gastroesophageal reflux disease

Heartburn & GERD Is it heartburn or GERD? Learn the difference.

A chronic condition in which the lower esophageal sphincter allows gastric acids to reflux into the esophagus, causing heartburn, acid indigestion, and possible injury to the esophageal lining.

Definition

Gastroesophageal reflux disease (GERD) is a gastric disorder which causes stomach acids to back up into the esophagus, the tube leading from the mouth to the stomach. This action causes pain, which is often called heartburn. GERD can disrupt sleep and make eating difficult. It can lead to respiratory infections, ulcers, and even cancer.

Description

The reflux action of gastroesophageal reflux disease is a function of the weakening of the lower esophageal sphincter (LES). The LES is a muscle located at the bottom of the esophagus and acts as a doorkeeper to the stomach. When food is eaten, it passes through the esophagus and the LES and into the stomach. The LES closes after food enters the stomach and usually keeps the stomach contents from returning up the esophagus.

In an infant, the LES may not be well formed, which causes the baby to spit up or vomit. In an older child or adolescent, the LES weakens and acids from the stomach come into the esophagus, causing the characteristic burning in the middle of the chest, known as heartburn.

Everyone has experienced this reflux occasionally, and it is not a concern. It is when the reflux occurs often that the condition should be evaluated. Infants and children who do not vomit or complain of heart-burn or stomachache may have this condition. When the stomach contents moves into the esophagus, there is the possibility that this material will be aspirated into the windpipe, which can cause asthma, pneumonia, and possibly suffocation or sudden death. GERD was thought to be implicated in sudden infant death syndrome (SIDS); however, subsequent studies concluded it was not.

Some children and adults have few episodes of heart-burn over their lifetimes, but they have frequent bouts of ear infection, sinusitis, bronchitis, and even asthma. Some children and adults only experience a vague indigestion. They come to the doctor because they are having trouble eating. They feel that there is something in their throats or that their food keeps getting stuck when they eat. This may be a serious condition called dysphagia, which develops from long-term GERD. The stricture of the esophagus is caused by a thickening of the lining of the esophagus in response to acids from the stomach. Sometimes, when swallowing hurts, the condition is called odynophagia. This type of GERD is often referred to as silent reflux.

Constant irritation by stomach acids in the esophagus can cause a condition called esophagitis, in which the esophagus becomes red and irritated. Because the lining of the esophagus is thinner and not as acid-proof as the stomach or the intestines, undiagnosed GERD over many years can cause ulcers along the esophagus. These can bleed and can, in turn, result in anemia. Scar tissue can also build up.

Sometimes, the body tries to protect the esophagus by growing a thicker lining, made up of cells like those in the stomach and intestine. This is known as Barrett's esophagus and is a pre-cancerous condition that usually leads to cancer of the esophagus.

Demographics

One-third of the adult population (95 million) have GERD symptoms once a month, while 15 million have symptoms every day. Though half of people who have GERD are between the ages of 45 and 64, infants, children, and teenagers also have GERD.

GERD affects 50 percent of all healthy, full-term newborns. It is the primary reason for most vomiting in infants during the first four months, at which time the vomiting should stop. Less than 5 percent of infants with GERD continue the problem into adulthood. However, this figure may be revised upward as more and more young children experience GERD symptoms and are diagnosed with this condition.

Some children seem to be more at risk for having GERD than others, particularly children who have hiatal hernia, cystic fibrosis, neurological impairment or delay, or an immature esophagus and LES.

Causes and Symptoms

Causes

GERD is caused by a weakened or immature LES. It can also be caused by a hiatal hernia that traps the stomach contents. Having too much acid in the stomach can also weaken the LES.

Heredity plays a small part in whether a child has GERD. GERD seems to be more prone to occur in some families than others.

Other factors that seem to weaken the LES are allergies and neurological disorders that affect specific muscles in the body. Diabetes and rapid weight gain can also be factors in causing GERD.

Some medications also can weaken the LES. They include calcium channel blockers used to treat high blood pressure, theophyline used to treat asthma, and antihistamines. Nitrates in medications and foods can also trigger GERD.

In infants, it may simply be a matter of having an immature digestive system. Once the body begins to mature, the GERD goes away. For adolescents, the hormones of puberty seem to trigger acid reflux.

Certain foods have been known to affect the muscle tone of the LES and increase stomach acids. Chocolate, peppermint, and high fat foods can allow the LES to relax and stay open more often. Citrus foods, tomatoes, and tomato products increase acid production in the stomach.

Lifestyle habits can also trigger episodes of acid reflux. Using caffeine and alcohol, smoking, eating large meals, and having poor posture can produce GERD.

Symptoms

Though heartburn is the characteristic symptom of GERD in adolescents and adults, GERD in children and infants is not so easy to recognize. Frequent vomiting or spitting up is the usual indicator for GERD in children. However, vomiting can be a symptom of many other childhood disorders, including stomach flu, allergy, or a related symptom to almost any illness. Frequent vomiting that continues after the first four months of life or is excessive at any time usually indicates the presence of GERD. Constant crying with back arching usually accompanies the frequent vomiting.

Children with GERD who are preschool age and older often have gas and abdominal pain above the navel. They only have intermittent vomiting. They can also experience chest pain or true heartburn symptoms, which can last up to two hours and get worse after eating. Bending over or lying down makes the heartburn worse.

