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Heartburn, Gastroesophageal Reflux (GER), and Gastroesophageal Reflux Disease (GERD)

National Digestive Diseases Information Clearinghouse

What is GERD? What are the symptoms of Gastroesophageal reflux disease (GERD) GERD? is a more serious form of gastroesophageal The main symptom of GERD in adults is National reflux (GER), which is common. GER Institute of frequent , also called acid indi- Diabetes and occurs when the lower esophageal sphinc- gestion—burning-type pain in the lower Digestive ter (LES) opens spontaneously, for varying and Kidney part of the mid-chest, behind the breast Diseases periods of time, or does not close properly bone, and in the mid-. Most and contents rise up into the children under 12 years with GERD, and NATIONAL . GER is also called acid reflux INSTITUTES some adults, have GERD without heart- OF HEALTH or acid regurgitation, because digestive burn. Instead, they may experience a juices—called acids—rise up with the food. dry , asthma symptoms, or trouble The esophagus is the tube that carries food swallowing. from the mouth to the stomach. The LES is a ring of muscle at the bottom of the esophagus that acts like a valve between What causes GERD? the esophagus and stomach. The reason some people develop GERD is still unclear. However, research shows that When acid reflux occurs, food or fluid can in people with GERD, the LES relaxes be tasted in the back of the mouth. When while the rest of the esophagus is working. refluxed stomach acid touches the lining of Anatomical abnormalities such as a hiatal the esophagus it may cause a burning sen- may also contribute to GERD. A sation in the chest or throat called heart- hiatal hernia occurs when the upper part of burn or acid . Occasional GER the stomach and the LES move above the is common and does not necessarily mean diaphragm, the muscle wall that separates one has GERD. Persistent reflux that the stomach from the chest. Normally, the occurs more than twice a week is consid- diaphragm helps the LES keep acid from ered GERD, and it can eventually lead to rising up into the esophagus. When a hiatal more serious health problems. People of hernia is present, acid reflux can occur all ages can have GERD. more easily. A hiatal hernia can occur in people of any age and is most often a nor- mal finding in otherwise healthy people over age 50. Most of the time, a hiatal hernia produces no symptoms.

U.S. Department of Health and Human Services Other factors that may contribute to GERD • drinks with caffeine or alcohol include • fatty and fried foods • • garlic and onions • pregnancy • mint flavorings • smoking • spicy foods Common foods that can worsen reflux • tomato-based foods, like spaghetti symptoms include sauce, salsa, chili, and pizza • citrus fruits • chocolate

What is GERD in children? feeding. If your child is older, your health care provider may recommend that your Distinguishing between normal, physio- child eat small, frequent meals and avoid logic reflux and GERD in children is the following foods: important. Most infants with GER are happy and healthy even if they frequently • sodas that contain caffeine spit up or vomit, and babies usually out- • chocolate grow GER by their first birthday. Reflux • peppermint that continues past 1 year of age may be GERD. Studies show GERD is common • spicy foods and may be overlooked in infants and • acidic foods like oranges, tomatoes, children. For example, GERD can pres- and pizza ent as repeated regurgitation, nausea, • fried and fatty foods heartburn, coughing, laryngitis, or respiratory problems like wheezing, Avoiding food 2 to 3 hours before bed asthma, or pneumonia. Infants and may also help. Your health care provider young children may demonstrate irritabil- may recommend raising the head of your ity or arching of the back, often during or child’s bed with wood blocks secured immediately after feedings. Infants with under the bedposts. Just using extra GERD may refuse to feed and experience pillows will not help. If these changes poor growth. do not work, your health care provider may prescribe medicine for your child. Talk with your child’s health care provider In rare cases, a child may need . if reflux-related symptoms occur regularly For information about GER in infants, and cause your child discomfort. Your children, and adolescents, see the health care provider may recommend Gastroesophageal Reflux in Infants and simple strategies for avoiding reflux, Gastroesophageal Reflux in Children and such as burping the infant several times Adolescents fact sheets from the National during feeding or keeping the infant in Institute of Diabetes and Digestive and an upright position for 30 minutes after Kidney Diseases (NIDDK).

