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GERD

Millions of people experience symptoms of heartburn, a sour taste in the back of the throat, and an intolerance after eating spicy, fatty, or greasy foods, that often indicated the presence of GERD (Gastroesophageal reflux disease).  Often the discomfort can last for hours after a particularly troublesome meal, or it can wake patients in the middle of the night with burning and a sour taste.  Many people control the symptoms by the use of antacids that often are able to provide short term relief for the problem.  Some often "live" with a roll of antacid tablets by their sides, in the car, in the drawer at work, at the bedside, to control these symptoms.

These symptoms are felt occasionally by many, many people, and most of us are able to control these symptoms simply by avoiding food that bothers us, or to take an occasional dose or two of medicine that is available at the drugstore or supermarket.  The question many have is whether or not my heartburn is anything to worry about.  Once we get an idea of what causes the symptoms, then it will be easier to know what to do to feel better.

Wave-like muscle contractions, known as peristalsis, move food down through the esophagus and into the stomach. In the stomach, acid and different substances, notably hydrochloric acid and pepsin, break down and digest the starch, fat, and protein in food.  Gastroesophageal reflux (GERD) is caused by the valve between the esophagus, or food-tube, relaxing and letting contents of the stomach, mainly acid (used by the body to help digest food) , pepsin (used to digest proteins),  and bile (used to help digest fats) backwash or reflux back into the esophagus.  This often happens easier when one has a hiatal hernia, when a small part of the stomach "slips" above the abdomen into the chest, allowing the backwash to happen easier.  The lining of the esophagus is not as well equipped to handle backwash of acid and bile, and often irritation of the esophagus happens, leading to symptoms.

Doctors have found that how often the backwash occurs, how much acid and bile are in the stomach, and how often the stomach empties all have a lot to do with symptoms of GERD. Controlling these factors, especially at night when much reflux occurs, has a lot to do with making patients feel better as well as avoiding longterm complications of GERD.

Diet and lifestyle changes often by themselves (without medicines) can eliminate the symptoms of GERD as well as help to heal irritation in the esophagus. 

Avoiding the following things can do a lot to help the average case of GERD:

  • Alcohol
  • Smoking
  • Caffeine
  • Chocolate
  • Mints (peppermint, spearmint)
  • Onions
  • Garlic
  • Citrus (including tomatoes)
  • Spicy foods
  • Fatty foods: fatty meats such as fried foods and burgers (MEATFAT), ice cream and the like (MILKFAT) and cakes and cookies (CAKEFAT)

Important lifestyle changes include the following:

  • If you tend to eat one or two large meals during the day, try to break these down into three to four smaller meals a day.  Chew well, and swallow slowly. DON'T RUSH when you eat.
  • Sit upright during meals and for at least one hour afterwards.
  • Elevate the head of the bed four inches to six inches. Use a foam-rubber bed wedge or blocks/books under the head of the bed.  DO NOT sleep propped up on three or four pillows - this tends to increase intraabdominal pressure and make reflux worse.
  • Wear loose-fitting clothes.  AVOID corsets , girdles, and the like.
  • Lose weight in a consistent, slow, well-controlled fashion.  Crash diets and diets that eliminate one or more food groups (like the protein-sparing carbohydrate-free diets that are in vogue now) can have serious side-effects.

Longstanding or severe GERD can lead to serious complications.  One problem that can develop from ongoing reflux is stricture.  This results from scar tissue forming in the end of the esophagus from continuous exposure to acid, resulting in narrowing of the esophagus.  This can lead to dangerous impaction, or sticking, of food in the esophagus. Foods that are prone to get lodged behind a stricture include breads and meats.  Severe strictures that form over time often need to be dilated, or stretched in a special hospital procedure.  GERD can also lead to an asthma like condition from the presence of excess acid in the esophagus, as well as refluxed acid slipping from the back of the throat, into the lungs.  This can result in episodes of wheezing and shortness of breath.  Ulcers and erosions, which consist of breaks in the lining of the esophagus to various degrees, can also form.  These can lead to more severe and longlasting symptoms of heartburn than simply acid reflux alone.  Ongoing irritation of the back of the throat by refluxed stomach contents can contribute to chronic sinus infections and severe irritation of the throat (reflux laryngitis).  One of the most concerning longterm complications of GERD is Barrett's esophagus, a precancerous condition of the end of the esophagus.  This results from the lining of the end of the esophagus "changing" in response to constant acid exposure. This change results in a type of lining that is more prone to lead to esophagus cancer (adenocarcinoma).  Up to one percent of people who have Barrett's esophagus develop cancer each year.  This has led to many experts recommending frequent checking of the end of the esophagus in Barrett's patients to look for developing cancer.

Doctors have many tools for checking patients for complicated GERD.  The simplest way especially in young healthy patients is to try a short treatment period with medicines available to decrease acid production, coat the esophagus, or promote more rapid emptying of the esophagus.  If this isn't completely effective, either an upper GI series (Barium X-ray) or an endoscopy (EGD) is often used for diagnosis and to detect complicated GERD.  The endoscopy consists of using a very thin lighted tube to look at the esophagus and usually take tiny tissue samples to diagnose GERD.  It is usually done with sedation and is well tolerated. Upper GI series can look at the esophagus in contrast (profile) to look for irregularities or narrowings that suggest GERD.  While the endoscopy does a better job at detecting GERD than X-ray, it is a slightly more expensive and invasive procedure.  24-hour monitoring of the esophagus for acid reflux (24-hour pH monitoring) is also very useful for diagnosis.

Once GERD is found, there are many effective ways to promote rapid healing of irriatation and give relief of symptoms.  Many with very mild GERD can use antacids exclusively for relief.  This often is ineffective except for the most mild cases.  H2 blockers, available over the counter or by prescription (Pepcid, Zantac, Tagamet, Axid) can be very useful in mild to moderate GERD.  For more serious GERD, PPIs (proton pump inhibitors) like Prilosec, Prevacid and Aciphex are available by prescription.  They prevent the stomach from making almost all the acid it normally does.  This helps the esophagus to feel better, allowing irritations to heal quickly.  For people with hiatal hernias that are large, new surgical techniques that are "less invasive" (laparoscopic) can fix the problem and bring longlasting relief.

Most who are diagnosed with GERD requiring prescription medicine to control won't need these medicines lifelong if they are able to control their diet, reduce weight, stop smoking, limit alcohol use, and avoid habits which make reflux happen more often, such as eating before bedtime.  Look at our "Dietary Guidelines" section for more helpful tips.