Children with GERD exhibit difference symptoms. They can either gain or lose weight. One group of children will eat more because they are uncomfortable and a full stomach seems to make them feel better temporarily. Another group of children are often very picky about what they eat, refusing specific foods. These children will only eat a few bites even though they might be very hungry. A third group of children report having trouble swallowing; they choke or gag whenever they eat, no matter what foods are served. A fourth group of children will drink liquids constantly because doing so soothes the burning feeling in their esophagus.

Respiratory symptoms are twice as likely to occur in children with GERD as those who do not have it. Children often have frequent sore throats when they wake up in the morning, sinus infections, bronchitis, and dry coughs. These children have a constantly runny nose or a hoarse, deep voice. They can also experience wheezing or other asthma symptoms. Some children aspirate the stomach contents, which can cause pneumonia or even sudden death.

Sleep is often disturbed. Children often wake up with a nighttime cough or choke when they lie down. Some children experience sleep apnea (interrupted breathing).

Other children have frequent ear infections or drool a lot. Some infants and toddlers will insist on being held upright and not laid down, often falling asleep over a parent's shoulder or in a parent's arms. In some extreme cases, when there is a lot of stomach acid regurgitation, the child's teeth will show enamel erosion.

Children with GERD may also have hiccups or belch a lot. They can also have bad breath and complain of having a sour taste in their mouths.

Some children with GERD have anemia. This condition usually develops because there is an ulcer in the lining of the esophagus that has begun to bleed.

When to Call the Doctor

It is important to call the doctor if GERD symptoms occur frequently or get worse. If symptoms disturb the child's sleep and interfere with school and play, a doctor should be consulted to determine a course of treatment. Also, if a child is not eating or gaining weight or has breathing difficulty, parents should seek medical advice as soon as possible. For a child of any age, if blood is present in vomit, a doctor should be called. If a child over two complains of swallowing difficulty, a serious condition could exist and a doctor should be called.

Diagnosis

In some cases, the doctor will diagnose GERD after taking a thorough medical history, listening carefully for GERD symptoms, and doing a physical exam. Many doctors will also order a series of tests to gauge the extent of damage done by GERD. Sometimes, chest x rays are ordered to check for pneumonia or lung damage due to aspiration of stomach contents.

The most common tests, however, are the upper GI (gastrointestinal) series and the upper GI endoscopy. The upper GI series looks at the esophagus, the stomach, and the duodenum, or the first section of the small intestine. The child is asks to drink a cup of liquid that coats the digestive track. Because this liquid has usually been barium, a metallic, chalky substance, the upper GI series is sometimes called a barium swallow.

X rays or images are then taken as the barium flows down the esophagus, into the stomach, and into the duodenum. The child may be asked to turn on his or her side so that the technician can gently massage the stomach to move the barium into the duodenum. Images are often sent to a video monitor where the doctors and technicians observe the behavior of the upper digestive tract and snap still images from the monitor.

The upper GI series is particularly important in diagnosing infants. It can tell if there are anatomical changes in the esophagus, such as a hiatal hernia, a condition where the stomach bulges above the diaphragm. It can also assess damage to the esophagus and can determine if there are stomach ulcers or ulcers in the duodenum.

The upper GI endoscopy, also called the esophagogastroduodenoscopy (EGD), by contrast, is a more sensitive test and offers a more complete picture of what is happening in the upper digestive tract. As of 2004, it was the test of choice for many gastroenterologists (doctors specializing in diseases of the digestive system).

For the endoscopy, the patient receives a mild sedative, then a small, flexible tube is inserted into the esophagus. The tube has a light and a tiny camera attached to its end. There also is a small instrument to take tissue samples if the doctor needs to do so. The camera broadcasts live images from the esophagus and stomach to a video monitor. Using these tools, the doctor can capture still images for further diagnosis and hospital records, and the doctor can examine suspicious areas more closely with the camera or by taking tissue samples.

The EGD allows the doctor to determine the extent of damage to the esophagus and to rule out serious complications like Barrett's esophagus. Mild GERD may show no damage to the esophagus at all. The GED is a good tool for determining esophagitis.

Another test the doctor may order is esophageal manometry. It measures how well the LES and motor function of the esophagus are. A thin tube is inserted through the nose and down the throat. Coupled with the 24-hour pH probe study, the test becomes the best determinant of GERD because it actually monitors how often the patient has reflux into the esophagus during a full day. One episode of acid reflux is considered having a pH of less than 4 for at least 15 to 30 seconds. This test can see if there is a correlation between episodes of acid reflux and other symptoms, such as chronic cough, wheezing, or sleep apnea.

The doctor may also order a gastric emptying study. For this test, the child is asked to drink milk mixed with a radioactive chemical. Then, the child is monitored, using a special camera. Episodes of reflux can be seen with this test.

Though esophagitis may have been found in one of these tests, the doctor will need to determine whether it was caused by GERD or by milk allergy, which does not respond to acid suppressant therapy.

Treatment

There are two main treatment methods for GERD. The first is lifestyle change. This usually means that patients should not eat within three hours of going to bed. This lets the stomach empty and the acid decrease. Lying down will cause the stomach contents to come back up. Elevating the bed about six inches will also keep the acid within the stomach. Eating smaller meals more frequently will control the amount of acid in the stomach. Patients should also avoid fatty foods, caffeine, mints and mint-flavoring, spicy foods, citrus fruits, and anything with tomatoes. Carbonated beverages can also irritate the already sensitive lining of the esophagus. Alcohol and smoking should be avoided. Improved posture, with no slumping, will reduce pressure on the stomach, as will losing excess weight.

