Diseases

Esophageal Reflux (Gastroesophageal Reflux Disease (GERD)) Information

GERD (acid reflux) facts

• GERD (gastroesophageal reflux disease) is a condition in which the acidified liquid content of the stomach backs up into the esophagus.
• The cause of GERD is complex and may involve multiple causes.
• GERD may damage the lining of the esophagus, thereby causing inflammation (esophagitis), although this is uncommon.
• The symptoms of uncomplicated GERD include:
  • heartburn,
  • regurgitation, and
  • nausea.
• Complications of GERD include:
  • ulcers and strictures of the esophagus,
  • Barrett's esophagus,
  • cough and asthma,
  • throat and laryngeal inflammation,
  • inflammation and infection of the lungs, and
  • a collection of fluid in the sinuses and middle ear.
• GERD may be diagnosed or evaluated by a variety of procedures and tests.
• GERD is treated with life-style changes, diet, over-the-counter (OTC) and prescription drugs (for example, antacids, proton pump inhibitors (PPIs), pro-motility drugs), and surgery.

GERD (acid reflux) medications

There are a variety of over-the-counter (for example, antacids and foam barriers) and prescription medications (for example, proton pump inhibitors, histamine antagonists, and promotility drugs) for treating GERD.Antacids for GERDDespite the development of potent medications for the treatment of GERD, antacids remain a mainstay of treatment. Antacids neutralize the acid in the stomach so that there is no acid to reflux. The problem with antacids is that their action is brief. They are emptied from the empty stomach quickly, in less than an hour, and the acid then re-accumulates. The best way to take antacids, therefore, is approximately one hour after meals, which is just before the symptoms of reflux begin after a meal. Since the food from meals slows the emptying from the stomach, an antacid taken after a meal stays in the stomach longer and is effective longer. For the same reason, a second dose of antacids approximately two hours after a meal takes advantage of the continuing post-meal slower emptying of the stomach and replenishes the acid-neutralizing capacity within the stomach.Antacids may be aluminum, magnesium, or calcium based. Calcium-based antacids (usually calcium carbonate), unlike other antacids, stimulate the release of gastrin from the stomach and duodenum. Gastrin is the hormone that is primarily responsible for the stimulation of acid secretion by the stomach. Therefore, the secretion of acid rebounds after the direct acid-neutralizing effect of the calcium carbonate is exhausted. The rebound is due to the release of gastrin, which results in an overproduction of acid. Theoretically at least, this increased acid is not good for GERD.Acid rebound, however, has not been shown to be clinically important. That is, treatment with calcium carbonate has not been shown to be less effective or safe than treatment with antacids not containing calcium carbonate. Nevertheless, the phenomenon of acid rebound is theoretically harmful. In practice, therefore, calcium-containing antacids such as Tums and Rolaids are not recommended for frequent use. The occasional use of these calcium carbonate-containing antacids, however, is not believed to be harmful. The advantages of calcium carbonate-containing antacids are their low cost, the calcium they add to the diet, and their convenience as compared to liquids.Aluminum-containing antacids have a tendency to cause constipation, while magnesium-containing antacids tend to cause diarrhea. If diarrhea or constipation becomes a problem, it may be necessary to switch antacids, or alternatively, use antacids containing both aluminum and magnesium.Histamine antagonistsAlthough antacids can neutralize acid, they do so for only a short period of time. For substantial neutralization of acid throughout the day, antacids would need to be given frequently, at least every hour.The first medication developed for more effective and convenient treatment of acid-related diseases, including GERD, was a histamine antagonist, specifically cimetidine (Tagamet). Histamine is an important chemical because it stimulates acid production by the stomach. Released within the wall of the stomach, histamine attaches to receptors (binders) on the stomach's acid-producing cells and stimulates the cells to produce acid. Histamine antagonists work by blocking the receptor for histamine and thereby preventing histamine from stimulating the