Gastroesophageal reflux disease (GERD) is a disorder in which contents of the stomach or small intestine repeatedly move back up into the esophagus (tube connecting the throat to the stomach). This regurgitating action is called reflux. Reflux causes heartburn, and although most people have an attack of heartburn at some point in their lives, persistent reflux and severe heartburn may indicate GERD.
Normally when a person swallows, the muscular walls of the esophagus move in waves to push the food down into the stomach. Right after the food enters the stomach, a band of muscle (the lower esophageal sphincter) closes off the esophagus. If the muscle fails to close tightly enough, the stomach contents can back up into the esophagus causing heartburn and other symptoms of GERD.
Substances in the digestive juices from the stomach (namely, acid, pepsin, and bile) can damage the inner lining of the esophagus, causing inflammation ulcers (open sores), and, possibly, precancerous changes to cells (called Barrett's esophagus).
Signs and SymptomsHeartburn — a burning sensation under the sternum in the chest — is the primary symptom of GERD. Heartburn often occurs after a meal and worsens at night, when you are lying flat. It is more likely to occur following a heavy meal, or if you bend, lift, or lie down just after eating.
Other symptoms of GERD include:
- Regurgitation of food
- Nausea and vomiting
- Chronic cough, wheezing
- Sore throat, hoarseness or change in voice, difficulty swallowing
- Chest pain
- Ongoing coughing
- Wheezing, gasping
- Severe vomiting
- Frequent burping
CausesGERD can often be traced to the malfunctioning of the lower esophageal sphincter (LES). The LES is a muscle responsible for opening and closing the lower end of the esophagus, which it accomplishes by relaxing and contracting at appropriate times. The LES may weaken or lose tone, allowing the contents of the stomach to escape back up the esophagus. Any of the following may compromise the LES:
- Hiatal hernia (a condition in which a portion of the stomach protrudes through an opening in the diaphragm where the esophagus normally fits snuggly and passes into the stomach.)
- Recurrent or persistent vomiting
- Nasogastric tubes (these are inserted through the nose and into the stomach for a variety of medical reasons)
- Smoking cigarettes
- Some medications including calcium channel blockers (a class of meds used for high blood pressure such as amlodipine, diltiazem, felodipine, nifedipine, nisoldipine, and verapamil), anticholinergic drugs (including benztropine, biperiden, dicyclomine, hyoscyamine, isopropamide, and scopolamine), iron pills, non-steroidal anti-inflammatory drugs (NSAIDs including aspirin and ibuprofen), potassium, dopamine (for Parkinson's disease), sedatives, bisphosphonates (alendronate and risedronate for osteoporosis), and beta blockers (such as atenolol, labetalol, metoprolol, nadolol, pindolol, and propranolol, for high blood pressure or heart disease.)
- Risk Factors
- Heavy meals
- Lying down or bending after a meal
- Eating immediately prior to exercise
- Prior esophageal surgery
- Esophageal stricture (narrowing of the esophagus)
- Cigarette smoking
- Alcohol intake
- Psychological stress
- Neurologic impairment
- Food allergies
- Frequent vomiting
- Cystic fibrosis
- Digestive disorders
DiagnosisGERD is generally not difficult to diagnose. Your symptoms, what you eat and drink, medications you are taking, and your lifestyle are usually enough to make a clear diagnosis. If the diagnosis is unclear to your doctor, one or more tests may be performed:
- Upper endoscopy, calledesophagealgastroduodenoscopy (EGD), which involves the insertion of a tube down your throat into the esophagus to look for signs of reflux, inflammation, ulcers, or other changes in the esophagus.
- A barium swallow, which involves visualization of the esophagus through a series of xrays following the swallowing of a substance called barium. This looks at the movement of the esophagus and whether any fluid comes back from the stomach into the esophagus.
- Manometry measures the pressure of the sphincter muscle; if low, this is consistent with GERD.
Treatment ApproachThe primary goals of treatment are to reduce the reflux (regurgitation), stop the harmful effect of the stomach's materials by reducing its acid content, improve the clearance of food through to the stomach, and protect the walls of the esophagus.