2 Heartburn, Gastroesophageal Reflux (GER), and Gastroesophageal Reflux Disease (GERD) How is GERD treated? magnesium, calcium, and aluminum—with hydroxide or bicarbonate ions to neutralize See your health care provider if you have the acid in your stomach. Antacids, how- had symptoms of GERD and have been ever, can have side effects. Magnesium salt using antacids or other over-the-counter can lead to , and aluminum salt reflux for more than 2 weeks. may cause . Aluminum and Your health care provider may refer you to magnesium salts are often combined in a a gastroenterologist, a doctor who treats single product to balance these effects. diseases of the stomach and intestines. Depending on the severity of your GERD, Calcium carbonate antacids, such as Tums, treatment may involve one or more of the Titralac, and Alka-2, can also be a supple- following lifestyle changes, medications, mental source of calcium. They can cause or surgery. constipation as well. Lifestyle Changes Foaming agents, such as Gaviscon, work by • If you smoke, stop. covering your stomach contents with foam to prevent reflux. • Avoid foods and beverages that worsen symptoms. H2 blockers, such as cimetidine (Tagamet • Lose weight if needed. HB), famotidine (Pepcid AC), nizatidine (Axid AR), and ranitidine (Zantac 75), • Eat small, frequent meals. decrease acid production. They are avail- • Wear loose-fitting clothes. able in prescription strength and over-the- • Avoid lying down for 3 hours after counter strength. These drugs provide a meal. short-term relief and are effective for about half of those who have GERD symptoms. • Raise the head of your bed 6 to 8 inches by securing wood blocks Proton pump inhibitors include omepra- under the bedposts. Just using zole (Prilosec, Zegerid), lansoprazole extra pillows will not help. (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex), and esomeprazole Medications (Nexium), which are available by prescrip- Your health care provider may recommend tion. Prilosec is also available in over-the- over-the-counter antacids or medications counter strength. Proton pump inhibitors that stop acid production or help the are more effective than H2 blockers and can muscles that empty your stomach. You can relieve symptoms and heal the esophageal buy many of these medications without a lining in almost everyone who has GERD. prescription. However, see your health Prokinetics help strengthen the LES and care provider before starting or adding make the stomach empty faster. This group a . includes bethanechol (Urecholine) and Antacids, such as Alka-Seltzer, Maalox, metoclopramide (Reglan). Metoclo- Mylanta, Rolaids, and Riopan, are usually pramide also improves muscle action in the the first drugs recommended to relieve digestive tract. Prokinetics have frequent heartburn and other mild GERD symp- side effects that limit their usefulness— toms. Many brands on the market use fatigue, sleepiness, depression, anxiety, different combinations of three basic salts— and problems with physical movement.