For an infant, lifestyle changes are simple. Holding a baby upright for about a half hour after breastfeeding or bottle feeding will help keep reflux to a minimum. Feeding a baby on formula smaller portions more frequently can also help manage spitting up. Some doctors recommend thickening the baby's formula with rice cereal or using pre-thickened formulas such as Enfamil. This will decrease the amount of spit up or vomit, but it does nothing for reflux. It does fill up the child on a smaller amount of food and can also make the baby sleep and thus stop crying. Placing a baby in a semi-prone position as in an infant car seat only makes GERD worse. Babies with GERD should sleep on their backs in a crib or bed that has the head of the bed elevated to a 30 degree angle.

Medication is the second main way to treat GERD. The doctor may first recommend non-prescription medications, such as antacids and histamine-2 receptor blockers (H2 blockers). Antacids, such as Gaviscon, Maalox, Mylanta, and Tums, help neutralize acid already in the stomach or esophagus. Some have a foaming agent, which also helps prevent acid from backing up into the esophagus. Antacids can be used every day for three weeks. If taken longer, they can produce diarrhea, interfere with calcium absorption in the body, and build up magnesium, which can damage the kidneys. The doctor will determine if they can be taken longer. Infants are only given antacids in limited doses because of the risk of aluminum toxicity.

Common H2 blockers are nizatidine (Axid), ranitidine (Zantac), famotidine (Pepcid), and cimetidine (Tagamet). These should be taken one hour before meals. They block acid formation but have no effect on acid already present in the stomach.

If these remedies do not work or the patient's GERD is very serious, the doctor will usually move onto the more powerful proton-pump inhibitors (PPIs). These include omeprazole (Prilosec), esomeprazole (Nexium), lansoprazole (Prevacid), rabeprazole (Aciphex), and pantoprazole (Protonix). These medications block the production of an enzyme that aids in the production of acid. PPIs stop acid production better than H2 blockers.

In addition to PPIs, the doctor may prescribe coating agents, such as sucralfate (Carafe), to cover the sores and mucous membranes of the esophagus and stomach. This acts as a protective barrier to stomach acids.

Some doctors also use promotility agents to tighten the LES and promote faster emptying of the stomach. These include metoclopramide (Reglan) and bethanechol (Duvoid). However, many doctors are reluctant to use these drugs because they have serious side effects. For example, cisapride (Propulsid) was pulled from the market because of safety concerns about lethal drug interactions.

One last option that doctors have to treat GERD is surgery. Because lifestyle changes and medications work for most children and adolescents with GERD, the election of surgery is only used for a small number of people for whom all the other options did not work.

Fundoplication is a surgical procedure that puts pressure on the LES to keep acid from backing up. During the surgery, the doctor wraps a part of the stomach around the esophagus and sews it down. This produces a one-way valve. This procedure can be done laparoscopically, a less invasive surgery where the doctor makes small cuts into the abdomen to insert a camera and the surgical instruments. This surgery produces very little scarring and has a faster recovery rate. Fundoplication is not always successful and can have complications. The surgery also comes undone in about 20 percent to 30 percent of cases.

Prognosis

Many babies outgrow infantile GERD, but some keep having symptoms well into adulthood. In most cases, GERD is easily managed. For 60 percent of children and adolescents with mild to moderate GERD, lifestyle changes and H2 blockers are very effective. For those with severe symptoms, including esophagitis, PPI therapy works well. For relapses, long-term therapy or surgery may be necessary.

Prevention

GERD can be prevented by maintaining a healthy body weight, avoiding alcohol and smoking, eating smaller meals, limiting fatty foods, and eliminating trigger foods.

Parental Concerns

GERD diagnosis is a recent phenomenon. Though it may have existed in the distant past, only since the 1990s have doctors begun to recognize GERD as an individual disease. Diagnosing GERD in children is sometimes controversial. Some doctors have recognized GERD as a temporary condition in infants but do not recognize GERD in children or in adolescents. Many doctors are, as of 2004, beginning to understand that GERD, like many other digestive disorders, can occur at any age. The North American Society for Pediatric Gastroenterology and Nutrition drafted guidelines for treating children and adolescents with GERD in 2001. Being educated about the disease can help parents discuss their child's GERD symptoms and treatment options with their child's doctor.

Parents should help children understand that they need to take their medications regularly and that they need to make lifestyle changes. It can be hard to explain to a child that chocolate and candy canes are off limits, but like food allergies, children will learn to modify their food choices because of their special sensitivities.

Parents can also help children cope emotionally with this disease. For some children, it is just a matter of eating right and taking medication once a day. For others, it is a lifelong struggle with food and their digestive tract. They will have good days and bad days. It may be difficult for children to communicate their condition to their friends or their teachers who might not always understand that on one day they are fine and on the next they are not. Parental support will help children and teenagers cope with GERD.

Resources

Books

Cheskin, Lawrence J., and Brian E. Lacy. Healing Heartburn. Baltimore, MD: Johns Hopkins University Press, 2002.

Shimberg, Elaine Fantie. Coping with Chronic Heartburn: What You Need to Know about Acid Reflux and GERD. New York: St. Martin's Press, 2001.

Sklar, Jill, and Annabel Cohen. Eating for Acid Reflux: A Handbook and Cookbook for Those with Heartburn. New York: Marlowe & Company, 2003.

