|Gastroesophageal Reflux Disease
|Also Listed As:
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
|Signs and Symptoms|
Heartburn -- 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
GERD is common in infants and young children, but is generally mild. If an
infant has the following symptoms, however, call a physician as soon as
- Ongoing coughing
- Wheezing, gasping
- Severe vomiting
- Frequent burping
GERD 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
- 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.)
- 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
Children with the following conditions are at particular risk for
- Neurologic impairment
- Food allergies
- Frequent vomiting
- Cystic fibrosis
- Digestive disorders
GERD 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.
The 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
For mild cases, these goals can be accomplished by making
lifestyle changes (such as avoiding
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
Making 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.)
If you experience more frequent symptoms at night, you may be relieved
- Raising the head of your bed about six inches
- Avoiding bedtime snacks
Stress may worsen symptoms. Therefore, relaxation, such as yoga, tai chi, and
meditation are worth considering, as part of your whole, comprehensive treatment
The 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
- Prokinetic agents - specifically
metoclopramide, which promotes movement of stomach acids along the
gastrointestinal tract, rather than backing up into the esophagus.
|Surgery and Other Procedures|
For 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 Supplements|
Nutritional therapy is one of the first treatments recommended for GERD.
Generally, this entails avoiding foods that cause heartburn. These may
- 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
- Carbonated beverages
- Fatty foods
- Full-fat cow's milk
Although more study is needed for all of the following, supplements or
specific food ingredients that may prove to be helpful for the treatment of GERD
symptoms or prevention of its complications include:
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.
Herbs, 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
- 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
GERD is quite common during pregnancy, particularly in the third trimester.
|Warnings and Precautions|
People 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
|Prognosis and Complications|
The 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
Berardi RR. Proton pump inhibition. An effective, safe approach to GERD
management. Postgrad Med. 2001;Spec No:24-35.
Blumenthal M, Goldberg A, Brinckmann J. Herbal Medicine: Expanded
Commission E Monographs. Newton, MA: Integrative Medicine Communications;
Borrelli F, Izzo AA. The plant kingdom as a source of anti-ulcer remedies.
[Review]. Phytother Res. 2000;14(8):581-591.
Bujanda L. The effects of alcohol consumption upon the gastrointestinal
tract. Am J Gastroenterol. 2000;95(12):3374-3382.
Cummings S, Ullman D. Everybody's Guide to Homeopathic Medicines. 3rd
ed. New York, NY: Penguin Putnam; 1997:157, 159.
Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison's Principles
of Internal Medicine. 14th ed. New York, NY: McGraw-Hill;
Feldman M, Barnett C. Relationships between the acidity and osmolality of
popular beverages and reported postprandial heartburn. Gastroenterology.
Foster S, Tyler V. Tyler's Honest Herbal. New York, NY: Haworth Press;
Jonas WB, Jacobs J. Healing with Homeopathy: The Doctors' Guide. New
York, NY: Warner Books; 1996: 219.
Kamolz T, Granderath FA, Bammer T, Pasiut M, Pointner R. Psychological
intervention influences the outcome of laparoscopic antireflux surgery in
patients with stress-related symptoms of gastroesophageal reflux disease.
Scand J Gastroenterol. 2001;36(8):800-805.
Moe GL, Kristal AR, Levine DS, Vaughan TL, Reid BJ. Waist-to-hip ratio,
weight gain, and dietary and serum selenium are associated with DNA content flow
cytometry in Barrett's esophagus. Nutr Cancer.2000;36(1):7-13
Rees WDW, Rhodes J, Wright JE, et al. Effect of deglycyrrhizinated liquorice
on gastric mucosal damage by aspirin. Scand J Gastroenterol.
Rosch W, Vinson B, Sassin I. A randomised clinical trial comparing the
efficacy of a herbal preparation STW 5 with the prokinetic drug cisapride in
patients with dysmotility type of functional dyspepsia. Z Gastroenterol.
Shaheen N, Ransohoff DF. Gastroesophageal reflux, Barrett esophagus, and
esophageal cancer, clinical applications. JAMA.
Turpie A, Runcie J, Thomson T. Clinical trial of deglycyrrhizinated liquorice
in gastric ulcer. Gut. 1969;10:299-303.
Ullman D. The Consumer's Guide to Homeopathy. New York, NY: Penguin
Putnam; 1995: 247.
van P, Numans ME, Bonis PA, Lau J. Short-term treatment with proton pump
inhibitors, H2-receptor antagonists and prokinetics for gastro-oesophageal
reflux disease-like symptoms and endoscopy negative reflux disease. Cochrane
Database Syst Rev. 2001;(4):CD002095.
|Review Date: December 2002|
|Reviewed By: Participants in the review process include: Jacqueline A. Hart, MD,
Department of Internal Medicine, Newton-Wellesley Hospital, Boston, Ma and
Senior Medical Editor A.D.A.M., Inc.; Lonnie Lee, MD, Internal Medicine, Silver
Springs, MD; Terry Yochum, DC, Rocky Mountain Chiropractic Center, Arvada,
Copyright © 2004 A.D.A.M., Inc
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