acid-producing cells. (Histamine antagonists are referred to as H2 antagonists because the specific receptor they block is the histamine type 2 receptor.) As histamine is particularly important for the stimulation of acid after meals, H2 antagonists are best taken 30 minutes before meals. The reason for this timing is so that the H2 antagonists will be at peak levels in the body after the meal when the stomach is actively producing acid. H2 antagonists also can be taken at bedtime to suppress nighttime production of acid.H2 antagonists are very good for relieving the symptoms of GERD, particularly heartburn. However, they are not very good for healing the inflammation (esophagitis) that may accompany GERD. In fact, they are used primarily for the treatment of heartburn in GERD that is not associated with inflammation or complications, such as erosions or ulcers, strictures, or Barrett's esophagus.Four different H2 antagonists are available by prescription, including cimetidine (Tagamet), ranitidine (Zantac), nizatidine (Axid), and famotidine, (Pepcid). All four are also available over-the-counter (OTC), without the need for a prescription. However, the OTC dosages are lower than those available by prescription.Proton pump inhibitorsThe second type of drug developed specifically for acid-related diseases, such as GERD, was a proton pump inhibitor (PPI), specifically, omeprazole (Prilosec). A PPI blocks the secretion of acid into the stomach by the acid-secreting cells. The advantage of a PPI over an H2 antagonist is that the PPI shuts off acid production more completely and for a longer period of time. Not only is the PPI good for treating the symptom of heartburn, but it also is good for protecting the esophagus from acid so that esophageal inflammation can heal.PPIs are used when H2 antagonists do not relieve symptoms adequately or when complications of GERD such as erosions or ulcers, strictures, or Barrett's esophagus exist. Five different PPIs are approved for the treatment of GERD, including omeprazole (Prilosec, Dexilant), lansoprazole (Prevacid), rabeprazole (Aciphex), pantoprazole (Protonix), and esomeprazole (Nexium), and dexlansoprazole (Dexilant). A sixth PPI product consists of a combination of omeprazole and sodium bicarbonate (Zegerid). PPIs (except for Zegarid) are best taken an hour before meals. The reason for this timing is that the PPIs work best when the stomach is most actively producing acid, which occurs after meals. If the PPI is taken before the meal, it is at peak levels in the body after the meal when the acid is being made.Pro-motility drugsPro-motility drugs work by stimulating the muscles of the gastrointestinal tract, including the esophagus, stomach, small intestine, and/or colon. One pro-motility drug, metoclopramide (Reglan), is approved for GERD. Pro-motility drugs increase the pressure in the lower esophageal sphincter and strengthen the contractions (peristalsis) of the esophagus. Both effects would be expected to reduce reflux of acid. However, these effects on the sphincter and esophagus are small. Therefore, it is believed that the primary effect of metoclopramide may be to speed up emptying of the stomach, which also would be expected to reduce reflux.Pro-motility drugs are most effective when taken 30 minutes before meals and again at bedtime. They are not very effective for treating either the symptoms or complications of GERD. Therefore, the pro-motility agents are reserved either for patients who do not respond to other treatments or are added to enhance other treatments for GERD.Foam barriersFoam barriers provide a unique form of treatment for GERD. Foam barriers are tablets that are composed of an antacid and a foaming agent. As the tablet disintegrates and reaches the stomach, it turns into foam that floats on the top of the liquid contents of the stomach. The foam forms a physical barrier to the reflux of liquid. At the same time, the antacid bound to the foam neutralizes acid that comes into contact with the foam. The tablets are best taken after meals (when the stomach is distended) and when lying down, both times when reflux is more likely to occur. Foam barriers are not often used as the first or only treatment for GERD. Rather, they are added to other drugs for GERD when the other drugs are not adequately effective in relieving symptoms. There is only one foam barrier, which is a combination of aluminum hydroxide gel, magnesium trisilicate, and alginate (Gaviscon).