3 Heartburn, Gastroesophageal Reflux (GER), and Gastroesophageal Reflux Disease (GERD) Because drugs work in different ways, com- The doctor also may perform a biopsy. binations of medications may help control Tiny tweezers, called forceps, are symptoms. People who get heartburn after passed through the endoscope and eating may take both antacids and H2 allow the doctor to remove small blockers. The antacids work first to neu- pieces of tissue from your esophagus. tralize the acid in the stomach, and then The tissue is then viewed with a micro- the H2 blockers act on acid production. scope to look for damage caused by By the time the antacid stops working, the acid reflux and to rule out other prob- H2 blocker will have stopped acid produc- lems if infection or abnormal growths tion. Your health care provider is the best are not found. source of information about how to use medications for GERD. • pH monitoring examination involves the doctor either inserting a small tube into the esophagus or clipping a tiny What if GERD symptoms device to the esophagus that will stay persist? there for 24 to 48 hours. While you go about your normal activities, the If your symptoms do not improve with device measures when and how much lifestyle changes or medications, you may acid comes up into your esophagus. need additional tests. This test can be useful if combined • Barium swallow radiograph uses with a carefully completed diary— x rays to help spot abnormalities such recording when, what, and amounts as a hiatal hernia and other structural the person eats—which allows the or anatomical problems of the esopha- doctor to see correlations between gus. With this test, you drink a solu- symptoms and reflux episodes. The tion and then x rays are taken. The procedure is sometimes helpful in test will not detect mild irritation, detecting whether respiratory symp- although strictures—narrowing of toms, including wheezing and cough- the esophagus—and ulcers can be ing, are triggered by reflux. observed. A completely accurate diagnostic test for • Upper is more accurate GERD does not exist, and tests have not than a barium swallow radiograph and consistently shown that acid exposure to may be performed in a hospital or a the lower esophagus directly correlates doctor’s office. The doctor may spray with damage to the lining. your throat to numb it and then, after lightly sedating you, will slide a thin, Surgery flexible plastic tube with a light and Surgery is an option when medicine and lens on the end called an endoscope lifestyle changes do not help to manage down your throat. Acting as a tiny GERD symptoms. Surgery may also be camera, the endoscope allows the doc- a reasonable alternative to a lifetime of tor to see the surface of the esophagus drugs and discomfort. and search for abnormalities. If you have had moderate to severe symp- toms and this procedure reveals injury to the esophagus, usually no other tests are needed to confirm GERD.

4 Heartburn, Gastroesophageal Reflux (GER), and Gastroesophageal Reflux Disease (GERD) Fundoplication is the standard surgical What are the long-term treatment for GERD. Usually a specific type of this procedure, called Nissen fundo- complications of GERD? plication, is performed. During the Nissen Chronic GERD that is untreated can cause fundoplication, the upper part of the serious complications. Inflammation of the stomach is wrapped around the LES to esophagus from refluxed stomach acid can strengthen the sphincter, prevent acid damage the lining and cause bleeding or reflux, and repair a hiatal hernia. ulcers—also called . Scars from tissue damage can lead to strictures— The may be per- narrowing of the esophagus—that make formed using a laparoscope, an instrument swallowing difficult. Some people develop that is inserted through tiny incisions in Barrett’s esophagus, in which cells in the the abdomen. The doctor then uses small esophageal lining take on an abnormal instruments that hold a camera to look at shape and color. Over time, the cells can the abdomen and pelvis. When performed lead to esophageal cancer, which is often by experienced surgeons, laparoscopic fun- fatal. Persons with GERD and its compli- doplication is safe and effective in people cations should be monitored closely by a of all ages, including infants. The proce- physician. dure is reported to have the same results as the standard fundoplication, and people Studies have shown that GERD may can leave the hospital in 1 to 3 days and worsen or contribute to asthma, chronic return to work in 2 to 3 weeks. cough, and pulmonary fibrosis. Endoscopic techniques used to treat For information about Barrett’s esophagus, chronic heartburn include the Bard see the Barrett’s Esophagus fact sheet from EndoCinch system, NDO Plicator, and the the NIDDK. Stretta system. These techniques require the use of an endoscope to perform the anti-reflux operation. The EndoCinch and NDO Plicator systems involve putting stitches in the LES to create pleats that help strengthen the muscle. The Stretta system uses electrodes to create tiny burns on the LES. When the burns heal, the scar tissue helps toughen the muscle. The long- term effects of these three procedures are unknown.