Periodicals

Arguin, Amy Lynn, and Martha K. Swartz. "Gastroesophageal Reflux in Infants: A Primary Care Perspective." Pediatric Nursing 30, i. 1 (January-February 2004): 45–53.

"GERD and Respiratory Infections." Pediatrics for Parents 20, i. 2 (February 2002): 4.

Organizations

American Academy of Pediatrics. 141 Northwest Point Blvd., Elk Grove Village, IL 60007–1098. Web site: www.aap.org.

American College of Gastroenterology. 4900 B South 31 St. Arlington, VA 22206. Web site: www.acg.gi.org.

Web Sites

"Gastroesophageal Reflux Disease." Cincinnati Children's Hospital. Available online at www.cincinnatichildrens.org/health/info/abdomen/diagnose/gerd.htm (accessed October 21, 2004).

"GERD Treatment Options in Infants and Children." WebGERD. Available online at www.webgerd.com/GerdTreatmentInInfants.htm (accessed October 21, 2004).

[Article by: Janie Franz]

For more information on gastroesophageal reflux disease, visit Britannica.com.

Gastroesophageal reflux disease
Classification and external resources
X-ray of the abdomen and chest in a patient with a gastrostomy. Radiocontrast was injected into the stomach and quickly seen migrating upwards through the entire esophagus. The patient had severe reflux-induced esophagitis.
ICD-10	K21.
ICD-9	530.81
OMIM	109350
DiseasesDB	23596
eMedicine	med/857  ped/1177 radio/300
MeSH	D005764

Gastroesophageal reflux disease (GERD), Gastro-oesophageal reflux disease (GORD), Gastric reflux disease, or Acid reflux disease is defined as chronic symptoms or mucosal damage produced by the abnormal reflux in the esophagus.^[1]

This is commonly due to transient or permanent changes in the barrier between the esophagus and the stomach. This can be due to incompetence of the lower esophageal sphincter, transient lower esophageal sphincter relaxation, impaired expulsion of gastric reflux from the esophagus, or a hiatus hernia. If the reflux reaches the throat, it is called laryngopharyngeal reflux disease.

Contents 1 Signs and symptoms 1.1 Adults 1.2 Children 2 Diagnosis 3 Pathophysiology 4 Treatment 4.1 Foods to be avoided 4.2 Positional therapy 4.3 Drug treatment 4.4 Posture and GERD 4.5 Surgical treatment 4.6 Other treatments 4.7 Natural remedies 5 Barrett's esophagus 6 References 7 External links

Signs and symptoms

Adults

The most-common symptoms of GERD are:

• Heartburn
• Regurgitation
• Trouble swallowing (dysphagia)

Less-common symptoms include:

• Pain with swallowing (odynophagia)
• Excessive salivation (this is common during heartburn, as saliva is generally slightly basic^[2] and is the body's natural response to heartburn, acting similarly to an antacid)
• Nausea^[3]
• Chest pain

GERD sometimes causes injury of the esophagus. These injuries may include:

• Reflux esophagitis—necrosis of esophageal epithelium causing ulcers near the junction of the stomach and esophagus.
• Esophageal strictures—the persistent narrowing of the esophagus caused by reflux-induced inflammation.
• Barrett's esophagus—metaplasia (changes of the epithelial cells from squamous to columnar epithelium) of the distal esophagus.
• Esophageal adenocarcinoma—a rare form of cancer.^[3]

Several other atypical symptoms are associated with GERD, but there is good evidence for causation only when they are accompanied by esophageal injury. These symptoms are:

• Chronic cough
• Laryngitis (hoarseness, throat clearing)
• Asthma
• Erosion of dental enamel
• Dentine hypersensitivity
• Sinusitis and damaged teeth^[4]

Some people have proposed that symptoms such as pharyngitis, sinusitis, recurrent ear infections, and idiopathic pulmonary fibrosis are due to GERD; however, a causative role has not been established.^[3]

Children

GERD may be difficult to detect in infants and children. Symptoms may vary from typical adult symptoms. GERD in children may cause repeated vomiting, effortless spitting up, coughing, and other respiratory problems. Inconsolable crying, failure to gain adequate weight, refusing food, bad breath, and belching or burping are also common. Children may have one symptom or many — no single symptom is universal in all children with GERD.

Common symptoms of Paediatric Reflux

• Irritability and pain, sometimes screaming suddenly when asleep. Constant or sudden crying or “colic” like

symptoms. Babies can be inconsolable especially when laid down flat.

• Poor sleep habits typically with arching their necks and back during or after feeding
• Excessive possetting or vomiting
• Frequent burping or frequent hiccups
• Excessive dribbling or running nose
• Swallowing problems, gagging and choking
• Frequent ear infections or sinus congestion
• Babies are often very gassy and extremely difficult to “burp” after feeds
• Refusing feeds or frequent feeds for comfort
• Night time coughing, extreme cases of acid reflux can cause apnoea and respiratory problems such as asthma,

bronchitis and pneumonia if stomach contents are inhaled.

• Bad breath – smelling acidy
• Rancid/acid smelling diapers with loose stool. Bowel movements can be very frequent or babies can be constipated.

