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Reflux Disease (GERD) Gastroesophageal reflux disease (GERD) is a condition in which the esophagus becomes irritated or inflamed because of acid backing up from the stomach. The esophagus or food pipe is the tube stretching from the throat to the stomach. When food is swallowed, it travels down the esophagus. The stomach produces hydrochloric acid after a meal to aid in the digestion of food. The inner lining of the stomach resists corrosion by this acid. The cells that line the stomach secrete large amounts of protective mucus. The lining of the esophagus does not share these resistant features and stomach acid can damage it. The esophagus lies just behind the heart, so the term heartburn was coined to describe the sensation of acid burning the esophagus (see Media file 1). Normally, a ring of muscle at the bottom of the esophagus, called the lower esophageal sphincter, prevents reflux (or backing up) of acid. This sphincter relaxes during swallowing to allow food to pass. It then tightens to prevent flow in the opposite direction. With GERD, however, the sphincter relaxes between swallows, allowing stomach contents and corrosive acid to well up and damage the lining of the esophagus. Causes No one knows the exact cause of gastroesophageal reflux. The following are several contributing factors that weaken or relax the lower esophageal sphincter, making reflux worse: Lifestyle - Use of alcohol or cigarettes, obesity, poor posture (slouching) Medications - Calcium channel blockers, theophylline (Tedral, Hydrophed, Marax, Bronchial, Quibron), nitrates, antihistamines Diet - Fatty and fried foods, chocolate, garlic and onions, drinks with caffeine, acid foods such as citrus fruits and tomatoes, spicy foods, mint flavorings Eating habits - Eating large meals, eating soon before bedtime Other medical conditions - Hiatal hernia, pregnancy, diabetes, rapid weight gain Hiatal hernia is a condition when the upper part of the stomach protrudes up above the diaphragm (the strong muscle that separates the organs of the chest from those of the abdomen). Normally, the diaphragm acts as an additional barrier, helping the lower esophageal sphincter keep acid from backing up into the esophagus. A hiatal hernia makes it easier for the acid to back up. Hiatal hernia can be caused by persistent coughing, vomiting, straining, or sudden physical exertion. Obesity and pregnancy can make the condition worse. Hiatal hernia is very common in people older than 50 years. Hiatal hernia usually requires no treatment. In rare cases when the hernia becomes twisted or is making GERD worse, surgery may be required. Symptoms Persistent heartburn is the most common symptom of GERD. Heartburn is a burning pain in the center of the chest, behind the breastbone. It often starts in the upper abdomen and spreads up into the neck. The pain can last as long as 2 hours. Heartburn is usually worse after eating. Lying down or bending over can bring on heartburn or make it worse. The pain usually does not start or get worse with physical activity. Heartburn is sometimes referred to as acid indigestion. Not everyone with GERD has heartburn. Other symptoms of GERD include the following: Regurgitation of bitter acid up into the throat while sleeping or bending over Bitter taste in the mouth Persistent dry cough Hoarseness (especially in the morning) Feeling of tightness in the throat, as if a piece of food is stuck there Wheezing The most common symptoms in children are repeated vomiting, coughing, and other respiratory problems. When to Seek Medical Care Call your health care provider when symptoms of GERD occur frequently, disrupt your sleep, interfere with work or other activities, or are not relieved by self-care measures alone. Make your health care provider aware that you are using self-care measures so that he or she can monitor how well they work and how often you need to use them. If you have any of the following, go immediately to the closest emergency department: Severe chest pain or pressure, especially if it radiates to your arm, neck, or back Vomiting followed by severe chest pain Vomiting blood Dark, tarry stools Difficulty swallowing solids or liquids Exams and Tests Your health care provider usually can diagnose reflux disease just by the symptoms you report. He or she will probably recommend lifestyle changes first and perhaps an over-the-counter antacid. If symptoms continue for more than 4 weeks despite this therapy, you may be referred to a gastroenterologist. The gastroenterologist may perform an upper GI series. This is a special series of x-rays of the esophagus, stomach, and upper part of the intestine. It is taken after you drink a contrast liquid that makes certain features show up better on the x-rays. This series is sometimes called a barium swallow for one type of contrast liquid that is used. This test gives less information than endoscopy but is sometimes ordered to rule out other conditions such as ulcers or blockage of the esophagus. Sometimes the upper GI series is skipped altogether. The gastroenterologist may perform an upper GI endoscopy, also called esophagogastroduodenoscopy or EGD, a procedure that can be done at the doctor!!!s office. This procedure allows the specialist to make diagnoses, assess damage, take biopsies if necessary, and even treat certain conditions on the spot. Esophageal manometry is a test that measures the function of the lower esophageal sphincter and the motor function of the esophagus. A tube is passed down your throat until it reaches the esophagus. It is often performed along with 24-hour pH probe study. Treatment Self-Care at Home Many people can relieve their symptoms by changing their habits and lifestyle. The following steps, if followed, may reduce your reflux significantly. Don!!!t eat within 3 hours of bedtime. This allows your stomach to empty and acid production to decrease. If you don!!!t eat, your body isn!!!t making acid to digest the food. Similarly, don!!!t lie down right after eating at any time of day. Elevate the head