Gastroesophageal Reflux (GER) and Gastroesophageal Reflux Disease (GERD) in Adults

National Digestive Diseases Information Clearinghouse

What is GER? Read more about over-the-counter medications in the section “How is GERD Gastroesophageal reflux (GER) occurs treated?” when stomach contents flow back up into the esophagus—the muscular tube that carries food and liquids from the mouth to the What is GERD? stomach. Gastroesophageal reflux disease (GERD) is GER is also called acid reflux or acid a more serious, chronic––or long lasting–– regurgitation because the stomach’s digestive form of GER. GER that occurs more juices contain acid. Sometimes people with than twice a week for a few weeks could GER can taste food or acidic fluid in the be GERD, which over time can lead to back of the mouth. Refluxed stomach acid more serious health problems. People with that touches the lining of the esophagus suspected GERD should see a health care can cause heartburn. Also called acid provider. indigestion, heartburn is an uncomfortable, burning feeling in the midchest, behind What causes GERD? the breastbone, or in the upper part of the Gastroesophageal reflux disease results when abdomen—the area between the chest and the lower esophageal sphincter—the muscle the hips. that acts as a valve between the esophagus Occasional GER is common. People may be and stomach—becomes weak or relaxes able to control GER by when it should not, causing stomach contents to rise up into the esophagus. • avoiding foods and beverages that contribute to heartburn, such as Abnormalities in the body such as hiatal chocolate, coffee, peppermint, greasy hernias may also cause GERD. Hiatal or spicy foods, tomato products, and hernias occur when the upper part of the alcoholic beverages stomach moves up into the chest. The stomach can slip through an opening found • avoiding overeating in the diaphragm. The diaphragm is the • quitting smoking muscle wall that separates the stomach from the chest. Hiatal hernias may cause GERD • losing weight if they are overweight because of stomach acid flowing back up • not eating 2 to 3 hours before sleep through the opening; however, most produce no symptoms. • taking over-the-counter medications Other factors that can contribute to GERD What is the gastrointestinal include (GI) tract? • obesity The GI tract is a series of hollow organs • pregnancy joined in a long, twisting tube from the mouth to the anus. The movement of • certain medications, such as asthma muscles in the GI tract, along with the medications, calcium channel blockers, release of hormones and enzymes, starts and many antihistamines, pain killers, the digestion of food. The upper GI tract sedatives, and antidepressants includes the mouth, esophagus, stomach, • smoking, or inhaling secondhand smoke small intestine, and duodenum, which is the first part of the small intestine. People of all ages can develop GERD, some for unknown reasons.

Stomach Mouth Esophagus

Lower Esophagus esophageal sphincter Acid Lower Small esophageal intestine sphincter

Stomach

Small intestine

Anus

GERD results when the lower esophageal sphincter—the muscle that acts as a valve between the esophagus and stomach—becomes weak or relaxes when it should not, causing stomach contents to rise up into the esophagus.

2 Gastroesophageal Reflux (GER) and Gastroesophageal Reflux Disease (GERD) in Adults What are the symptoms of a look at the shape of the upper GI tract. An x-ray technician performs this test at GERD? a hospital or an outpatient center, and a The main symptom of GERD is frequent radiologist—a doctor who specializes in heartburn, though some adults with GERD medical imaging—interprets the images. do not have heartburn. Other common This test does not require anesthesia. No GERD symptoms include eating or drinking is allowed before the • a dry, chronic cough procedure, as directed by the health care staff. People should check with their • wheezing gastroenterologist about what to do to • asthma and recurrent pneumonia prepare for an upper GI series. • nausea During the procedure, the person will stand or sit in front of an x-ray machine and drink • vomiting barium, a chalky liquid. Barium coats the • a sore throat, hoarseness, or laryngitis— esophagus, stomach, and small intestine so swelling and irritation of the voice box the radiologist and gastroenterologist can see theses organs’ shapes more clearly on • difficulty swallowing or painful x rays. The barium shows problems related swallowing to GERD, such as hiatal hernias. While an • pain in the chest or the upper part of upper GI series cannot detect mild irritation, the abdomen the test can detect esophageal strictures— • dental erosion and bad breath narrowing of the esophagus that can result from GERD—as well as ulcers, or sores. How is GERD diagnosed? A person may experience bloating and nausea for a short time after the test. For A health care provider may refer people with several days afterward, barium liquid in suspected GERD to a gastroenterologist—a the GI tract causes white or light-colored doctor who specializes in digestive diseases— stools. A health care provider will give the for diagnosis and treatment. person specific instructions about eating and Lifestyle changes and medications are often drinking after the test. the first lines of treatment for suspected Upper endoscopy. A gastroenterologist GERD. If symptoms improve with these may use an upper endoscopy, also known treatment methods, a GERD diagnosis as an esophagogastroduodenoscopy, if a often does not require testing. However, person continues to have GERD symptoms to confirm a diagnosis, a person may need despite lifestyle changes and treatment testing if symptoms do not improve. People with medications. An upper endoscopy is a with possible GERD who have trouble common test used to evaluate the severity swallowing also may require testing. of GERD. This procedure involves using A completely accurate test for diagnosing an endoscope—a small, flexible tube with a GERD does not exist. However, several light—to see the upper GI tract. tests can help with diagnosis: A gastroenterologist performs this test at Upper GI series. While a gastroenterologist a hospital or an outpatient center. The does not use an upper GI series to diagnose person may receive a liquid anesthetic that is acid reflux or GERD, the test can provide gargled or sprayed on the back of the throat.

