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GERD: GastroEsophageal Reflux Disease (Heartburn)
Overview of GERD

Heartburn, a burning discomfort in the chest, is a common condition experienced by millions of Americans. An occasional episode can be insignificant, but regular episodes of heartburn can be a sign of a serious problem, called GERD, and deserves medical attention.

Gastroesophageal reflux disease (GERD) is a chronic condition that occurs when irritating stomach acid or, occasionally bile flows backwards (refluxes) into the esophagus. The reflux of acid irritates the lining of your esophagus and causes the signs and symptoms of GERD.

With a good understanding of the causes of heartburn and a consistent treatment program, most people find relief.

Anatomy of the esophagus and stomach (upper GI tract)  

Esophagus: Once food is swallowed, it moves through a long, hollow, muscular tube, called the esophagus.Esophagus

What causes reflux (GERD)?

Lower esophageal sphincter: At the lower end of the esophagus and entrance to the stomach, the food is pushed past the lower esophageal sphincter (LES) which is a ring of muscle that acts like a valve between the esophagus and stomach. This muscle allows the food to enter the stomach but not back into the esophagus. Once the food is in the stomach, the sphinctor should remain closed keeping the stomach contents in the stomach.

Stomach: In the stomach, the food is mixed with digestive stomach acid, which starts breaking down the food for digestion.

Gastroesophageal reflux (GERD) occurs when the Lower Esophageal Sphinctor muscle either relaxes inappropriately or is weak. This allows stomach juices to back up, or reflux, into the esophagus, creating heartburn. When the acid contents from the stomach regularly back up into the esophagus, a chronic condition called gastroesophageal reflux disease, or GERD, occurs.

Heartburn, a burning discomfort in the chest, is a common condition experienced by millions of Americans. However, anyone experiencing heartburn twice a week or more may have GERD. An occasional episode can be insignificant, but regular episodes of heartburn can be a sign of a serious problem and deserves medical attention. With proper understanding of the causes of heartburn and a consistent treatment program, most people find relief.

Symptoms

Frequent or constant heartburn is the most common symptom of gastroesophageal reflux disease (GERD). The burning and pressure symptoms of heartburn can last for several hours and often worsen after eating food. Many people describe their symptoms as burning discomfort which is localized behind the breastbone.

However, you can have GERD without having heartburn. You may only have symptoms such as excessive clearing of the throat, problems swallowing, the feeling that food is stuck in your throat, burning in the back of the throat, or pain in the chest.

Symptoms of GERD--you may have one or more of these:

  • Heartburn, chest pain, or acid indigestion. This is the main symptom of GERD in adults. It's often described as a burning-type pain in the lower part of the mid-chest, behind the breast bone, and in the mid-abdomen. Most children under 12 with GERD, and some adults, have GERD without heartburn. Instead, they may have a dry cough, asthma symptoms, or trouble swallowing.
  • Bitter or sour taste of acid in the back of the throat especially when bending over or lying down. When acid reflux occurs, food or fluid can be tasted in the back of the mouth.
  • Throat symptoms: persistent sore throat, chronic hoarseness, excessive clearing of the throat, problems swallowing, the feeling that food is stuck in your throat, a feeling of a lump in the throat, or burning in the back of the throat.
  • Lung or airway symptoms: chronic cough or asthma (Lung problems can develop when reflux causes stomach fluid to overflow into the breathing tubes. This often occurs at night when a person is lying down and may cause wheezing, bronchitis and pneumonia.)
Complications of GERD

Chronic acid reflux can at times result in serious complications:

  • Esophagitis, an inflammation of the esophagus that can result in esophageal bleeding or ulcers.
  • Cancer of the esophagus: Studies show that nighttime heartburn increases the risk of developing cancer of the esophagus.
  • A stricture (narrowing or partial closure) of the lower esophagus may occur, significantly interfering with a person’s ability to swallow.
  • Barrett’s esophagus, a change in the cells of the tissue lining the bottom of the esophagus that can increase the chance of developing cancer. In most cases, individuals with Barrett’s esophagus should be monitored more closely with periodic upper GI endoscopy and biopsies.
  • Lung problems can develop when reflux causes stomach fluid to overflow into the airways. This often occurs at night when a person is lying down and may result in wheezing, bronchitis and pneumonia.
  • Inflammation of the throat, voice box and airways can occur from chronic acid reflux.

