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Heartburn Gastroesophageal Reflux GER and Gastroesophageal

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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
                  reflux (GER), which is common. GER             The main symptom of GERD in adults
U.S. Department
                  occurs when the lower esophageal sphinc-       is frequent heartburn, also called acid
of Health and
Human Services    ter (LES) opens spontaneously, for varying     indigestion—burning-type pain in the
                  periods of time, or does not close prop-       lower part of the mid-chest, behind the
NATIONAL          erly and stomach contents rise up into the     breast bone, and in the mid-abdomen.
INSTITUTES
                  esophagus. GER is also called acid reflux      Most children under 12 years with GERD,
OF HEALTH
                  or acid regurgitation, because digestive       and some adults, have GERD without
                  juices—called acids—rise up with the food.     heartburn. Instead, they may experience
                  The esophagus is the tube that carries food    a dry cough, asthma symptoms, or trouble
                  from the mouth to the stomach. The LES         swallowing.
                  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
                  When acid reflux occurs, food or fluid can     is still unclear. However, research shows
                  be tasted in the back of the mouth. When       that in people with GERD, the LES relaxes
                  refluxed stomach acid touches the lining of    while the rest of the esophagus is working.
                  the esophagus it may cause a burning sensa-    Anatomical abnormalities such as a hiatal
                  tion in the chest or throat called heartburn   hernia may also contribute to GERD. A
                  or acid indigestion. Occasional GER is         hiatal hernia occurs when the upper part of
                  common and does not necessarily mean one       the stomach and the LES move above the
                  has GERD. Persistent reflux that occurs        diaphragm, the muscle wall that separates
                  more than twice a week is considered           the stomach from the chest. Normally, the
                  GERD, and it can eventually lead to more       diaphragm helps the LES keep acid from
                  serious health problems. People of all ages    rising up into the esophagus. When a hia-
                  can have GERD.                                 tal hernia is present, acid reflux can occur
                                                                 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.
Other factors that may contribute to GERD        •	 drinks with caffeine or alcohol
include                                          •	 fatty and fried foods
 •	 obesity                                      •	 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 surgery.
 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 diarrhea, and aluminum salt
reflux medications for more than 2 weeks.      may cause constipation. 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 medication.
                                               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 endoscopy 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 esophagitis. Scars
                                               from tissue damage can lead to strictures—
The Nissen fundoplication 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                               • The persistence of GER along with
                                                   other symptoms—arching and irritabil-
 • Frequent heartburn, also called acid
                                                   ity in infants, or abdominal and chest
   indigestion, is the most common
                                                   pain in older children—is GERD.
   symptom of GERD in adults. Anyone
                                                   GERD is the outcome of frequent and
   experiencing heartburn twice a week or
                                                   persistent GER in infants and children
   more may have GERD.
                                                   and may cause repeated vomiting,
 • You can have GERD without hav-                  coughing, and respiratory problems.
   ing heartburn. Your symptoms could
   include a dry cough, asthma symptoms,       Hope through Research
   or trouble swallowing.
                                               The reasons certain people develop GERD
 • If you have been using antacids for         and others do not remain unknown.
   more than 2 weeks, it is time to see        Several factors may be involved, and
   your health care provider. Most doc-        research is under way to explore risk factors
   tors can treat GERD. Your health            for developing GERD and the role of
   care provider may refer you to a gas-       GERD in other conditions such as asthma
   troenterologist, a doctor who treats        and laryngitis.
   diseases of the stomach and intestines.
                                               Participants in clinical trials can play a more
 • Health care providers usually recom-        active role in their own health care, gain
   mend lifestyle and dietary changes to       access to new research treatments before
   relieve symptoms of GERD. Many              they are widely available, and help others
   people with GERD also need medica-          by contributing to medical research. For
   tion. Surgery may be considered as a        information about current studies, visit
   treatment option.                           www.ClinicalTrials.gov.

 • Most infants with GER are healthy
   even though they may frequently spit
   up or vomit. Most infants outgrow
   GER by their first birthday. Reflux
   that continues past 1 year of age may
   be GERD.




6 Heartburn, Gastroesophageal Reflux (GER), and Gastroesophageal Reflux Disease (GERD)
For More Information                             Acknowledgments
American College of Gastroenterology             Publications produced by the Clearinghouse 
P.O. Box 342260                                  are carefully reviewed by both NIDDK 
Bethesda, MD  20827–2260                         scientists and outside experts.  This 
Phone:  301–263–9000                             publication was reviewed by M. Brian 
Internet:  www.acg.gi.org                        Fennerty, M.D., Oregon Health and Science 
                                                 University, and Benjamin D. Gold, M.D., 
American Gastroenterological Association         Emory University School of Medicine.
4930 Del Ray Avenue 
Bethesda, MD  20814 
Phone:  301–654–2055                              You may also find additional information about this 
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Email:  member@gastro.org                         This publication may contain information about  
Internet:  www.gastro.org                         medications.  When prepared, this publication 
                                                  included the most current information available.   
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                                                  contact the U.S. Food and Drug Administration  
Gastrointestinal Disorders                        toll-free at 1–888–INFO–FDA (1–888–463–6332)  
P.O. Box 170864                                   or visit www.fda.gov.  Consult your health care 
                                                  provider for more information.
Milwaukee, WI  53217–8076 
Phone:  1–888–964–2001 or 414–964–1799 
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Fax:  215–233–3918  
Email:  naspghan@naspghan.org  
Internet:  www.naspghan.org

Pediatric/Adolescent Gastroesophageal
Reflux Association
P.O. Box 7728 
Silver Spring, MD  20907 
Phone:  301–601–9541 
Email:  gergroup@aol.com 
Internet:  www.reflux.org




7    Heartburn, Gastroesophageal Reflux (GER), and Gastroesophageal Reflux Disease (GERD)
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The National Digestive Diseases Information
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and Kidney Diseases (NIDDK). The
NIDDK is part of the National Institutes of
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 This publication is 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

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