3 Gastroesophageal Reflux (GER) and Gastroesophageal Reflux Disease (GERD) in Adults If sedation is used, a health care provider This test is most useful when combined with will place an intravenous (IV) needle in the a carefully kept diary of when, what, and person’s vein. how much food the person eats and GERD symptoms that result. The gastroenterologist After the person receives sedation, the can see correlations between symptoms and gastroenterologist carefully feeds an certain foods or times of day. The procedure endoscope through the mouth and down can also help show whether reflux triggers the esophagus, then into the stomach and respiratory symptoms. duodenum. A small camera mounted on the endoscope transmits a video image to a Esophageal manometry. Esophageal monitor, allowing close examination of the manometry measures muscle contractions intestinal lining. The gastroenterologist uses in the esophagus. A gastroenterologist may the endoscope to take a biopsy, a procedure order this test when considering a person for that involves taking a small piece of anti-reflux surgery. The gastroenterologist esophageal tissue. A pathologist—a doctor performs this test during an office visit. A who specializes in diagnosing diseases—will person may receive anesthetic spray on examine the tissue with a microscope and the inside of the nostrils or back of the determine the extent of inflammation. throat. The gastroenterologist passes a soft, thin tube through the person’s nose A gastroenterologist diagnoses GERD when into the stomach. The person swallows as the test shows injury to the esophagus in the gastroenterologist pulls the tube slowly a person who has had moderate to severe back into the esophagus. A computer GERD symptoms. measures and records the pressure of the Esophageal pH monitoring. The most muscle contractions in different parts of the accurate test to detect acid reflux, esophageal esophagus. The test can show if symptoms pH monitoring measures the amount of are due to a weak sphincter muscle. A liquid or acid in the esophagus as the person health care provider can also use the test to goes about normal activities, including eating diagnose other disorders of the esophagus and sleeping. A gastroenterologist performs that might have similar symptoms as this test at a hospital or an outpatient center heartburn. Most people can resume regular as a part of an upper endoscopy. The person activity, eating, and medications right after can remain awake during the test. Sedation the test. is not required for the test; however, it can be used if necessary. How is GERD treated? A gastroenterologist will pass a thin tube, Treatment for GERD may involve one or called a nasogastric probe, through the more of the following, depending on the person’s nose or mouth to the stomach. The severity of symptoms: lifestyle changes, gastroenterologist will then pull the tube medications, or surgery. back into the esophagus, where it will be taped to the person’s cheek and remain in Lifestyle Changes place for 24 hours. The end of the tube in Some people can reduce GERD symptoms by the esophagus has a small probe to measure when and how much liquid or acid comes up • losing weight, if needed into the esophagus. The other end of the • wearing loose-fitting clothing around tube, attached to a monitor outside the body, the stomach area, as tight clothing can shows the measurements taken. constrict the area and increase reflux