Vomiting feeds Possetting after a feed is quite normal with most infants. They gain weight, feed well and have no other symptoms, but still this can be upsetting for parents. As the child gets older the lower oesophageal sphincter becomes more competent so the vomiting should begin to show signs of improvement and eventually stop. Some babies suffer more with reflux and about 60% of these babies with persistent reflux may have weight gain issues. It is a very popular misconception though that all babies and children with reflux are underweight. This isn't always the case, some may comfort eat and feed very frequently and not all are sick. Many doctors advise that babies outgrow reflux once they can sit up, or once they stand. Many do, but some will not only fail to outgrow it, but will noticeably worsen with developmental milestones, teething episodes, viral illness and weaning.

Silent Reflux Some babies with reflux do not vomit at all. This is actually more of a problem because the acidic stomach contents go up the throat and back down again, causing twice the pain and twice the damage.^{[citation needed]} There is no clear relationship between symptoms and the severity of reflux.

It is estimated that of the approximately 4 million babies born in the U.S. each year, up to 35% of them may have difficulties with reflux in the first few months of their life, known as spitting up.^[5] Most of those children will outgrow their reflux by their first birthday. However, a small but significant number of them will not outgrow the condition. This is particularly true where there is a family history of GERD present.

Diagnosis

Endoscopic image of peptic stricture, or narrowing of the esophagus near the junction with the stomach. This is a complication of chronic gastroesophageal reflux disease and can be a cause of dysphagia or difficulty swallowing

A detailed historical knowledge is vital for an accurate diagnosis. Useful investigations may include barium swallow X-rays, esophageal manometry, 24 hour esophageal impedance-pH monitoring, and Esophagogastroduodenoscopy (EGD). In general, an EGD is done when the patient either does not respond well to treatment or has alarm symptoms including dysphagia, anemia, blood in the stool (detected chemically), wheezing, weight loss, or voice changes. Some physicians advocate either once-in-a-lifetime or 5/10-yearly endoscopy for patients with longstanding GERD, to evaluate the possible presence of dysplasia or Barrett's esophagus, a precursor lesion for esophageal adenocarcinoma.^[6]

Esophagogastroduodenoscopy (EGD) (a form of endoscopy) involves insertion of a thin scope through the mouth and throat into the esophagus and stomach (often while the patient is sedated) in order to assess the internal surfaces of the esophagus, stomach, and duodenum.

Biopsies can be performed during gastroscopy and these may show:

• Edema and basal hyperplasia (non-specific inflammatory changes)
• Lymphocytic inflammation (non-specific)
• Neutrophilic inflammation (usually due to reflux or Helicobacter gastritis)
• Eosinophilic inflammation (usually due to reflux)
• Goblet cell intestinal metaplasia or Barretts esophagus
• Elongation of the papillae
• Thinning of the squamous cell layer
• Dysplasia or pre-cancer
• Carcinoma

Reflux changes may be non-erosive in nature, leading to the entity "non-erosive reflux disease".

Another test that has been used is the "Bernstein test".^[7]

Pathophysiology

GERD is caused by a failure of the cardia. In healthy patients, the "Angle of His"—the angle at which the esophagus enters the stomach—creates a valve that prevents duodenal bile, enzymes, and stomach acid from traveling back into the esophagus where they can cause burning and inflammation of sensitive esophageal tissue.

Another paradoxical cause of GERD-like symptoms is not enough stomach acid (hypochlorhydria). The valve that empties the stomach into the intestines is triggered by acidity. If there is not enough acid, this valve does not open, and the stomach contents are churned up into the esophagus. However, there is still enough acidity to irritate the esophagus.

Factors that can contribute to GERD:

• Hiatus hernia, which increases the likelihood of GERD due to mechanical and motility factors.^[8]
• Obesity: increasing body mass index is associated with more severe GERD.^[9]
• Zollinger-Ellison syndrome, which can be present with increased gastric acidity due to gastrin production
• Hypercalcemia, which can increase gastrin production, leading to increased acidity
• Scleroderma and systemic sclerosis, which can feature esophageal dysmotility
• The use of medicines such as prednisolone
• Visceroptosis or Glénard syndrome, in which the stomach has sunk in the abdomen upsetting the motility and acid secretion of the stomach.

GERD has been linked to laryngitis, chronic cough, pulmonary fibrosis, earache, and asthma, even when not clinically apparent, as well as to laryngopharyngeal reflux and ulcers of the vocal cords.

Factors that have been linked with GERD but not conclusively:

• Obstructive sleep apnea^[10][11]
• Gallstones, which can impede the flow of bile into the Duodenum, which can affect the ability to neutralize gastric acid

In 1999, a review of existing studies found that, on average, 40% of GERD patients also had H. pylori infection.^[12] The eradication of H. pylori can lead to an increase in acid secretion,^[13] leading to the question of whether H. pylori-infected GERD patients are any different than non-infected GERD patients. A double-blind study, reported in 2004, found no clinically significant difference between these two types of patients with regard to the subjective or objective measures of disease severity.^[14]

Treatment

Physicians normally recommend lifestyle modifications, whether or not recommending drugs to treat GERD.