What you can do
  • Over-the-counter medications are helpful:
    • Antacids are sold over-the-counter and are helpful in neutralizing stomach acid which often will relieve heartburn, acid indigestion, and some cases of stomach upset. Some examples of antacids include: Gaviscon, Tums (calcium carbonate--also a source of calcium), Alka-Seltzer, Maalox, Mylanta, Rolaids, and Pepto-Bismol. Some antacids also contain simethicone, an ingredient that helps eliminate excess gas.
      • Precautions: It's important that you read the label and take only as directed. If you are using the tablets, chew them well before swallowing for faster relief. Some antacids contain ingredients that can cause diarrhea, such as magnesium, or constipation, such as aluminum or calcium carbonate. Anatacids can significantly reduce the absorption of other medications. Patients with impaired renal (kidney) function should check with their health care professional before using antacids.

    • H2 blockers These products are all sold both in both prescription strength and in lower doses over-the counter (OTC). OTC products include: Pepcid AC, Tagamet HB, Zantac 75, and Axid AR. H2 blockers work by reducing production of stomach acid, and are used for relief of heartburn, acid indigestion, sour stomach, and other conditions, such as stomach ulcers. A product that contains an antacid plus famotidine (Pepcid Complete) is also available over-the-counter. These agents relieve heartburn within an hour and provide a longer duration of action (about 6 to 10 hours) than antacids. They are best taken 15 to 60 minutes before the offending food is eaten.
      • Precautions: Treating reflux symptoms for prolonged periods of time without a health care provider's supervision is ill advised as use of this medicine could be covering up a more serious underlying condition such as Barrett's esophagitis or even early cancer.

    • A Proton Pump Inhibitor is available in both prescription strength and in lower dose over-the counter strength as Prilosec OTC (omeprazole magnesium). Prilosec should be taken first thing in the morning on an empty stomach, 30 minutes before breakfast. This product is intended for patients with frequent heartburn (2 or more days a week) or heartburn that is more severe. Several other proton pump inhibitors are available by prescription.
      • Precautions: Prolonged use of this OTC product without physician supervision or evaluation is not recommended. The reason for this is because use of this medicine could be covering up a more serious underlying condition such as Barrett's esophagitis or even early cancer.

  • Identify and avoid your specific food triggers Keep a food diary: For at least a week, write down when you eat, what you eat, and when you experience symptoms. This will greatly help you identify and avoid foods that trigger your symptoms. It's best to either limit or avoid those foods and drinks altogether to minimize symptoms. Take this diary with you on your next visit to your health care professional.
      • Here is a list of common food aggravators--you may want to delete some foods or have other foods to add to this list: Fried and fatty foods, spices, onion, coffee (both decaf and regular), citrus, peppermint, spearmint, carbonated beverages, tomato products, pepper, chocolate, and alcohol.

  • Identify any prescription and nonprescription medications that you are taking that appear to be causing or aggravating reflux symptoms. Record this information in your diary, and take it with you to your next office visit. If the offending medication cannot be stopped, other alternatives are available such as switching the offending medication to another medication which is less likely to contribute to heartburn or treating the heartburn with medication.
    • The categories of medications likely to contribute to reflux include: those used to treat asthma and breathing difficulties, heart and blood pressure, arthritis and inflammation, osteoporosis, certain hormones, chemotherapy, antiParkinson's medications, central nervous system depressants such as narcotic pain relievers, Aspirin, NSAIDS (Advil, Alleve, etc), medications for insomnia, muscle relaxants, anti-anxiety medications and certain antidepressants. For a more specific list of medications thought to contribute to reflux, click here. Also, use this online drug reference from the National Library of Medicine and National Institute of Health to look up the side-effects of any medications you might be taking.