4 Gastroesophageal Reflux (GER) and Gastroesophageal Reflux Disease (GERD) in Adults • remaining upright for 3 hours after with GERD. Health care providers most meals commonly prescribe PPIs for long-term management of GERD. However, studies • raising the head of the bed 6 to 8 inches show people who take PPIs long term or in by securing wood blocks under the high doses are more likely to have hip, wrist, bedposts––just using extra pillows will and spinal fractures. People should take not help these medications on an empty stomach in • avoiding smoking and being around order for stomach acid to activate them. others who are smoking Prokinetics, which include bethanechol Medications (Urecholine) and metoclopramide People can purchase many GERD (Reglan), help make the stomach empty medications without a prescription; however, faster. However, both bethanechol and people with persistent symptoms should still metoclopramide have side effects that often see a health care provider. limit their use, including nausea, diarrhea, tiredness, depression, anxiety, and problems Antacids, which include over-the-counter with physical movement. Prokinetics can medications such as Alka-Seltzer, Maalox, interact with other medications, so people Mylanta, Rolaids, and Riopan, are a first- taking prokinetic agents should tell their line approach health care providers usually health care provider about all medications recommend to relieve heartburn and other they are taking. mild GERD symptoms. Antacids, however, can have side effects, including diarrhea and Antibiotics, including one called constipation. erythromycin, have been shown to improve gastric emptying. Erythromycin H2 blockers, such as cimetidine (Tagamet has fewer side effects than bethanechol HB), famotidine (Pepcid AC), nizatidine and metoclopramide; however, like all (Axid AR), and ranitidine (Zantac 75), antibiotics, it can cause diarrhea. decrease acid production. These medications are available in both over-the-counter and All of these medications work in different prescription strengths. H2 blockers provide ways, so combinations of medications may short-term or on-demand relief and are help control symptoms. People who get effective for many people with GERD heartburn after eating may take antacids symptoms. They can also help heal the and H2 blockers. The antacids neutralize esophagus, although not as well as proton stomach acid, and the H2 blockers stop acid pump inhibitors (PPIs). production. By the time the antacids stop working, the H2 blockers have stopped acid PPIs include omeprazole (Prilosec, Zegerid), production. lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex), and Surgery esomeprazole (Nexium), which are When a person cannot manage severe available by prescription. Omeprazole and GERD symptoms through medication or lansoprazole also come in over-the-counter lifestyle changes, a health care provider may strength. PPIs are more effective than recommend surgery. A health care provider H2 blockers and can relieve symptoms and may also recommend surgery for GERD heal the esophageal lining in most people that results from a physical abnormality or

5 Gastroesophageal Reflux (GER) and Gastroesophageal Reflux Disease (GERD) in Adults for GERD symptoms that lead to severe What are the long-term respiratory problems. Fundoplication is the standard surgical treatment for GERD and complications of GERD? leads to long-term reflux control in most Untreated GERD can sometimes cause cases. A gastroenterologist or surgeon may serious complications over time, including also use endoscopic techniques to treat • esophagitis—irritation of the esophagus GERD. However, the success rates of from refluxed stomach acid that endoscopic techniques are not completely damages the lining and causes bleeding known, as researchers have not tested them or ulcers. Adults who have chronic enough in clinical trials. People are more esophagitis over many years are more likely to develop complications from surgery likely to develop precancerous changes than from medications. Anti-reflux surgery in the esophagus. is most successful in people younger than 50. • strictures that lead to swallowing Fundoplication is an operation to sew the difficulties. top of the stomach around the esophagus to add pressure to the lower end of the • respiratory problems, such as trouble esophagus and reduce reflux. A surgeon breathing. performs fundoplication using a laparoscope, • Barrett’s esophagus, a condition in a thin tube with a tiny video camera attached which the tissue lining the esophagus used to look inside the body. The surgeon is replaced by tissue similar to the performs the operation at a hospital or an lining of the intestine. A small number outpatient center, and the person receives of people with Barrett’s esophagus general anesthesia. People can leave the develop a rare yet often deadly type hospital or outpatient center in 1 to 3 days of cancer of the esophagus. Read and return to their daily activities in 2 to more in Barrett’s Esophagus at 3 weeks. www.digestive.niddk.nih.gov. Endoscopic techniques, such as A health care provider should monitor a endoscopic sewing and radiofrequency, person with GERD to prevent or treat long- help control GERD in a small number term complications. of people. Endoscopic sewing uses small stitches to tighten the sphincter muscle. Radiofrequency creates heat lesions that Eating, Diet, and Nutrition help tighten the sphincter muscle. Surgery People with GERD can often reduce reflux for both techniques requires an endoscope. by avoiding foods and drinks that worsen A surgeon performs the operation at a symptoms. Other dietary changes that can hospital or an outpatient center, and the help reduce symptoms include decreasing person receives anesthesia. Although the fat intake and eating small, frequent meals devices for these procedures are approved, instead of three large meals. People who results may not be as good as laparoscopic are overweight can talk with a health care surgery, and these procedures are not provider about dietary changes that can commonly used. help them lose weight, which may decrease GERD symptoms.