5 Heartburn, Gastroesophageal Reflux (GER), and Gastroesophageal Reflux Disease (GERD) Points to Remember • Most infants with GER are healthy even though they may frequently spit • Frequent heartburn, also called acid up or vomit. Most infants outgrow indigestion, is the most common GER by their first birthday. Reflux symptom of GERD in adults. Anyone that continues past 1 year of age may experiencing heartburn twice a week be GERD. or more may have GERD. • The persistence of GER along with • You can have GERD without having other symptoms—arching and irritabil- heartburn. Your symptoms could ity in infants, or abdominal and chest include a dry cough, asthma symp- pain in older children—is GERD. toms, or trouble swallowing. GERD is the outcome of frequent and • If you have been using antacids for persistent GER in infants and children more than 2 weeks, it is time to see and may cause repeated , your health care provider. Most doc- coughing, and respiratory problems. tors can treat GERD. Your health care provider may refer you to a gas- troenterologist, a doctor who treats diseases of the stomach and intestines. Hope Through Research The reasons certain people develop • Health care providers usually recom- GERD and others do not remain mend lifestyle and dietary changes to unknown. Several factors may be relieve symptoms of GERD. Many involved, and research is under way to people with GERD also need medica- explore risk factors for developing tion. Surgery may be considered as a GERD and the role of GERD in other treatment option. conditions such as asthma and laryngitis.

6 Heartburn, Gastroesophageal Reflux (GER), and Gastroesophageal Reflux Disease (GERD) For More Information You may also find additional information on this topic using the following databases: American College of The NIDDK Reference Collection is a collection P.O. Box 342260 of thousands of materials produced for patients and Bethesda, MD 20827–2260 health care professionals, including fact sheets, Phone: 301–263–9000 brochures, and audiovisual materials. Visit www.catalog.niddk.nih.gov/resources. Internet: www.acg.gi.org MedlinePlus brings together a wealth of information from the National Library of Medicine, the National American Gastroenterological Association Institutes of Health, and other government agencies National Office and health-related organizations. MedlinePlus offers 4930 Del Ray Avenue easy access to medical journal articles, a medical dic- tionary and medical encyclopedia, health information Bethesda, MD 20814 in Spanish, hospital and physician directories, drug Phone: 301–654–2055 and supplement lists, interactive patient tutorials, Fax: 301–654–5920 links to hundreds of clinical trials, and the latest health news. Visit www..gov. Email: [email protected] Internet: www.gastro.org International Foundation for Functional The U.S. Government does not endorse or favor any Gastrointestinal Disorders specific commercial product or company. Trade, P.O. Box 170864 proprietary, or company names appearing in this Milwaukee, WI 53217–8076 document are used only because they are considered necessary in the context of the information provided. Phone: 1–888–964–2001 or 414–964–1799 If a product is not mentioned, the omission does not Fax: 414–964–7176 mean or imply that the product is unsatisfactory. Email: [email protected] Internet: www.aboutgerd.org North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition P.O. Box 6 Flourtown, PA 19031 Phone: 215–233–0808 Fax: 215–233–3918 Email: [email protected] Internet: www.naspghan.org Pediatric/Adolescent Gastroesophageal Reflux Association, Inc. P.O. Box 486 Buckeystown, MD 21717–0486 Phone: 301–601–9541 Email: [email protected] Internet: www.reflux.org

7 Heartburn, Gastroesophageal Reflux (GER), and Gastroesophageal Reflux Disease (GERD) National Digestive Diseases Information Clearinghouse 2 Information Way Bethesda, MD 20892–3570 Phone: 1–800–891–5389 Fax: 703–738–4929 Email: [email protected] Internet: www.digestive.niddk.nih.gov

The National Digestive Diseases Information Clearinghouse (NDDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health of the U.S. Department of Health and Human Services. Established in 1980, the Clearing- house provides information about digestive diseases to people with digestive disorders and to their families, health care professionals, and the public. The NDDIC answers inquiries, develops and distributes publications, and works closely with professional and patient organizations and Government agencies to coordinate resources about digestive diseases.

Publications produced by the Clearinghouse are carefully reviewed by both NIDDK scientists and outside experts. This fact sheet was reviewed by M. Brian Fennerty, M.D., Oregon Health and Science University, and Benjamin D. Gold, M.D., Emory University School of Medicine.

This publication is not copyrighted. The Clearinghouse encourages users of this fact sheet to duplicate and distribute as many copies as desired.

This fact sheet is also available at www.digestive.niddk.nih.gov.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health

NIH Publication No. 07–0882 May 2007