Foods to be avoided

Certain foods and lifestyle are considered to promote gastroesophageal reflux, but a 2006 review suggested that evidence for most dietary interventions is anecdotal; only weight loss and elevating the head of the bed were supported by evidence.^[15] A subsequent randomized crossover study showed benefit by avoiding eating two hours before bedtime.^[8]

• Coffee, alcohol, and excessive amounts of Vitamin C supplements stimulate gastric acid secretion. Taking these before bedtime especially can cause evening reflux.
• Antacids based on calcium carbonate (but not aluminum hydroxide) were found to actually increase the acidity of the stomach. However, all antacids reduced acidity in the lower esophagus, so the net effect on GERD symptoms may still be positive.^[16]
• Foods high in fats and smoking reduce lower esophageal sphincter competence, so avoiding these may help. Fat also delays stomach emptying.
• Eating within 2–3 hours before bedtime.
• Large meals. Having smaller, more frequent meals reduces GERD risk, as it means there is less food in the stomach at any one time.
• Carbonated soft drinks with or without sugar.
• Chocolate and peppermint.
• Acidic foods: tomatoes and tomato-based preparations; citrus fruits and citrus juices.
• Cruciferous vegetables:cabbage, cauliflower, broccoli, and Brussels sprouts.
• Milk and milk-based products containing calcium^{[citation needed]} and fat, within 2 hours of bedtime.

Positional therapy

Sleeping on the left side has been shown to reduce nighttime reflux episodes in patients.^[17]

A meta-analysis suggested that elevating the head of bed is an effective therapy, although this conclusion was only supported by nonrandomized studies.^[15] The head of the bed can be elevated by plastic or wooden bed risers that support bed posts or legs, a therapeutic bed wedge pillow, or a wedge or an inflatable mattress lifter that fits in between mattress and box spring. The height of the elevation is critical and must be at least 6 to 8 inches (15 to 20 cm) to be at least minimally effective to prevent the backflow of gastric fluids. Some innerspring mattresses do not work well when inclined and may cause back pain; some prefer foam mattresses. Some practitioners use higher degrees of incline than provided by the commonly suggested 6 to 8 inches (15 to 20 cm) and claim greater success.

Drug treatment

A number of drugs are registered for GERD treatment, and they are among the most-often-prescribed forms of medication in most Western countries. They can be used in combination with other drugs, although some antacids can interfere with the function of other drugs:

• Proton pump inhibitors (such as omeprazole, pantoprazole, lansoprazole, and rabeprazole) are the most effective in reducing gastric acid secretion. These drugs stop acid secretion at the source of acid production, i.e., the proton pump.
• Gastric H₂ receptor blockers (such as ranitidine, famotidine and cimetidine) can reduce gastric secretion of acid. These drugs are technically antihistamines. They relieve complaints in about 50% of all GERD patients. Compared to placebo (which also is associated with symptom improvement), they have a number needed to treat of eight (8).^[18]
• Antacids before meals or symptomatically after symptoms begin can reduce gastric acidity (increase pH).
• Alginic acid (Gaviscon) may coat the mucosa as well as increase pH and decrease reflux. A meta-analysis of randomized controlled trials suggests alginic acid may be the most effective of non-prescription treatments with a number needed to treat of 4.^[18]
• Prokinetics strengthen the lower esophageal sphincter (LES) and speed up gastric emptying. Cisapride, a member of this class, was withdrawn from the market for causing Long QT syndrome.
• Sucralfate (Carafate) is also useful as an adjunct in helping to heal and prevent esophageal damage caused by GERD, however it must be taken several times daily and at least two (2) hours apart from meals and medications.
• Mosapride citrate is a 5-HT4 receptor agonist used outside the United States largely as a therapy for GERD and dyspepsia.^[19]

Clinical trials which compare GERD treatments head-to-head provide physicians with critical information. Unfortunately most pharmaceutical-company sponsored studies are conducted versus placebo and not an active control. However, the DIAMOND has shown rough equivalence of efficacy between a "step-up" approach to therapy (antacids, followed by histamine antagonists, followed by PPIs) and a "step-down" approach (the reverse). The primary endpoint of the study was treatment success after 6 months, and was achieved for 70% of patients in "step-down" versus 72% of patients in "step-up".^[20]

Posture and GERD

In adults, a slouched posture is an important factor contributing to GERD. With a slouched posture there is no straight path between the stomach and esophagus; muscles around the esophagus go into a spasm. Gas and acidity get blocked in the spasm, causing coughing and other asthma-like symptoms.^{[citation needed]}

Surgical treatment

The standard surgical treatment, sometimes preferred over longtime use of medication, is the Nissen fundoplication. The upper part of the stomach is wrapped around the LES to strengthen the sphincter and prevent acid reflux and to repair a hiatal hernia. The procedure is often done laparoscopically.^[21]

An obsolete treatment is vagotomy ("highly selective vagotomy"), the surgical removal of vagus nerve branches that innervate the stomach lining. This treatment has been largely replaced by medication.

Another treatment is transoral incisionless fundoplication (TIF) with the use of a device called Esophyx, which allows doctors to rebuild the valve between the stomach and the diaphragm by going through the esophagus.^[22]

Other treatments

In 2000 the U.S. Food and Drug Administration (FDA) approved two endoscopic devices to treat chronic heartburn. One system, Endocinch, puts stitches in the LES to create little pleats that help strengthen the muscle. However, long-term results were disappointing, and the device is no longer sold by Bard. Another, the Stretta Procedure, uses electrodes to apply radio frequency energy to the LES. The long-term outcomes of both procedures compared to a Nissen fundoplication are still being determined.

Subsequently the NDO Surgical Plicator was cleared by the FDA for endoscopic GERD treatment. The Plicator creates a plication, or fold, of tissue near the gastroesophageal junction, and fixates the plication with a suture-based implant. The company ceased operations in mid 2008, and the device is no longer on the market.

Another treatment that involved injection of a solution during endoscopy into the lower esophageal wall was available for about one year ending in late 2005. It was marketed under the name Enteryx. It was removed from the market due to several reports of complications from misplaced injections.

