Gastroesophageal reflux disease (GERD)

Gastroesophageal reflux disease (GERD) occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach (esophagus). This backwash (acid reflux) can irritate the lining of your esophagus.

Many people experience acid reflux from time to time. However, when acid reflux happens repeatedly over time, it can cause GERD.

Most people are able to manage the discomfort of GERD with lifestyle changes and medications. And though it's uncommon, some may need surgery to ease symptoms.

Common signs and symptoms of GERD include:

• A burning sensation in your chest (heartburn), usually after eating, which might be worse at night or while lying down
• Backwash (regurgitation) of food or sour liquid
• Upper abdominal or chest pain
• Trouble swallowing (dysphagia)
• Sensation of a lump in your throat

If you have nighttime acid reflux, you might also experience:

• An ongoing cough
• Inflammation of the vocal cords (laryngitis)
• New or worsening asthma

When to see a doctor

Seek immediate medical care if you have chest pain, especially if you also have shortness of breath, or jaw or arm pain. These may be signs and symptoms of a heart attack.

Make an appointment with your doctor if you:

• Experience severe or frequent GERD symptoms
• Take over-the-counter medications for heartburn more than twice a week

GERD is caused by frequent acid reflux or reflux of nonacidic content from the stomach.

When you swallow, a circular band of muscle around the bottom of your esophagus (lower esophageal sphincter) relaxes to allow food and liquid to flow into your stomach. Then the sphincter closes again.

If the sphincter does not relax as it should or it weakens, stomach acid can flow back into your esophagus. This constant backwash of acid irritates the lining of your esophagus, often causing it to become inflamed.

Conditions that can increase your risk of GERD include:

• Obesity
• Bulging of the top of the stomach up above the diaphragm (hiatal hernia)
• Pregnancy
• Connective tissue disorders, such as scleroderma
• Delayed stomach emptying

Factors that can aggravate acid reflux include:

• Smoking
• Eating large meals or eating late at night
• Eating certain foods (triggers) such as fatty or fried foods
• Drinking certain beverages, such as alcohol or coffee
• Taking certain medications, such as aspirin

Over time, chronic inflammation in your esophagus can cause:

• Inflammation of the tissue in the esophagus (esophagitis). Stomach acid can break down tissue in the esophagus, causing inflammation, bleeding, and sometimes an open sore (ulcer). Esophagitis can cause pain and make swallowing difficult.
• Narrowing of the esophagus (esophageal stricture). Damage to the lower esophagus from stomach acid causes scar tissue to form. The scar tissue narrows the food pathway, leading to problems with swallowing.
• Precancerous changes to the esophagus (Barrett esophagus). Damage from acid can cause changes in the tissue lining the lower esophagus. These changes are associated with an increased risk of esophageal cancer.

Your health care provider might be able to diagnose GERD based on a history of your signs and symptoms and a physical examination.

To confirm a diagnosis of GERD, or to check for complications, your doctor might recommend:

• Upper endoscopy. Your doctor inserts a thin, flexible tube equipped with a light and camera (endoscope) down your throat. The endoscope helps your provider see inside your esophagus and stomach. Test results may not show problems when reflux is present, but an endoscopy may detect inflammation of the esophagus (esophagitis) or other complications.

  An endoscopy can also be used to collect a sample of tissue (biopsy) to be tested for complications such as Barrett esophagus. In some instances, if a narrowing is seen in the esophagus, it can be stretched or dilated during this procedure. This is done to improve trouble swallowing (dysphagia).

• Ambulatory acid (pH) probe test. A monitor is placed in your esophagus to identify when, and for how long, stomach acid regurgitates there. The monitor connects to a small computer that you wear around your waist or with a strap over your shoulder.

  The monitor might be a thin, flexible tube (catheter) that's threaded through your nose into your esophagus. Or it might be a clip that's placed in your esophagus during an endoscopy. The clip passes into your stool after about two days.

• X-ray of the upper digestive system. X-rays are taken after you drink a chalky liquid that coats and fills the inside lining of your digestive tract. The coating allows your doctor to see a silhouette of your esophagus and stomach. This is particularly useful for people who are having trouble swallowing.

  You may also be asked to swallow a barium pill that can help diagnose a narrowing of the esophagus that may interfere with swallowing.

• Esophageal manometry. This test measures the rhythmic muscle contractions in your esophagus when you swallow. Esophageal manometry also measures the coordination and force exerted by the muscles of your esophagus. This is typically done in people who have trouble swallowing.
• Transnasal esophagoscopy. This test is done to look for any damage in your esophagus. A thin, flexible tube with a video camera is put through your nose and moved down your throat into the esophagus. The camera sends pictures to a video screen.

Your doctor is likely to recommend that you first try lifestyle changes and nonprescription medications. If you don't experience relief within a few weeks, your doctor might recommend prescription medication and additional testing.