6 Gastroesophageal Reflux (GER) and Gastroesophageal Reflux Disease (GERD) in Adults Hope through Research Points to Remember The Division of Digestive Diseases and • Gastroesophageal reflux (GER) Nutrition at the National Institute of occurs when stomach contents flow Diabetes and Digestive and Kidney Diseases back up into the esophagus. (NIDDK) supports basic and clinical research into GI diseases, including GER • GER is also called acid reflux or and GERD. acid regurgitation because the stomach’s digestive juices contain Clinical trials are research studies involving acid. people. Clinical trials look at safe and effective new ways to prevent, detect, or • Gastroesophageal reflux disease treat disease. Researchers also use clinical (GERD) is a more serious, chronic trials to look at other aspects of care, such form of GER. as improving the quality of life for people • GERD results when the lower with chronic illnesses. To learn more about esophageal sphincter becomes clinical trials, why they matter, and how to weak or relaxes when it should not, participate, visit the NIH Clinical Research causing stomach contents to rise up Trials and You website at www.nih.gov/health/ into the esophagus. clinicaltrials. For information about current studies, visit www.ClinicalTrials.gov. • The main symptom of GERD is frequent heartburn, though some adults with GERD do not have For More Information heartburn. American College of Gastroenterology • Other common GERD symptoms 6400 Goldsboro Road, Suite 200 include asthma or recurrent Bethesda, MD 20817–5846 pneumonia, difficulty swallowing or Phone: 301–263–9000 painful swallowing, and pain in the Fax: 301–263–9025 chest. Email: [email protected] Internet: www.gi.org • A health care provider may refer people with suspected GERD to American Gastroenterological Association a gastroenterologist for diagnosis 4930 Del Ray Avenue and treatment. Bethesda, MD 20814 Phone: 301–654–2055

• Treatment for GERD may involve Fax: 301–654–5920 one or more of the following, Email: [email protected] depending on the severity of Internet: www.gastro.org symptoms: lifestyle changes, medications, or surgery. International Foundation for Functional Gastrointestinal Disorders • A health care provider should 700 West Virginia Street, Suite 201 monitor a person with GERD Milwaukee, WI 53204 to prevent or treat long-term Phone: 1–888–964–2001 or 414–964–1799 complications. Fax: 414–964–7176 Email: [email protected] Internet: www.iffgd.org

7 Gastroesophageal Reflux (GER) and Gastroesophageal Reflux Disease (GERD) in Adults Acknowledgments National Digestive Diseases Publications produced by the Clearinghouse Information Clearinghouse are carefully reviewed by both NIDDK 2 Information Way scientists and outside experts. This Bethesda, MD 20892–3570 publication was originally reviewed by M. Phone: 1–800–891–5389 Brian Fennerty, M.D., Oregon Health and TTY: 1–866–569–1162 Science University, and Benjamin D. Gold, Fax: 703–738–4929 M.D., Emory University School of Medicine. Email: [email protected] Internet: www.digestive.niddk.nih.gov

You may also find additional information about this The National Digestive Diseases Information topic by visiting MedlinePlus at www.medlineplus.gov. Clearinghouse (NDDIC) is a service of the This publication may contain information about National Institute of Diabetes and Digestive medications and, when taken as prescribed, and Kidney Diseases (NIDDK). The the conditions they treat. When prepared, this publication included the most current information NIDDK is part of the National Institutes of available. For updates or for questions about Health of the U.S. Department of Health any medications, contact the U.S. Food and Drug and Human Services. Established in 1980, Administration toll-free at 1–888–INFO–FDA (1–888–463–6332) or visit www.fda.gov. Consult your the Clearinghouse provides information health care provider for more 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 The U.S. Government does not endorse or favor any specific commercial product or company. rade, T distributes publications, and works closely proprietary, or company names appearing in this with professional and patient organizations document are used only because they are considered and Government agencies to coordinate necessary in the context of the information provided. If a product is not mentioned, the omission does not resources about digestive diseases. mean or imply that the product is unsatisfactory.

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NIH Publication No. 13–0882 September 2013

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