GERD (acid reflux) tests

Esophageal acid testingEsophageal acid testing is considered a "gold standard" for diagnosing GERD. As discussed previously, the reflux of acid is common in the general population. However, patients with the symptoms or complications of GERD have reflux of more acid than individuals without the symptoms or complications of GERD. Moreover, normal individuals and patients with GERD can be distinguished moderately well from each other by the amount of time that the esophagus contains acid.The amount of time that the esophagus contains acid is determined by a test called a 24-hour esophageal pH test. (pH is a mathematical way of expressing the amount of acidity.) For this test, a small tube (catheter) is passed through the nose and positioned in the esophagus. On the tip of the catheter is a sensor that senses acid. The other end of the catheter exits from the nose, wraps back over the ear, and travels down to the waist, where it is attached to a recorder. Each time acid refluxes back into the esophagus from the stomach, it stimulates the sensor and the recorder records the episode of reflux. After a 20 to 24 hour period of time, the catheter is removed and the record of reflux from the recorder is analyzed.There are problems with using pH testing for diagnosing GERD. Despite the fact that normal individuals and patients with GERD can be separated fairly well on the basis of pH studies, the separation is not perfect. Therefore, some patients with GERD will have normal amounts of acid reflux and some patients without GERD will have abnormal amounts of acid reflux. It requires something other than the pH test to confirm the presence of GERD, for example, typical symptoms, response to treatment, or the presence of complications of GERD. GERD also may be confidently diagnosed when episodes of heartburn correlate with acid reflux as shown by acid testing.pH testing has uses in the management of GERD other than just diagnosing GERD. For example, the test can help determine why GERD symptoms do not respond to treatment. Perhaps 10 to 20 percent of patients will not have their symptoms substantially improved by treatment for GERD. This lack of response to treatment could be caused by ineffective treatment. This means that the medication is not adequately suppressing the production of acid by the stomach and is not reducing acid reflux. Alternatively, the lack of response can be explained by an incorrect diagnosis of GERD. In both of these situations, the pH test can be very useful. If testing reveals substantial reflux of acid while medication is continued, then the treatment is ineffective and will need to be changed. If testing reveals good acid suppression with minimal reflux of acid, the diagnosis of GERD is likely to be wrong and other causes for the symptoms need to be sought.pH testing also can be used to help evaluate whether reflux is the cause of symptoms (usually heartburn). To make this evaluation, while the 24-hour ph testing is being done, patients record each time they have symptoms. Then, when the test is being analyzed, it can be determined whether or not acid reflux occurred at the time of the symptoms. If reflux did occur at the same time as the symptoms, then reflux is likely to be the cause of the symptoms. If there was no reflux at the time of symptoms, then reflux is unlikely to be the cause of the symptoms.Lastly, pH testing can be used to evaluate patients prior to endoscopic or surgical treatment for GERD. As discussed above, some 20% of patients will have a decrease in their symptoms even though they don't have GERD (the placebo effect). Prior to endoscopic or surgical treatment, it is important to identify these patients because they are not likely to benefit from the treatments. The pH study can be used to identify these patients because they will have normal amounts of acid reflux.A newer method for prolonged measurement (48 hours) of acid exposure in the esophagus utilizes a small, wireless capsule that is attached to the esophagus just above the LES. The capsule is passed to the lower esophagus by a tube inserted through either the mouth or the nose. After the capsule is attached to the esophagus, the tube is removed. The capsule measures the acid refluxing into the esophagus and transmits this information to a receiver that is worn at the waist. After the study, usually after 48 hours, the information from the receiver is downloaded into a computer and analyzed. The capsule falls off of the esophagus after 3-5 days and is passed in the stool. (The capsule is not reused.)The advantage of the capsule over standard pH testing is that there is no discomfort from a catheter that passes through the throat and nose. Moreover, with the capsule, patients look normal (they don't have a catheter protruding from their noses) and are more likely to go about