Natural remedies

Contemporary popular natural remedies^[23] include aloe vera juice,^[24] apple cider vinegar, and marshmallow root tea, but there is no clinical data to support their effectiveness.

Barrett's esophagus

Main article: Barrett's Esophagus

GERD may lead to Barrett's esophagus, a type of metaplasia which is in turn a precursor condition for carcinoma. The risk of progression from Barrett's to dysplasia is uncertain but is estimated at about 20% of cases.^[25] Due to the risk of chronic heartburn progressing to Barrett's, EGD every 5 years is recommended for patients with chronic heartburn, or who take drugs for chronic GERD.^{[citation needed]}

References

1. ^ DeVault KR, Castell DO (1999). "Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. The Practice Parameters Committee of the American College of Gastroenterology". Am. J. Gastroenterol. 94 (6): 1434–42. doi:10.1111/j.1572-0241.1999.1123_a.x. PMID 10364004. 
2. ^ http://www.healingdaily.com/conditions/saliva-ph-test.htm
3. ^ ^{a b c} Kahrilas, PJ (2008). "Gastroesophageal Reflux Disease". New England Journal of Medicine. 359 (16): 1700–1707. doi:10.1056/NEJMcp0804684. http://content.nejm.org/cgi/content/short/359/16/1700. 
4. ^ [1]
5. ^ "Spitting Up in Babies". familydoctor.org. http://familydoctor.org/online/famdocen/home/children/parents/infants/218.html. 
6. ^ Diagnosis - Endoscopy. Retrieved on 2009-03-20.
7. ^ Jung B, Steinbach J, Beaumont C, Mittal RK (March 2004). "Lack of association between esophageal acid sensitivity detected by prolonged pH monitoring and Bernstein testing". Am. J. Gastroenterol. 99 (3): 410–5. doi:10.1111/j.1572-0241.2004.04089.x. PMID 15056077. http://dx.doi.org/10.1111/j.1572-0241.2004.04089.x. 
8. ^ ^{a b} Piesman M, Hwang I, Maydonovitch C, Wong RK (2007). "Nocturnal reflux episodes following the administration of a standardized meal. Does timing matter?". Am. J. Gastroenterol. 102 (10): 2128–2134. doi:10.1111/j.1572-0241.2007.01348.x. PMID 17573791. 
9. ^ Ayazi S, Crookes P, Peyre C, (2007). "Objective documentation of the link between gastroesophageal reflux disease and obesity". Am. J. Gastroenterol. 102 (S): 138–139. 
10. ^ Morse CA, Quan SF, Mays MZ, Green C, Stephen G, Fass R (2004). "Is there a relationship between obstructive sleep apnea and gastroesophageal reflux disease?". Clin. Gastroenterol. Hepatol. 2 (9): 761–8. doi:10.1016/S1542-3565(04)00347-7. PMID 15354276. 
11. ^ Kasasbeh A, Kasasbeh E, Krishnaswamy G (2007). "Potential mechanisms connecting asthma, esophageal reflux, and obesity/sleep apnea complex—a hypothetical review". Sleep Med Rev 11 (1): 47–58. doi:10.1016/j.smrv.2006.05.001. PMID 17198758. 
12. ^ H.J. O'Connor (Feb 1999). "Helicobacter pylori and gastro-oesophageal reflux disease-clinical implications and management". Aliment Pharmacol Ther 13 (2): 117-27. doi:10.1046/j.1365-2036.1999.00460.x. PMID 10102940. http://www.ncbi.nlm.nih.gov/pubmed/10102940. 
13. ^ El-Omar E, Oien K, Nujuni AE, et al. (1997). "Helicobacter pylori infection and chronic gastric acid hyposecretion". Gastroenterology 113: 15–24. PMID 9207257. http://www.ncbi.nlm.nih.gov/pubmed/9207257?dopt=Abstract. 
14. ^ C.A. Fallone, A.N. Barkun, S. Mayrand, G. Wakil, G. Friedman, A. Szilagyi, C. Wheeler & D. Ross (2004). "There is no difference in the disease severity of gastro-oesophageal reflux disease between patients infected and not infected with Helicobacter pylori". Aliment Pharmacol Ther 20 (7): 761-768. doi:10.1111/j.1365-2036.2004.02171.x. http://www3.interscience.wiley.com/cgi-bin/fulltext/118774431/HTMLSTART. 
15. ^ ^{a b} Kaltenbach T, Crockett S, Gerson LB (2006). "Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach". Arch. Intern. Med. 166 (9): 965–71. doi:10.1001/archinte.166.9.965. PMID 16682569. 
16. ^ Decktor DL, Robinson M, Maton PN, Lanza FL, Gottlieb S (1995). "Effects of Aluminum/Magnesium Hydroxide and Calcium Carbonate on Esophageal and Gastric pH in Subjects with Heartburn". Am J Ther 2 (8): 546–552. doi:10.1097/00045391-199508000-00006. PMID 11854825. 
17. ^ Khoury, RM; Camacho-Lobato L, Katz PO, Mohiuddin MA, Castell DO (1999). "Influence of spontaneous sleep positions on nighttime recumbent reflux in patients with gastroesophageal reflux disease". Am. J. Gastroenterol. 94 (8): 2069–73. doi:10.1111/j.1572-0241.1999.01279.x. PMID 10445529. 
18. ^ ^{a b} Tran T, Lowry A, El-Serag H (2007). "Meta-analysis: the efficacy of over-the-counter gastro-oesophageal reflux disease drugs". Aliment Pharmacol Ther 25 (2): 143–53. doi:10.1111/j.1365-2036.2006.03135.x. PMID 17229239. 
19. ^ "www.medscape.com". http://www.medscape.com/viewarticle/518324_4. 
20. ^ van Marrewjik et al. (2009). "Effect and cost-effectiveness of step-up versus step-down treatment with antacids, H2-receptor antagonists, and proton pump inhibitors in patients with new onset dyspepsia (DIAMOND study): a primary-care-based randomized controlled study". The Lancet 373: 215–25. doi:10.1016/S0140-6736(09)60070-2. 
21. ^ Abbas A, Deschamps C, Cassivi SD, et al. (2004). "The role of laparoscopic fundoplication in Barrett’s esophagus". Annals of Thoracic Surgery 77 (2): 393–396. doi:10.1016/S0003-4975(03)01352-3. PMID 14759403. 
22. ^ New Surgery For Acid Reflux Sufferers. Retrieved on 2009-01-16.
23. ^ Wong, Cathy. "Natural Remedies for Heartburn". http://altmedicine.about.com/od/therapiesfrometol/a/heartburn.htm. 
24. ^ Kane,Dr. Emily. "Aloe for acid reflux: you've seen aloe juice at the health food store, now learn how it helps heal acid reflux, also called heartburn". http://findarticles.com/p/articles/mi_m0FKA/is_4_69/ai_n18791510/. 
25. ^ Dysplasia and Barrett’s Esophagus. Retrieved on 2009-02-01.