of your bed 6 inches with blocks. Gravity helps prevent reflux. Don!!!t eat large meals. Eating a lot of food at one time increases the amount of acid needed to digest it. Eat smaller, more frequent meals throughout the day. Avoid fatty or greasy foods, chocolate, caffeine, mints or mint-flavored foods, spicy foods, citrus, and tomato-based foods. These foods decrease the competence of the LES. Avoid drinking alcohol. Alcohol increases the likelihood that acid from your stomach will back up. Stop smoking. Smoking weakens the lower esophageal sphincter and increases reflux. Lose excess weight. Overweight and obese people are much more likely to have bothersome reflux than people of healthy weight. Stand upright or sit up straight, maintain good posture. This helps food and acid pass through the stomach instead of backing up into the esophagus. Talk to your health care provider about taking over-the-counter pain relievers such as aspirin, ibuprofen, or medicines for osteoporosis. These can aggravate reflux in some people. Nonprescription (over-the-counter) remedies These also may help relieve your symptoms. Check with your health care provider before trying any of these. Antacids: These are effective when taken 1 hour after meals and at bedtime because they neutralize acid already present. Some familiar brand names of antacids are Gaviscon, Maalox, Mylanta, and Tums. Some are combined with a foaming agent. Foam in the stomach apparently helps prevent acid from backing up into the esophagus. These agents are safe to use every day over a few weeks, but if taken over a longer period can cause side effects: Diarrhea Impaired metabolism of calcium in the body Build-up of magnesium in the body, which can damage the kidneys If you use these daily for more than 3 weeks, you should let your health care provider know. Histamine-2 receptor blockers (H2-blockers): These prevent acid production. H2-blockers are effective only if taken at least 1 hour before meals because they don!!!t affect acid that is already present. Common H2-blockers are cimetidine (Tagamet), famotidine (Pepcid), ranitidine (Zantac), and nizatidine (Axid). Medical Treatment If self-care and treatment with nonprescription medication does not work, your health care provider likely will prescribe one of a class of stronger antacids. This therapy may be needed only for a short time or over a longer period while you make gradual changes in your lifestyle. Medications These drugs use different mechanisms to reduce reflux. Proton pump inhibitors (PPIs) PPIs include omeprazole, esomeprazole, lansoprazole, rabeprazole, and pantoprazole . They block the production of an enzyme needed to produce stomach acid. PPIs stop acid production more completely than H2-blockers. Coating agents Sucralfate (Carafate) coats mucous membranes and sores to provide an additional protective barrier against stomach acid. Promotility agents Promotility agents include metoclopramide (Reglan, Clopra, Maxolon) and bethanechol (Duvoid, Urabeth, Urecholine). They help tighten the lower esophageal sphincter and promote faster emptying of the stomach. Health care providers often are reluctant to prescribe these medications because they have fairly significant side effects. Promotility agents also do not work as well as PPIs for most people. One of these agents, cisapride (Propulsid), has been removed from the US market because of safety concerns related to lethal drug interactions. Surgery Surgery is never the first option for treating GERD. Changes in lifestyle and habits, nonprescription antacids, and prescription medications all must be tried before resorting to surgery. Only if all else fails is surgery recommended. Because lifestyle changes and medications work well in most people, surgery is done on only a small number of people. The operation used most often for GERD is called fundoplication. Fundoplication works by increasing pressure in the lower esophagus to keep acid from backing up. The surgeon wraps part of your stomach around your esophagus like a collar and tacks it down to provide more of a one-way valve effect. This procedure now can be done laparoscopically, without a large incision in your abdomen. The surgeon makes a couple of very small cuts in your belly and inserts long narrow instruments and a fiberoptic camera (laparoscope) through the slits. This method leaves very little scarring and can produce a much faster recovery. Like all surgical procedures, fundoplication does not always work and can have complications. Prevention The best and safest way to prevent reflux disease from occurring is to change the things that cause reflux. Maintain a healthy body weight. Avoid large meals and eating within 3 hours of bedtime. Limit fatty or greasy foods, chocolate, caffeine, and other irritating foods. Avoid alcohol. Stop smoking. Maintain good posture, especially while seated. Avoid working out, bending, or stooping on a full stomach. Outlook Reflux disease (GERD) is treatable, but relapses are common, especially if you do not change your lifestyle. For people with mild-to-moderate disease (grades 1-2), home care and H2-blockers are effective about 60% of the time. Severe esophagitis (grades 3-4) usually requires PPI therapy. If relapses occur, long-term therapy or surgery will be necessary to avoid complications. Complications of acid reflux can include any of the following. Most of these are rare, but GERD can be the first step toward any of them. The best treatment for any of these is prevention. Esophagitis and esophageal ulcers - Inflammation, irritation of the lining of the esophagus Laryngopharyngeal reflux - When acid from the stomach gets into the throat, the voice becomes hoarse. Bleeding - Due to ulcers in the damaged esophageal lining Strictures - Narrowing of the esophagus due to chronic scarring Swallowing problems - Due to strictures Respiratory problems - When acid from the stomach gets into the breathing passages Barrett esophagus - Changes in the cells lining the esophagus, a precancerous condition Cancer of the esophagus - Has a very low incidence rate