their daily activities, for example, go to work, without feeling self-conscious. Because the capsule records for a longer period than the catheter (48 versus 24 hours), more data on acid reflux and symptoms are obtained. Nevertheless, it is not clear whether obtaining additional information is important.Capsule pH testing is expensive. Sometimes the capsule does not attach to the esophagus or falls off prematurely. For periods of time the receiver may not receive signals from the capsule, and some of the information about reflux of acid may be lost. Occasionally there is pain with swallowing after the capsule has been placed, and the capsule may need to be removed endoscopically. Use of the capsule is an exciting use of new technology although it has its own specific problems.Esophageal motility testingEsophageal motility testing determines how well the muscles of the esophagus are working. For motility testing, a thin tube (catheter) is passed through a nostril, down the back of the throat, and into the esophagus. On the part of the catheter that is inside the esophagus are sensors that sense pressure. A pressure is generated within the esophagus that is detected by the sensors on the catheter when the muscle of the esophagus contracts. The end of the catheter that protrudes from the nostril is attached to a recorder that records the pressure. During the test, the pressure at rest and the relaxation of the lower esophageal sphincter are evaluated. The patient then swallows sips of water to evaluate the contractions of the esophagus.Esophageal motility testing has two important uses in evaluating GERD. The first is in evaluating symptoms that do not respond to treatment for GERD since the abnormal function of the esophageal muscle sometimes causes symptoms that resemble the symptoms of GERD. Motility testing can identify some of these abnormalities and lead to a diagnosis of an esophageal motility disorder. The second use is evaluation prior to surgical or endoscopic treatment for GERD. In this situation, the purpose is to identify patients who also have motility disorders of the esophageal muscle. The reason for this is that in patients with motility disorders, some surgeons will modify the type of surgery they perform for GERD.Gastric emptying studiesGastric emptying studies are studies that determine how well food empties from the stomach. As discussed above, about 20 % of patients with GERD have slow emptying of the stomach that may be contributing to the reflux of acid. For gastric emptying studies, the patient eats a meal that is labeled with a radioactive substance. A sensor that is similar to a Geiger counter is placed over the stomach to measure how quickly the radioactive substance in the meal empties from the stomach.Information from the emptying study can be useful for managing patients with GERD. For example, if a patient with GERD continues to have symptoms despite treatment with the usual medications, doctors might prescribe other medications that speed-up emptying of the stomach. Alternatively, in conjunction with GERD surgery, they might do a surgical procedure that promotes a more rapid emptying of the stomach. Nevertheless, it is still debated whether a finding of reduced gastric emptying should prompt changes in the surgical treatment of GERD.Symptoms of nausea, vomiting, and regurgitation may be due either to abnormal gastric emptying or GERD. An evaluation of gastric emptying, therefore, may be useful in identifying patients whose symptoms are due to abnormal emptying of the stomach rather than to GERD.Acid perfusion testThe acid perfusion (Bernstein) test is used to determine if chest pain is caused by acid reflux. For the acid perfusion test, a thin tube is passed through one nostril, down the back of the throat, and into the middle of the esophagus. A dilute, acid solution and a physiologic salt solution (similar to the fluid that bathes the body's cells) are alternately poured (perfused) through the catheter and into the esophagus. The patient is unaware of which solution is being infused. If the perfusion with acid provokes the patient's usual pain and perfusion of the salt solution produces no pain, it is likely that the patient's pain is caused by acid reflux.The acid perfusion test, however, is used only rarely. A better test for correlating pain and acid reflux is a 24-hour esophageal pH or pH capsule study during which patients note when they are having pain. It then can be determined from the pH recording if there was an episode of acid reflux at the time of the pain. This is the preferable way of deciding if acid reflux is causing a patient's pain. It does not work well, however, for patients who have infrequent pain, for example every two to three days, which may be missed by a one or two day pH study. In these cases, an acid perfusion test may be reasonable.

