is tight.
Gastroesophageal reflux disease (GERD) can also cause a dry cough
and bad breath. Gastroesophageal reflux disease (GERD) in Children
Studies* show that gastroesophageal reflux disease is common and
may be overlooked in infants and children. It can cause repeated
vomiting, coughing, and other respiratory problems. Children's
immature digestive systems are usually to blame, and most infants grow
out of gastroesophageal reflux disease (GERD) by the time they are 1
year old. Still, you should talk to your child's doctor if the problem
occurs regularly and causes discomfort. Your doctor may recommend
simple strategies for avoiding reflux, like burping the infant several times
during feeding or keeping the infant in an upright position for 30
minutes after feeding. If your child is older, the doctor may recommend
avoiding sodas that contain caffeine, chocolate and peppermint, spicy
foods like pizza, acidic foods like oranges and tomatoes and fried and
fatty foods. [Jung AD. Gastroesophageal reflux in infants and children.
American Family Physician. 2001;64(11):1853¡V1860.]

Avoiding food 2 to 3 hours before bed may also help. The doctor may
recommend that the child sleep with head raised. If these changes do
not work, the doctor may prescribe medicine for your child. In rare
cases, a child may need surgery. What causes gastroesophageal reflux
disease? No one knows why people get gastroesophageal reflux
disease. A hiatal hernia may contribute. A hiatal hernia occurs when the
upper part of the stomach is above the diaphragm, the muscle wall that
separates the stomach from the chest. The diaphragm helps the LES
keep acid from coming up into the esophagus. When a hiatal hernia is
present, it is easier for the acid to come up. In this way, a hiatal hernia
can cause reflux. A hiatal hernia can happen in people of any age;
many otherwise healthy people over 50 have a small one.

Other factors that may contribute to gastroesophageal reflux disease
include alcohol use, overweight, pregnancy and smoking

Also, certain foods can be associated with reflux events, including citrus
fruits, chocolate, drinks with caffeine, fatty and fried foods, garlic and
onions, mint flavorings, spicy foods, tomato-based foods, like spaghetti
sauce, chili, and pizza

How is gastroesophageal reflux disease treated? If you have had
heartburn or any of the other symptoms for a while, you should see
your doctor. You may want to visit an internist, a doctor who specializes
in internal medicine, or a gastroenterologist, a doctor who treats
diseases of the stomach and intestines. Depending on how severe your
gastroesophageal reflux disease is, treatment may involve one or more
of the following lifestyle changes and medications or surgery. Your
doctor may also advise you to change your lifestyle, such as stop
smoking, stop drinking alcohol, control weight (if needed), eating small
meals, wearing loose-fitting clothes, avoiding lying down for 3 hours
after a meal and raising the head of your bed 6-8 inches higher.

Medications include (1) Antacids, such as Alka-Seltzer, Maalox,
Mylanta, Pepto-Bismol, Rolaids, and Riopan, (2) Foaming agents, such
as Gaviscon, work by covering your stomach contents with foam to
prevent reflux. (3) H2 blockers, such as cimetidine (Tagamet HB),
famotidine (Pepcid AC), nizatidine (Axid AR), and ranitidine (Zantac 75),
impede acid production. (4) Proton pump inhibitors - omeprazole
(Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix),
rabeprazole (Aciphex), and esomeprazole (Nexium), (5) Prokinetics,
helps strengthen the sphincter and makes the stomach empty
faster-bethanechol (Urecholine) and metoclopramide (Reglan).

Because drugs work in different ways, combinations of drugs may help
control symptoms. People who get heartburn after eating may take both
antacids and H2 blockers. The antacids work first to neutralize the acid
in the stomach, while the H2 blockers act on acid production.

What if symptoms persist?

If your heartburn does not improve with lifestyle changes or drugs, you
may need additional tests.

A barium swallow radiograph uses x rays to help spot abnormalities
such as a hiatal hernia and severe inflammation of the esophagus. With
this test, you drink a solution and then x rays are taken. Mild irritation
will not appear on this test, although narrowing of the
esophagus¡Xcalled stricture¡Xulcers, hiatal hernia, and other
problems will.

Upper endoscopy is more accurate than a barium swallow radiograph
and may be performed in a hospital or a doctor's office. The doctor will
spray your throat to numb it and slide down a thin, flexible plastic tube
called an endoscope. A tiny camera in the endoscope allows the doctor
to see the surface of the esophagus and to search for abnormalities. If
you have had moderate to severe symptoms and this procedure reveals
injury to the esophagus, usually no other tests are needed to confirm
gastroesophageal reflux disease (GERD).

The doctor may use tiny tweezers (forceps) in the endoscope to remove
a small piece of tissue for biopsy. A biopsy viewed under a microscope
can reveal damage caused by acid reflux and rule out other problems if
no infecting organisms or abnormal growths are found.

