Gastroesophageal Reflux Disease (GERD), commonly referred to as heartburn, is a condition resulting from stomach acid moving backward from the stomach into the esophagus (the tube that connects the mouth to the stomach). The acid causes burning, inflammation and pain on the lining of the esophagus and can eventually lead to permanent damage of the lining. A tightness in the chest may also be felt, and sometimes heartburn can be confused with symptoms of a heart attack. This backward flow of acid is also called reflux when symptoms are brief and intermittent and do not cause ongoing symptoms.
GERD usually occurs because the muscular valve where the esophagus joins the stomach does not close properly. Some people just have occasional symptoms, while others may have chronic heartburn on a daily basis. Over time, esophagitis, an inflammation and damage to the tissues, may occur.
Chronic reflux with continual exposure of the esophagus to acid can also lead to a condition called Barrett's esophagus. The esophagus passageway may narrow and develop ulcers. Barrett's esophagus also increases the risk of esophageal cancer.
What causes GERD and who is at risk?
Gastroesophageal reflux is a common condition that often occurs with symptoms after meals. In some people, the reflux is related to a problem with the lower esophageal sphincter, a band of muscle fibers that usually closes off the esophagus from the stomach. If this sphincter doesn't close properly, food and liquid can move backward into the esophagus and may cause the symptoms.
Some risk factors that lead to reflux include:
- hiatal hernia
- alcohol use
- being overweight or pregnant (due to elevated stomach pressure)
Certain foods, such as citrus, tomato, mint, garlic, onions, fatty foods, peppermint, chocolate or spicy foods can worsen reflux. Alcohol, coffee, tea, and carbonated beverages, as well as eating too close to bedtime or laying down right after a meal can aggravate symptoms, as well.
Medications may aggravate GERD symptoms by decreasing the lower esophageal sphincter pressure and include:
- nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin, ibuprofen or naproxen
- synthetic hormones known as progestins
- certain muscle relaxants
- bisphosphonates used for osteoporosis and related conditions
- drugs with anticholinergic effects like some antihistamines
- various heart or blood pressure medications like calcium channel blockers or nitroglycerin
What are the symptoms of GERD?
Common symptoms of GERD include:
- Involves a burning pain in the chest (under the breastbone) that may move up into the throat; a sour or bitter-tasting acid may back up into the throat
- Increased by bending, stooping, lying down, or eating
- Relieved by antacids
- More frequent or worse at night and may wake you up
- Belching, burping or bloating
- Regurgitation of food
- Nausea or vomiting
- Hoarseness or change in voice
- Sore throat
- Cough or wheezing
- Dysphagia (difficulty swallowing) -- narrowing of the esophagus can create the sensation of food being stuck in your throat
If you experience vomiting with blood or black, tarry stools, contact your doctor immediately as this may be a sign of bleeding.
How does a doctor diagnose GERD?
Your doctor will evaluate you by asking questions about your symptoms, for example:
- How often do you have your symptoms?
- When is the pain worse?
- Have you lost weight or are you vomiting?
- Do you have black stools?
- Is swallowing difficult?
- Have any medications been helpful?
She or he will do a physical exam, ask about your health history and your current medications, including any over-the-counter, herbals or vitamin supplements you might take.
Your doctor may be able to diagnose your condition with just an office visit, physical exam, and questioning about your symptoms. Lifestyle changes and nonprescription medications may be all that is needed if you have mild acid reflux disease. If you are older or have more severe symptoms, additional tests may be needed. Your heart may be evaluated to rule out any risk of coronary artery disease.
A procedure known as an endoscopy (or upper endoscopy) is typically used if further evaluation is needed or your symptoms do not improve. This will allow your doctor to look for inflammation and ulcers.
A gastroenterologist will perform this test, which is usually a very safe test done in an office, clinic or outpatient hospital. Your doctor may spray your throat with a solution for numbing. After sedation, a flexible tube with a tiny camera is inserted into your mouth and throat to view the esophagus, stomach and top parts of the small intestine. Your doctor may take a sample of tissue for a biopsy. It is usually a quick procedure, 15 to 30 minutes, and you will go home in few hours. Someone else will need to drive you home due to the sedation.
Other procedures or tests for GERD may include:
- Barium swallow x-ray (upper GI series): to look for structural changes in the esophagus. Barium is a substance that you will drink to help your stomach and intestines show up better in x-rays.
- Stool guaiac: to look for blood in the stool coming from the esophagus or other related areas in your body
- Continuous esophageal pH monitoring: to measure the acidity level of the esophagus over a 24-hour period
- Esophageal manometry: to assess for abnormal sphincter pressure
- Bernstein test (acid perfusion test): a procedure used with other tests, such as the pH test, to reproduce symptoms of heartburn to help your doctor make the GERD diagnosis.
Call your doctor if:
Call your healthcare provider if symptoms worsen or do not improve with lifestyle changes or medication, or if you have acid reflux symptoms two or more times per week.
Many people can manage GERD with lifestyle and diet changes, weight loss, and over-the-counter (OTC) medications.