GERD surgery

The drugs described above usually are effective in treating the symptoms and complications of GERD. Nevertheless, sometimes they are not. For example, despite adequate suppression of acid and relief from heartburn, regurgitation, with its potential for complications in the lungs, may still occur. Moreover, the amounts and/or numbers of drugs that are required for satisfactory treatment are sometimes so great that drug treatment is unreasonable. In such situations, surgery can effectively stop reflux.The surgical procedure that is done to prevent reflux is technically known as fundoplication and is called reflux surgery or anti-reflux surgery. During fundoplication, any hiatal hernial sac is pulled below the diaphragm and stitched there. In addition, the opening in the diaphragm through which the esophagus passes is tightened around the esophagus. Finally, the upper part of the stomach next to the opening of the esophagus into the stomach is wrapped around the lower esophagus to make an artificial lower esophageal sphincter. All of this surgery can be done through an incision in the abdomen (laparotomy) or using a technique called laparoscopy. During laparoscopy, a small viewing device and surgical instruments are passed through several small puncture sites in the abdomen. This procedure avoids the need for a major abdominal incision.Surgery is very effective at relieving symptoms and treating the complications of GERD. Approximately 80% of patients will have good or excellent relief of their symptoms for at least 5 to 10 years. Nevertheless, many patients who have had surgery will continue to take drugs for reflux. It is not clear whether they take the drugs because they continue to have reflux and symptoms of reflux or if they take them for symptoms that are being caused by problems other than GERD. The most common complication of fundoplication is swallowed food that sticks at the artificial sphincter. Fortunately, the sticking usually is temporary. If it is not transient, endoscopic treatment to stretch (dilate) the artificial sphincter usually will relieve the problem. Only occasionally is it necessary to re-operate to revise the prior surgery.EndoscopyVery recently, endoscopic techniques for the treatment of GERD have been developed and tested. One type of endoscopic treatment involves suturing (stitching) the area of the lower esophageal sphincter, which essentially tightens the sphincter.A second type involves the application of radio-frequency waves to the lower part of the esophagus just above the sphincter. The waves cause damage to the tissue beneath the esophageal lining and a scar (fibrosis) forms. The scar shrinks and pulls on the surrounding tissue, thereby tightening the sphincter and the area above it.A third type of endoscopic treatment involves the injection of materials into the esophageal wall in the area of the LES. The injected material is intended to increase pressure in the LES and thereby prevent reflux. In one treatment the injected material was a polymer. Unfortunately, the injection of polymer led to serious complications, and the material for injection is no longer available. Another treatment involving injection of expandable pellets also was discontinued. Limited information is available about a third type of injection which uses gelatinous polymethylmethacrylate microspheres.Endoscopic treatment has the advantage of not requiring surgery. It can be performed without hospitalization. Experience with endoscopic techniques is limited. It is not clear how effective they are, especially long-term. Because the effectiveness and the full extent of potential complications of endoscopic techniques are not clear, it is felt generally that endoscopic treatment should only be done as part of experimental trials.Prevention of transient LES relaxationTransient LES relaxations appear to be the most common way in which acid reflux occurs. Although there is an available drug that prevents relaxations (baclofen), it has side effects that are too frequent to be generally useful. Much attention is being directed at the development of drugs that prevent these relaxations without accompanying side effects.

Lifestyle changes and GERD (acid reflux) diet

As discussed above, reflux of acid is more injurious at night than during the day. At night, when individuals are lying down, it is easier for reflux to occur. The reason that it is easier is because gravity is not opposing the reflux, as it does in the upright position during the day. In addition, the lack of an effect of gravity allows the refluxed liquid to travel further up the esophagus and remain in the esophagus longer. These problems can be overcome partially by elevating the upper body in bed. The elevation is accomplished either by putting blocks under the bed's feet at the head of the bed or, more conveniently, by sleeping with the upper body on a foam rubber wedge. These maneuvers raise the esophagus above the stomach and partially restore the effects of gravity. It is important that the upper body and not just the head be elevated. Elevating only the head does not raise the esophagus and fails to restore the effects of gravity.Elevation of the upper body at night generally is recommended for all patients with GERD. Nevertheless, most patients with GERD have reflux only during the day and elevation at night is of little benefit for them. It is not possible to know for certain which patients will benefit from elevation at night unless acid testing clearly demonstrates night reflux. However, patients who have heartburn, regurgitation, or other symptoms of GERD at night are probably experiencing reflux at night and definitely should elevate their upper body when sleeping. Reflux also occurs less frequently when patients lie on their left rather than their right sides.GERD dietSeveral changes in eating habits can be beneficial in treating GERD. Reflux is worse following meals. This probably is so because the stomach is distended with food at that time and transient relaxations of the lower esophageal sphincter are more frequent. Therefore, smaller and earlier evening meals may reduce the amount of reflux for two reasons. First, the smaller meal results in lesser distention of the stomach. Second, by bedtime, a smaller and earlier meal is more likely to have emptied from the stomach than is a larger one. As a result, reflux is less likely to occur when patients with GERD lie down to sleep.Certain foods are known to reduce the pressure in the lower esophageal sphincter and thereby promote reflux. These foods should be avoided and include:

• chocolate,
• peppermint,
• alcohol, and
• caffeinated drinks.