In an ambulatory pH monitoring examination, the doctor puts a tiny tube
into the esophagus that will stay there for 24 hours. While you go about
your normal activities, it measures when and how much acid comes up
into your esophagus. This test is useful in people with
gastroesophageal reflux disease (GERD) symptoms but no esophageal
damage. The procedure is also helpful in detecting whether respiratory
symptoms, including wheezing and coughing, are triggered by reflux.
Surgery Surgery is an option when medicine and lifestyle changes do
not work. Surgery may also be a reasonable alternative to a lifetime of
drugs and discomfort.

Fundoplication, usually a specific variation called Nissen fundoplication,
is the standard surgical treatment for gastroesophageal reflux disease
(GERD). The upper part of the stomach is wrapped around the LES to
strengthen the sphincter and prevent acid reflux and to repair a hiatal
hernia.

This fundoplication procedure may be done using a laparoscope and
requires only tiny incisions in the abdomen. To perform the
fundoplication, surgeons use small instruments that hold a tiny camera.
Laparoscopic fundoplication has been used safely and effectively in
people of all ages, even babies. When performed by experienced
surgeons, the procedure is reported to be as good as standard
fundoplication. Furthermore, people can leave the hospital in 1 to 3
days and return to work in 2 to 3 weeks.

In 2000, the U.S. Food and Drug Administration (FDA) approved two
endoscopic devices to treat chronic heartburn. The Bard EndoCinch
system puts stitches in the LES to create little pleats that help
strengthen the muscle. The Stretta system uses electrodes to create
tiny cuts on the LES. When the cuts heal, the scar tissue helps toughen
the muscle. The long-term effects of these two procedures are
unknown. Implant Recently the FDA approved an implant that may help
people with gastroesophageal reflux disease D who wish to avoid
surgery. Enteryx is a solution that becomes spongy and reinforces the
LES to keep stomach acid from flowing into the esophagus. It is injected
during endoscopy. The implant is approved for people who have
gastroesophageal reflux disease and who require and respond to
proton pump inhibitors. The long-term effects of the implant are
unknown.

What are the long-term complications of gastroesophageal
reflux disease (GERD)? Sometimes gastroesophageal reflux disease
(GERD) can cause serious complications. Inflammation of the
esophagus from stomach acid causes bleeding or ulcers. In addition,
scars from tissue damage can narrow the esophagus and make
swallowing difficult. Some people develop Barrett's esophagus, where
cells in the esophageal lining take on an abnormal shape and color,
which over time can lead to cancer.

Also, studies have shown that asthma, chronic cough, and pulmonary
fibrosis may be aggravated or even caused by gastroesophageal reflux
disease (GERD).

Points to Remember Heartburn, also called acid indigestion, is the most
common symptom of gastroesophageal reflux disease (GERD). Anyone
experiencing heartburn twice a week or more may have
gastroesophageal reflux disease (GERD).

You can have gastroesophageal reflux disease (GERD) without having
heartburn. Your symptoms could be excessive clearing of the throat,
problems swallowing, the feeling that food is stuck in your throat,
burning in the mouth, or pain in the chest.

In infants and children, gastroesophageal reflux disease may cause
repeated vomiting, coughing, and other respiratory problems. Most
babies grow out of gastroesophageal reflux disease by their first
birthday.

If you have been using antacids for more than 2 weeks, it is time to see
a doctor. Most doctors can treat gastroesophageal reflux disease. Or
you may want to visit an internist¡Xa doctor who specializes in internal
medicine¡Xor a gastroenterologist¡Xa doctor who treats diseases of
the stomach and intestines.

Doctors usually recommend lifestyle and dietary changes to relieve
heartburn. Many people with gastroesophageal reflux disease (GERD)
also need medication. Surgery may be an option.

CAUSES OF GERD
No one knows why some people who have heartburn develop
gastroesophageal reflux disease. Several factors may be involved, and
research is under way on many levels. Risk factors¡Xwhat makes some
people get gastroesophageal reflux disease but not others¡Xare being
explored, as is gastroesophageal reflux disease 's role in other
conditions such as asthma and bronchitis.

The role of hiatal hernia in gastroesophageal reflux disease (GERD)
continues to be debated and explored. It is a complex topic because
some people have a hiatal hernia without having reflux, while others
have reflux without having a hernia.

Much research is needed into the role of the bacterium Helicobacter
pylori. Our ability to eliminate H. pylori has been responsible for
reduced rates of peptic ulcer disease and some gastric cancers. At the
same time, gastroesophageal reflux disease (GERD), Barrett's
esophagus, and cancers of the esophagus have increased.
Researchers wonder whether having H. pylori helps prevent
gastroesophageal reflux disease (GERD) and other diseases. Future
treatment will be greatly affected by the results of this research.

Resource for this article: The National Digestive Diseases
Information Clearinghouse (NDDIC) 2 Information Way Bethesda, MD
20892¡V3570, Email: nddic@info.niddk.nih.govAugust 2, 2005.    
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