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Gastroesophageal reflux disease, or 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 GERD. Heartburn that
occurs more than twice a week may be considered GERD, and it can
eventually lead to more serious health problems.
Anyone, including infants, children, and pregnant
women, can have GERD.
The main symptoms are persistent heartburn and
acid regurgitation. Some people have 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. GERD can also cause a dry cough and bad breath.
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Studies* show that GERD 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
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
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.
*Jung AD. Gastroesophageal reflux in
infants and children. American Family Physician.
2001;64(11):1853-1860.
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No one knows why people get GERD. 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 GERD
include
Also, certain foods can be associated with reflux
events, including
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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 GERD is, treatment may
involve one or more of the following lifestyle changes and
medications or surgery.
Medications
Your doctor may recommend over-the-counter
antacids, which you can buy without a prescription, or medications
that stop acid production or help the muscles that empty your
stomach.
Antacids, such as Alka-Seltzer, Maalox,
Mylanta, Pepto-Bismol, Rolaids, and Riopan, are usually the first
drugs recommended to relieve heartburn and other mild GERD symptoms.
Many brands on the market use different combinations of three basic
salts-magnesium, calcium, and aluminum-with hydroxide or bicarbonate
ions to neutralize the acid in your stomach. Antacids, however, have
side effects. Magnesium salt can lead to diarrhea, and aluminum
salts can cause constipation. Aluminum and magnesium salts are often
combined in a single product to balance these effects.
Calcium carbonate antacids, such as Tums,
Titralac, and Alka-2, can also be a supplemental source of calcium.
They can cause constipation as well.
Foaming agents, such as Gaviscon, work by
covering your stomach contents with foam to prevent reflux. These
drugs may help those who have no damage to the esophagus.
H2 blockers, such
as cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid
AR), and ranitidine (Zantac 75), impede acid production. They are
available in prescription strength and over the counter. These drugs
provide short-term relief, but over-the-counter H2 blockers should not be used for more than a few
weeks at a time. They are effective for about half of those who have
GERD symptoms. Many people benefit from taking H2 blockers at bedtime in combination with a proton
pump inhibitor.
Proton pump inhibitors include omeprazole
(Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix),
rabeprazole (Aciphex), and esomeprazole (Nexium), which are all
available by prescription. Proton pump inhibitors are more effective
than H2 blockers and can relieve symptoms in
almost everyone who has GERD.
Another group of drugs, prokinetics, helps
strengthen the sphincter and makes the stomach empty faster. This
group includes bethanechol (Urecholine) and metoclopramide (Reglan).
Metoclopramide also improves muscle action in the digestive tract,
but these drugs have frequent side effects that limit their
usefulness.
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. By the time the antacid stops
working, the H2 blocker will have stopped
acid production. Your doctor is the best source of information on
how to use medications for GERD.
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If your heartburn does not improve with lifestyle
changes or drugs, you may need additional tests.
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 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.
Recently the FDA approved an implant that may
help people with GERD 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 GERD and who
require and respond to proton pump inhibitors. The long-term effects
of the implant are unknown.
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Sometimes 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
GERD.
For information about Barrett's esophagus, please
see the Barrett's Esophagus fact sheet from the National Institute
of Diabetes and Digestive and Kidney Diseases.
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- Heartburn, also called acid indigestion, is
the most common symptom of GERD. Anyone experiencing heartburn
twice a week or more may have GERD.
- You can have 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, GERD may cause
repeated vomiting, coughing, and other respiratory problems. Most
babies grow out of GERD 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 GERD.
Or 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.
- Doctors usually recommend lifestyle and
dietary changes to relieve heartburn. Many people with GERD also
need medication. Surgery may be an option.
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No one knows why some people who have heartburn
develop GERD. Several factors may be involved, and research is under
way on many levels. Risk factors-what makes some people get GERD but
not others-are being explored, as is GERD's role in other conditions
such as asthma and bronchitis.
The role of hiatal hernia in 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, GERD, Barrett's
esophagus, and cancers of the esophagus have increased. Researchers
wonder whether having H. pylori helps prevent GERD and other
diseases. Future treatment will be greatly affected by the results
of this research.
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American College of Gastroenterology
(ACG)
4900-B South 31st Street
Arlington, VA
22206-1656
Phone: 703-820-7400
Fax: 703-931-4520
Internet:
www.acg.gi.org
American Gastroenterological Association
(AGA)
National Office
4930 Del Ray Avenue
Bethesda, MD
20814
Phone: 301-654-2055
Fax: 301-652-3890
Email:
webinfo@gastro.org
Internet: www.gastro.org
North American Society for Pediatric
Gastroenterology, Hepatology, and Nutrition (NASPGHAN)
P.O.
Box 6
Flourtown, PA 19031
Phone: 215-233-0808
Fax:
215-233-3939
Email: naspghan@naspghan.org
Internet:
www.naspghan.org
Pediatric/Adolescent Gastroesophageal Reflux
Association Inc. (PAGER)
P.O. Box 1153
Germantown, MD
20875-1153
Phone: 301-601-9541
Email:
gergroup@aol.com
Internet: www.reflux.org
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The U.S. Government does not endorse or favor any
specific commercial product or company. Trade, proprietary, or
company names appearing in this document are used only because they
are considered necessary in the context of the information provided.
If a product is not mentioned, this does not mean or imply that the
product is unsatisfactory.
2 Information Way
Bethesda, MD
20892-3570
Email: nddic@info.niddk.nih.gov
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. Department
of Health and Human Services. 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 and
distributes publications, and works closely with professional and
patient organizations and Government agencies to coordinate
resources about digestive diseases.
Publications produced by the clearinghouse are
carefully reviewed by both NIDDK scientists and outside experts.
This fact sheet was reviewed by G. Richard Locke, M.D., Mayo Clinic;
and Joel Richter, M.D., Cleveland Clinic Foundation.
This e-text is not copyrighted. The clearinghouse
encourages users of this e-pub to duplicate and distribute as many
copies as desired.
NIH Publication No. 03-0882
June
2003
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