For mild cases, these goals can be accomplished by making lifestyle changes (such as avoiding certain foods) and by taking over-the-counter medication. An herbalist may suggest licorice or other herbs for their soothing properties. Prescription medicines may be recommended as needed.
For moderate to severe cases, prescription medication may be used more regularly and the condition monitored more closely. If these measures fail, surgery may ultimately be required.
LifestyleMaking changes to or avoiding certain habits can go a long way to relieving or preventing your symptoms of GERD.
The following are typical suggestions for people with GERD:
- Avoid behavior that does not allow food to easily move down into and through the stomach. This includes bending, lying down, or participating in jarring exercises soon after a meal.
- Don't eat heavy meals
- Avoid acidic foods and drinks. These include caffeinated beverages, decaffeinated coffee, and orange juice
- Avoid alcohol, chocolate, spearmint, and peppermint. These can relax the low esophageal sphincter.
- Avoid carbonated beverages
- Avoid eating fatty foods, including full-fat milk, which also may relax the lower esophageal sphincter tone. Take medication with plenty of water
- Lose weight if you are overweight
- Quit smoking
- Avoid medications that provoke symptoms. These include smooth-muscle relaxants such as calcium channel blockers (including amlodipine, diltiazem, felodipine, nifedipine, nisoldipine, and verapamil, which are used for high blood pressure), anticholinergic drugs (including benztropine, biperiden, dicyclomine, hyoscyamine, isopropamide, and scopolamine), iron pills, non-steroidal anti-inflammatory drugs (NSAIDs including aspirin and ibuprofen), potassium, dopamine (for Parkinson's disease), sedatives, bisphosphonates (alendronate and risedronate for osteoporosis), and beta blockers (such as atenolol, labetalol, metoprolol, nadolol, pindolol, and propranolol, for high blood pressure or heart disease.)
- Raising the head of your bed about six inches
- Avoiding bedtime snacks
MedicationsThe main aim of drug treatment is to control the acidity of the stomach. This can be achieved with either nonprescription or prescription drugs, depending on the severity and frequency of your reflux. Your doctor will determine which medicine is best for you.
There are several different types of medications used for GERD, and each works in a different way. Over-the-counter antacids neutralize the stomach acids; histamine H2 blockers interfere with the production of acid; and proton pump inhibitors suppress molecules in the glands responsible for the release of acid. Avoid taking other medications within three hours of an antacid because antacids may limit the absorption of other drugs.
- Over-the-counter antacids — typically recommended for mild symptoms of GERD; most brands are a combination of three active ingredients: magnesium salts (often combined with aluminum to prevent diarrhea); calcium carbonate (effective and fast-acting, but may cause constipation); and aluminum salts (may also cause constipation and excessive use may cause calcium loss).
- Histamine H2 receptor blockers (such as cimetidine, famotidine, nizatidine, and ranitidine) — relieve symptoms for 6 to 24 hours; usually taken at bedtime. These are available both over the counter and by prescription. The prescription forms are more potent.
- Proton pump inhibitors (including esomeprazole, lansoprazole, omeprazole, pantoprazole, and rabeprazole) is the most effective class of drugs for relieving symptoms of GERD; these drugs also speed the healing of the esophagus.
- Prokinetic agents – specifically metoclopramide, which promotes movement of stomach acids along the gastrointestinal tract, rather than backing up into the esophagus.
Surgery and Other ProceduresFor a small number of people, diet, medication, and lifestyle changes are not enough to relieve symptoms of GERD. In such cases, a surgical procedure called fundoplication may be performed to prevent reflux and repair a hiatal hernia (a condition that may cause GERD). As many as 90% of people who have had this operation report no longer having heartburn.
Nutrition and Dietary SupplementsNutritional therapy is one of the first treatments recommended for GERD. Generally, this entails avoiding foods that cause heartburn. These may include:
- Acidic foods and drinks such as those that contain caffeine (including caffeinated and decaffeinated coffee, tea, and chocolate)
- Citrus drinks
- Alcohol, spearmint, and peppermint — these relax the low esophageal sphincter.
- Carbonated beverages
- Fatty foods
- Full-fat cow's milk
Bromelain (Ananas comosus)
Bromelain is an enzyme found in the pineapple plant. It contains protein-digesting enzymes, which help promote and maintain proper digestion. These enzymes may also relieve symptoms of stomach upset or heartburn, particularly when used with other enzymes such as amylase (which digests starch) and lipase (which digests fat). Studies in people are needed.