Nonprescription medications

Options include:

• Antacids that neutralize stomach acid. Antacids containing calcium carbonate, such as Mylanta, Rolaids and Tums, may provide quick relief. But antacids alone won't heal an inflamed esophagus damaged by stomach acid. Overuse of some antacids can cause side effects, such as diarrhea or sometimes kidney problems.
• Medications to reduce acid production. These medications — known as histamine (H-2) blockers — include cimetidine (Tagamet HB), famotidine (Pepcid AC) and nizatidine (Axid AR). H-2 blockers don't act as quickly as antacids, but they provide longer relief and may decrease acid production from the stomach for up to 12 hours. Stronger versions are available by prescription.
• Medications that block acid production and heal the esophagus. These medications — known as proton pump inhibitors — are stronger acid blockers than H-2 blockers and allow time for damaged esophageal tissue to heal. Nonprescription proton pump inhibitors include lansoprazole (Prevacid 24 HR), omeprazole (Prilosec OTC) and esomeprazole (Nexium 24 HR).

If you start taking a nonprescription medication for GERD, be sure to inform your doctor.

Prescription medications

Prescription-strength treatments for GERD include:

• Prescription-strength proton pump inhibitors. These include esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix), rabeprazole (Aciphex) and dexlansoprazole (Dexilant).

  Although generally well tolerated, these medications might cause diarrhea, headaches, nausea, or in rare instances, low vitamin B-12 or magnesium levels.

• Prescription-strength H-2 blockers. These include prescription-strength famotidine and nizatidine. Side effects from these medications are generally mild and well tolerated.

Surgery and other procedures

GERD can usually be controlled with medication. But if medications don't help or you wish to avoid long-term medication use, your doctor might recommend:

• Fundoplication. The surgeon wraps the top of your stomach around the lower esophageal sphincter, to tighten the muscle and prevent reflux. Fundoplication is usually done with a minimally invasive (laparoscopic) procedure. The wrapping of the top part of the stomach can be complete (Nissen fundoplication) or partial. The most common partial procedure is the Toupet fundoplication. Your surgeon will recommend the type that is best for you.
• LINX device. A ring of tiny magnetic beads is wrapped around the junction of the stomach and esophagus. The magnetic attraction between the beads is strong enough to keep the junction closed to refluxing acid, but weak enough to allow food to pass through. The LINX device can be implanted using minimally invasive surgery. The magnetic beads do not have an effect on airport security or magnetic resonance imaging.

• Transoral incisionless fundoplication (TIF). This new procedure involves tightening the lower esophageal sphincter by creating a partial wrap around the lower esophagus using polypropylene fasteners. TIF is performed through the mouth by using an endoscope and requires no surgical incision. Its advantages include quick recovery time and high tolerance.

  If you have a large hiatal hernia, TIF alone is not an option. However, TIF may be possible if it is combined with laparoscopic hiatal hernia repair.

Because obesity can be a risk factor for GERD, your health care provider could suggest weight-loss surgery as an option for treatment. Talk with your provider to find out if you're a candidate for this type of surgery.

Lifestyle changes may help reduce the frequency of acid reflux. Try to:

• Maintain a healthy weight. Excess pounds put pressure on your abdomen, pushing up your stomach and causing acid to reflux into your esophagus.
• Stop smoking. Smoking decreases the lower esophageal sphincter's ability to function properly.
• Elevate the head of your bed. If you regularly experience heartburn while trying to sleep, place wood or cement blocks under the feet at the head end of your bed. Raise the head end by 6 to 9 inches. If you can't elevate your bed, you can insert a wedge between your mattress and box spring to elevate your body from the waist up. Raising your head with additional pillows isn't effective.
• Start on your left side. When you go to bed, start by lying on your left side to help make it less likely that you will have reflux.
• Don't lie down after a meal. Wait at least three hours after eating before lying down or going to bed.
• Eat food slowly and chew thoroughly. Put down your fork after every bite and pick it up again once you have chewed and swallowed that bite.
• Avoid foods and drinks that trigger reflux. Common triggers include alcohol, chocolate, caffeine, fatty foods or peppermint.
• Avoid tight-fitting clothing. Clothes that fit tightly around your waist put pressure on your abdomen and the lower esophageal sphincter.

Some complementary and alternative therapies, such as ginger, chamomile and slippery elm, may be recommended to treat GERD. However, none have been proved to treat GERD or reverse damage to the esophagus. Talk to your health care provider if you're considering taking alternative therapies to treat GERD.

You may be referred to a doctor who specializes in the digestive system (gastroenterologist).

What you can do

• Be aware of any pre-appointment restrictions, such as restricting your diet before your appointment.
• Write down your symptoms, including any that may seem unrelated to the reason why you scheduled the appointment.
• Write down any triggers to your symptoms, such as specific foods.
• Make a list of all your medications, vitamins and supplements.
• Write down your key medical information, including other conditions.
• Write down key personal information, including any recent changes or stressors in your life.
• Write down questions to ask your doctor.
• Ask a relative or friend to accompany you, to help you remember what the doctor says.

Questions to ask your doctor

• What's the most likely cause of my symptoms?
• What tests do I need? Is there any special preparation for them?
• Is my condition likely temporary or chronic?
• What treatments are available?
• Are there any restrictions I need to follow?
• I have other health problems. How can I best manage these conditions together?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment anytime you don't understand something.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may leave time to go over points you want to spend more time on. You may be asked:

• When did you begin experiencing symptoms? How severe are they?
• Have your symptoms been continuous or occasional?
• What, if anything, seems to improve or worsen your symptoms?
• Do your symptoms wake you up at night?
• Are your symptoms worse after meals or lying down?
• Does food or sour material ever come up in the back of your throat?
• Do you have trouble swallowing food, or have you had to change your diet to avoid difficulty swallowing?
• Have you gained or lost weight?