External links

• GERD patient information page at NIH
• Overview of acid peptic disorders from the Cleveland Clinic.

v • d • e Digestive system · Digestive disease · Gastroenterology (primarily K20-K93, 530-579) Upper GI tract Esophagus Esophagitis (Candidal) · rupture (Boerhaave syndrome, Mallory-Weiss syndrome) · UES (Zenker's diverticulum) · LES (Barrett's esophagus) · Esophageal motility disorder (Nutcracker esophagus, Achalasia, Diffuse esophageal spasm, GERD) · Esophageal stricture · Megaesophagus Stomach Gastritis (Atrophic, Ménétrier's disease, Gastroenteritis) · Peptic (gastric) ulcer (Cushing ulcer, Dieulafoy's lesion) · Dyspepsia · Pyloric stenosis · Achlorhydria · Gastroparesis · Gastroptosis · Portal hypertensive gastropathy · Gastric antral vascular ectasia · Gastric dumping syndrome · Gastric volvulus Intestinal/ enteropathy Small intestine/ (duodenum/jejunum/ileum) Enteritis (Duodenitis, Jejunitis, Ileitis) — Peptic (duodenal) ulcer (Curling's ulcer) — Malabsorption: Coeliac · Tropical sprue · Blind loop syndrome · Whipple's · Short bowel syndrome · Steatorrhea · Milroy disease Large intestine (appendix/colon) Appendicitis · Colitis (Pseudomembranous, Ulcerative, Ischemic, Microscopic, Collagenous, Lymphocytic) · Functional colonic disease (IBS, Intestinal pseudoobstruction/Ogilvie syndrome) — Megacolon/Toxic megacolon · Diverticulitis/Diverticulosis Large and/or small Enterocolitis (Necrotizing) · IBD (Crohn's disease) — vascular: Abdominal angina · Mesenteric ischemia · Angiodysplasia — Bowel obstruction: Ileus · Intussusception · Volvulus · Fecal impaction — Constipation · Diarrhea (Infectious) Rectum Proctitis (Radiation proctitis) · Proctalgia fugax · Rectal prolapse Anus Anal fissure/Anal fistula · Anal abscess  · Anal dysplasia  · Pruritus ani Accessory Liver Hepatitis (Viral hepatitis, Autoimmune hepatitis, Alcoholic hepatitis) · Cirrhosis (PBC) · Fatty liver (NASH) · vascular (Hepatic veno-occlusive disease, Portal hypertension, Nutmeg liver) · Alcoholic liver disease · Liver failure (Hepatic encephalopathy, Acute liver failure) · Liver abscess (Pyogenic, Amoebic) · Hepatorenal syndrome · Peliosis hepatis Gallbladder Cholecystitis · Gallstones/Cholecystolithiasis · Cholesterolosis · Rokitansky-Aschoff sinuses · Postcholecystectomy syndrome Bile duct/ other biliary tree Cholangitis (PSC, Secondary sclerosing cholangitis, Ascending) · Cholestasis/Mirizzi's syndrome · Biliary fistula · Haemobilia · Gallstones/Cholelithiasis common bile duct (Choledocholithiasis, Biliary dyskinesia) Pancreatic Pancreatitis (Acute, Chronic, Hereditary) · Pancreatic pseudocyst · Exocrine pancreatic insufficiency · Pancreatic fistula Hernia Diaphragmatic: Congenital diaphragmatic · Hiatus — Abdominal hernia: Inguinal (Indirect, Direct) · Umbilical · Incisional · Femoral — Obturator hernia · Spigelian hernia · Internal hernia Peritoneal Peritonitis (Spontaneous bacterial peritonitis) · Hemoperitoneum · Pneumoperitoneum GI bleeding/BIS Upper (Hematemesis, Melena) · Lower (Hematochezia) See also: congenital and neoplasia

jp:逆流性食道炎

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