Many medications for reflux and GERD that used to be available only with a prescription in the U.S are now available OTC. However, if your symptoms do not improve in 2 to 3 weeks, or worsen, be sure to see your doctor as you may need a higher prescription dose, a different medication, or further evaluation.
General measures to help prevent GERD symptoms include:
- Weight reduction
- Avoid lying down after meals
- Sleeping with the head of the bed elevated
- Taking medication with plenty of water
- Avoiding dietary fat, chocolate, caffeine, peppermint (they may cause lower esophageal pressure)
- Avoiding alcohol and tobacco
Medications for GERD
There are several medications that can be used to treat GERD. The most commonly used agents include:
Antacids work by raising the stomach pH to help neutralize acid. They can be used as first-line agents for acid indigestion (dyspepsia) or mild heartburn as they are inexpensive, available over-the-counter (OTC) at retail outlets, and relatively safe. However, if your symptoms continue or worsen, see your doctor.
Examples of common antacids include:
- Milk of Magnesia
Products may be available as liquids and/or tablets. The liquid forms may work faster but the tablets may be more convenient and portable. Some products, such as Mylanta, contain a medicine known as simethicone which allows for easier passage of gas. These medicines work for a short period of time and do not heal the inflammation of the esophagus. Take as directed on the specific package labeling.
Most people who use antacids do not have any side effects. However, magnesium can cause diarrhea, and aluminum can cause constipation. Many products contain both agents and this may help to offset these side effects. Also, be sure to review for possible drug interactions between your medications and antacids; check with your pharmacist. The minerals in antacids may bind with many medicines and prevent absorption leading to lower effectiveness.
Histamine-2 (H2) Antagonists
H2 antagonists (also called H2 blockers) block gastric acid secretion from the cells of the stomach lining. They are effective in patients with mild to moderate GERD symptoms. Many agents are available at the pharmacy without a prescription. They can also used to treat stomach or intestinal ulcers, and for excessive acid production (Zollinger-Ellison syndrome) although dosing for these conditions should be directed by your doctor. Most products are available in generic and store brands for cost-savings.
Histamine-2 (H2) Blockers
Pepcid, Pepcid AC
Zantac, Zantac 150, others (all ranitidine discontinued from U.S. market in April 2020)
There are also OTC products that combine H2 blockers and antacids for dual action, such as famotidine, magnesium and calcium (Pepcid Complete).
Ranitidine Withdrawal from US Market
In April 2020, the FDA requested all manufacturers of ranitidine withdraw all prescription and over-the-counter (OTC) ranitidine drugs from the market immediately.
- This action was due to a contaminant known as N-Nitrosodimethylamine (NDMA) found in ranitidine medications.
- The FDA found that the NDMA impurity, which is a possible cancer-causing agent, increases over time and when stored at temperatures higher than room temperature.
- High temperatures may result in consumer exposure to unacceptable levels of NDMA.
Proton Pump Inhibitors (PPIs)
Proton pump inhibitors work by shutting off the stomach's acid production. PPIs irreversibly block the H+/K+ ATPase enzyme (the proton pump) which controls acid production. This enzyme is found in the parietal cells of the stomach.
PPIs may also be used to treat conditions such as Zollinger-Ellison syndrome (a condition associated with an overproduction of stomach acid), to promote healing of stomach ulcers or intestinal ulcers, or for erosive esophagitis (damage to your esophagus caused by stomach acid). PPIs may also be used in conjunction with an antibiotic and other agents such as bismuth to treat and prevent a duodenal ulcer caused by infection with Helicobacter pylori (H. pylori).
Proton Pump Inhibitors (PPIs)
Nexium, Nexium 24Hr
Prilosec, Prilosec OTC
Aciphex, Aciphex Sprinkle
Other options for GERD might include include sucralfate (Carafate) which can help protect the esophagus from irritation and inflammation, or motility drugs like metoclopramide. Omeprazole is also available combined with sodium bicarbonate (Zegerid, Zegerid OTC). Sodium bicarbonate is an antacid that raises the stomach pH to keep the omeprazole from breaking down in acid.
If you have questions or concerns about any medicine you use for GERD, ask your doctor for advice.
Surgery for GERD
Most people with GERD or more serious stomach acid conditions can be help with medications. Infrequently, some patients with severe or uncontrollable GERD symptoms may need surgery to strengthen the lower esophageal sphincter to make it less likely that acid will back up in the esophagus.
- Anti-reflux operations such as Nissen fundoplication may help patients who have persistent symptoms despite medical treatment. In this surgery, the lower esophageal sphincter is strengthened to prevent reflux. In this procedure, the surgeon wraps the top of the stomach around the lower part of the esophagus. Surgeons usually perform this surgery laparoscopically, a minimally invasive type of surgery. You typically stay in the hospital for 1 to 3 days.
- The Linx Reflux Management device is also used to strengthen the lower esophageal sphincter. This device is a ring of magnetized titanium beads that helps to block some stomach acid from refluxing into the esophagus, but allows food to pass into the stomach. It is placed on the lower esophageal sphincter in a minimally invasive laparoscopic surgery. In most cases, patients can return home on the same day as the surgery.