Symptoms and procedures to diagnose GERD

Symptoms and response to treatment (therapeutic trial)The usual way that GERD is by its characteristic symptom, heartburn. Heartburn is most frequently described as a sub-sternal (under the middle of the chest) burning that occurs after meals and often worsens when lying down. To confirm the diagnosis, physicians often treat patients with medications to suppress the production of acid by the stomach. If the heartburn then is diminished to a large extent, the diagnosis of GERD is considered confirmed. This approach of making a diagnosis on the basis of a response of the symptoms to treatment is commonly called a therapeutic trial.There are problems with this approach For instance, patients who have conditions that can mimic GERD, specifically duodenal or gastric (stomach) ulcers, also can actually respond to such treatment. In this situation, if the physician assumes that the problem is GERD, the cause of the ulcer disease would be missed such as a type of infection called Helicobacter pylori (H. pylori), or nonsteroidal anti-inflammatory drugs or NSAIDS (for example, ibuprofen), can also cause ulcers and these conditions would be treated differently from GERD.Moreover, as with any treatment, there is perhaps a 20% placebo effect, which means that 20% of patients will respond to a placebo (inactive) pill or, indeed, to any treatment. This means that 20% of patients who have causes of their symptoms other than GERD (or ulcers) will have a decrease in their symptoms after receiving the treatment for GERD. Thus, on the basis of their response to treatment (the therapeutic trial), these patients then will continue to be treated for GERD, even though they do not have GERD. What's more, the true cause of their symptoms will not be pursued.EndoscopyUpper gastrointestinal endoscopy (also known as esophago-gastro-duodenoscopy or EGD) is a common way of diagnosing GERD. EGD is a procedure in which a tube containing an optical system for visualization is swallowed. As the tube progresses down the gastrointestinal tract, the lining of the esophagus, stomach, and duodenum can be examined.The esophagus of most patients with symptoms of reflux looks normal. Therefore, in most patients, endoscopy will not help in the diagnosis of GERD. However, sometimes the lining of the esophagus appears inflamed (esophagitis). Moreover, if erosions (superficial breaks in the esophageal lining) or ulcers (deeper breaks in the lining) are seen, a diagnosis of GERD can be made confidently. Endoscopy will also identify several of the complications of GERD, specifically, ulcers, strictures, and Barrett's esophagus. Biopsies also may be obtained.Finally, other common problems that may be causing GERD like symptoms can be diagnosed (for example ulcers, inflammation, or cancers of the stomach or duodenum) with EGD.BiopsiesBiopsies of the esophagus that are obtained through the endoscope are not considered very useful for diagnosing GERD. They are useful, however, in diagnosing cancers or causes of esophageal inflammation other than acid reflux, particularly infections. Moreover, biopsies are the only means of diagnosing the cellular changes of Barrett's esophagus. More recently, it has been suggested that even in patients with GERD whose esophagi appear normal to the eye, biopsies will show widening of the spaces between the lining cells, possibly an indication of damage. It is too early to conclude, however, that seeing widening is specific enough to be confidently that GERD is present.X-raysBefore the introduction of endoscopy, an X-ray of the esophagus (called an esophagram) was the only means of diagnosing GERD. Patients swallowed barium (contrast material), and X-rays of the barium-filled esophagus were then taken. The problem with the esophagram was that it was an insensitive test for diagnosing GERD. That is, it failed to find signs of GERD in many patients who had GERD because the patients had little or no damage to the lining of the esophagus. The X-rays were able to show only the infrequent complications of GERD, for example, ulcers and strictures. X-rays have been abandoned as a means of diagnosing GERD, although they still can be useful along with endoscopy in the evaluation of complications.Examination of the throat and larynxWhen GERD affects the throat or larynx and causes symptoms of cough, hoarseness, or sore throat, patients often visit an ear, nose, and throat (ENT) specialist. The ENT specialist frequently finds signs of inflammation of the throat or larynx. Although diseases of the throat or larynx usually are the cause of the inflammation, sometimes GERD can be the cause. Accordingly, ENT specialists often try acid-suppressing treatment to confirm the diagnosis of GERD. This approach, however, has the same problems as discussed above, that result from using the response to treatment to confirm GERD.