  • Raise the head of your bed so that your head and chest are about 4 to 6" higher than your feet. You can do this by placing six-inch blocks under the bed posts at the head of the bed or placing a wedge between the mattress and boxspring. Don't sleep on piles of pillows as it will only put your head at an angle that can increase pressure on your stomach and make your heartburn worse. You could also lie on special wedge designed to help you sleep on an incline. For a temporary solution at a hotel, fold up an extra blanket and put it between the top of the mattress and the boxspring in such a way that the head of the bed is slightly elevated. This is not advised for stomach sleepers, however, as this might put strain on your back.

  • Don't go to bed within 2 to 3 hours of eating. When you lie down within 2 to 3 hours of eating, acid that is
    working to digest your food may flow up into your esophagus causing heartburn. To avoid this
    problem, plan an early dinner and do not snack within 2 to 3 hours of your bedtime.

  • Weight loss if overweight. Even moderate weight gain among persons of normal weight may cause or worsen symptoms of reflux

  • Smaller more frequent meals. Decrease the size of portions at meal times and try eating four to five small meals instead of three large ones.

  • Eat a high fiber diet A recent study showed significant improvement in GERD symptoms in people who followed a high fiber diet

  • Avoid tight-fitting clothing around the waist.

  • Stop smoking if you smoke. Nicotine, one of the main active ingredients in cigarettes, can weaken the lower esophageal sphincter
In the News...
Weight Loss and Raising the Head of the Bed are Key Treatments for Reflux
A recent study from Stanford Medical School found that giving up wine, chocolate, spicy food and coffee to avoid heartburn did not work in treating gastroesophageal reflux disease. The researchers found only two lifestyle changes for which there was clear evidence of benefit: weight loss and raising the head of the bed to reduce the reflux of stomach acid back into the esophagus while lying down. Archives of Internal Medicine, June 2006  
Screening Tool for significant heartburn
How significant is your heartburn? A panel of experts from the American College of Gastroenterology developed a self-test to help gauge the severity of heartburn problems to find out if you might suffer from GERD and if you are taking the right steps to treat it.
Diagnosis

Often your health care provider can diagnose acid reflux based upon your symptoms alone without the need for any testing. (See screening tool above) However, tests may be required to diagnose GERD, to determine its severity, and to rule out any serious underlying conditions such as Barrett's esophagitis or cancer:

  • Upper GI Endoscopy — The patient is given a sedative and a lighted, flexible tube called an endoscope is passed into the esophagus and stomach to inspect the lining visually. If necessary, a biopsy can be taken for further testing.
  • Upper GI Series — The patient drinks liquid contrast to coat the esophagus and stomach, and x-rays are taken.
  • Esophageal Manometry — A specialized tube is passed into the esophagus to measure esophageal muscle function and the function of the lower esophageal sphincter (LES) muscle.
  • Twenty-four–hour pH monitoring — A very thin tube is passed to the bottom of the esophagus to measure the amount of acid reflux. The test is performed for 24 hours while the patient goes about normal activities, including eating. The episodes of acid reflux can be compared with symptoms reported by the patient.
Treatment
Most people can manage the discomfort of heartburn with lifestyle modifications and over-the-counter medications. But if heartburn is severe, these remedies may offer only temporary or partial relief in which case it is important to see your health care professional. Frequently a physician can diagnose acid reflux based on symptoms alone without the need for any testing. However, tests may be required to diagnose GERD, to determine its severity, or to look for complications.
VideoTutorial
GERD an excellent videotutorial from the National Library of Medicine and the National Institute of Health
Internet References
--Written by N Thompson, ARNP in collaboration with M Thompson, MD, Internal Medicine, Last updated November 2009

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