Gamma Linolenic Acid (GLA)
This omega-6 fatty acid comes from evening primrose, black currant, borage, and fungal oils. There is very early evidence from test tube and animal studies that GLA from evening primrose oil (EPO) may have anti-ulcer properties. It is premature to know how this might apply to people.
Selenium, which is found in large quantities in whole grain products, may have some protection against Barrett's esophagus (precancerous cellular changes along the lining of the esophagus which can result from GERD) becoming cancerous. Again, more research is required.
HerbsHerbs, like medications, may produce side effects or interact with other substances including drugs. They should, therefore, be used with caution and only under the guidance of a professionally trained and qualified herbalist.
Licorice (Glycyrrhiza glabra)
An herbalist may recommend that you try licorice. Licorice is a demulcent (soothing, coating agent) often used to prevent and treat stomach ulcers. Animal studies and early trials in people support this use for licorice. For example, preparations containing glycyrrhizin (an active compound in licorice) may be as effective as leading anti-ulcer medications in relieving pain associated with stomach ulcers and preventing the ulcers from recurring. So far, however, there are no studies on licorice specifically as a treatment for GERD. Herbalists may consider it for this purpose, however, because of the similarity in symptoms.
Turmeric (Curcuma longa)
Turmeric has long been used in both Ayurvedic and Chinese medicine to treat digestive disorders. Scientific research is beginning to test the merit of this traditional use. In an animal study, for example, extracts of turmeric root reduced the release of acid from the stomach and protected against injuries such as inflammation and ulcers, both of which are potential complications from GERD. Further studies are needed to know to what extent these protective effects apply to people as well. (Note: at very high doses, turmeric may induce ulcers. It is very important to stick with the dose recommended by an herbal specialist.)
Other herbs that might be considered by an herbal specialist because of traditional use include:
- Astragalus (Astragalus membranaceus) - Clinically, astragalus is used mainly for disorders of the digestive system, including ulcers.
- Devil's claw (Harpagophytum procumbens) - Since its introduction to Europe from Africa in the early 1900s, dried roots of Devil's claw have been used to relieve heartburn, amongst other conditions and symptoms.
- Slippery Elm (Ulmus fulva) - While there has been little scientific research on slippery elm, it has a long history of use based on clinical experience, including for ulcers and gastrointestinal inflammation.
Although few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider the following remedies for the treatment of GERD symptoms based on their knowledge and experience. Before prescribing a remedy, homeopaths take into account your constitutional type. A constitutional type is defined as a person's physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each individual.
- Pulsatilla — for heartburn, queasiness, a bad taste in the mouth brought on by eating rich foods and fats (especially ice cream); symptoms may include vomiting partly digested food; this remedy is most appropriate for an individual whose tongue is coated with a white or yellow substance
- Ipecacuahna — for persistent and severe nausea, with or without vomiting and diarrhea, caused by an excess of rich or fatty foods
- Carbo vegetabilis — for bloating and indigestion, especially with flatulence and fatigue
- Nux vomica — for heartburn, nausea, retching without vomiting, and sour burps caused by overeating, alcohol use, or coffee drinking; this remedy is most appropriate for individuals who also feel irritable and sensitive to noise and light
PregnancyGERD is quite common during pregnancy, particularly in the third trimester.
Warnings and PrecautionsPeople with high blood pressure, obesity, diabetes, or kidney, heart, or liver conditions should avoid licorice. This herb should also not be used by pregnant or breastfeeding women or by men with decreased libido or other sexual dysfunctions. Use of any licorice product is not recommended for longer than four to six weeks.
Contact your health care provider if the medication recommended does not help or if you experience side effects, such as cramping or diarrhea.
Prognosis and ComplicationsThe acidic contents of the stomach can damage the esophagus, causing narrowing, ulcers, erosion , and precancerous changes to cells known as Barrett's esophagus. GERD can also result in respiratory diseases, ear, nose, throat conditions, and tooth decay. Most people can effectively manage their symptoms with lifestyle modifications and medications.
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