What is GERD

Gastroesophageal reflux disease (GERD) happens when a muscle at the end of your esophagus (lower esophageal sphincter) does not close properly (see Figures 2 and 3). This allows stomach contents (stomach acid) to leak back or reflux, into the esophagus and irritate the lining of your esophagus. Heartburn is a burning feeling in the chest caused by stomach acid travelling up towards the throat (acid reflux).

Many people experience acid reflux from time to time. GERD is mild acid reflux that occurs at least twice a week, or moderate to severe acid reflux that occurs at least once a week. GERD affects about 20 percent of the U.S. population ¹.

Most people can manage the discomfort of GERD with lifestyle changes and over-the-counter medications. But some people with GERD may need stronger medications or surgery to ease symptoms. You should see a doctor if you have persistent GER symptoms that do not get better with over-the-counter medications or change in your diet.

Doctors also refer to GERD as:

• acid indigestion
• acid reflux
• acid regurgitation
• heartburn
• reflux

Figure 1. Esophagus

Figure 2. Lower esophageal sphincter (LES)

Figure 3. lower esophageal sphincter (endoscopic view)

Heartburn during pregnancy

Heartburn symptoms are one of the most commonly reported complaints among pregnant women, being reported by 30% to 80% of pregnant women ². Heartburn usually starts during the first trimester and tends to worsen during the second and third trimesters. Although gestational GERD symptoms typically resolve with delivery, women may still experience reflux symptoms post-partum that require ongoing medical therapy.

Studies have shown elevated levels of the hormone progesterone accompanied by increased intra-abdominal pressures from the enlarging uterus, may lower esophageal sphincter (LES) pressure in pregnant women contributing to heartburn symptoms, according to research highlighted in the newly updated “Pregnancy in Gastrointestinal Disorders” monograph ³ by the American College of Gastroenterology ⁴. From the monograph, physician experts from the American College of Gastroenterology have compiled important health tips on managing heartburn symptoms, and importantly, identifying which heartburn medications are safe for use in pregnant women and those, which should be avoided.

Strategies to Ease Heartburn Symptoms during Pregnancy

According to the American College of Gastroenterology ⁴, pregnant women can treat and relieve their heartburn symptoms through lifestyle and dietary changes. The following tips can help reduce heartburn discomfort:

• Avoid eating late at night or before retiring to bed.
• Avoid eating foods that are common heartburn triggers like greasy or spicy food, chocolate, peppermint, tomato sauces, caffeine, carbonated drinks, and citrus fruits.
• Wear loose-fitting clothes. Clothes that fit tightly around your waist put pressure on your abdomen and the lower esophageal sphincter.
• Eat smaller meals. Overfilling the stomach can result in acid reflux and heartburn.
• Don’t lie down after eating. Wait at least 3 hours after eating before going to bed. When you lie down, it’s easier for stomach contents (including acid) to back up into the esophagus, particularly when you go to bed with a full stomach.
• Raise the head of the bed 4 to 6 inches. This can help reduce acid reflux by decreasing the amount of gastric contents that reach the lower esophagus.
• Avoid tobacco and alcohol. Abstinence from alcohol and smoking can help reduce reflux symptoms and avoid fetal exposure to potentially harmful substances.

The Do’s and Don’ts of Using Heartburn Drugs during Pregnancy

Pregnant women with mild reflux usually do well with simple lifestyle changes. If lifestyle and dietary changes are not enough, you should consult your doctor before taking any medication to relieve heartburn symptoms.

According to ACG President Amy E. Foxx-Orenstein, DO, FACG, “Heartburn medications to treat acid reflux during pregnancy should be balanced to alleviate the mother’s symptoms of heartburn, while protecting the developing fetus.” Based on a review of published scientific clinical studies (in animals and humans) on the safety of heartburn medications during pregnancy, researchers conclude there are certain drugs that are considered safe for use in pregnancy and those which should be avoided.

Antacids are one of the most common over-the-counter medications to treat heartburn. As with any drug, antacids should be used cautiously during pregnancy.

Antacids

• Antacids containing aluminum, calcium, or magnesium are considered safe and effective in treating the heartburn of pregnancy.
• Magnesium-containing antacids should be avoided during the last trimester of pregnancy because it could interfere with uterine contractions during labor.
• Avoid antacids containing sodium bicarbonate. Sodium bicarbonate could cause metabolic alkalosis and increase the potential of fluid overload in both the fetus and mother.

Histamine-type II (H-2) Receptor Antagonists

While limited data exists in humans on the safety of histamine-type II (H-2) receptor antagonists, ranitidine (Zantac®) is the only H-2 antagonist, which has been studied specifically during pregnancy.

In a double-blind, placebo controlled, triple crossover study, ranitidine (Zantac®) taken once or twice daily in pregnant heartburn patients not responding to antacids and lifestyle modification, was found to be more effective than placebo in reducing the symptoms of heartburn and acid regurgitation. No adverse effects on the fetus were reported ⁵

A study on the safety of cimetidine (Tagamet®) and ranitidine (Zantac®) suggests that pregnant women taking these drugs from the first trimester through their entire pregnancy have delivered normal babies ⁶

Proton Pump Inhibitors

Proton pump inhibitors should be reserved for pregnant patients with more severe heartburn symptoms and those not responding to antacids and lifestyle and dietary changes. Lansoprazole (Prevacid®) is the preferred proton pump inhibitor because of case reports of safety in pregnant women. Limited data exists about human safety during pregnancy with the newer proton pump inhibitors.

Table 1. GERD medication used in pregnancy

[Source ³]

Table 2. GERD medication used during lactation (breastfeeding)

Note: Antacids and sucralfate are not concentrated in breast milk and are therefore safe during lactation. All H2 receptor antagonists are excreted in human breast milk. In 1994, the American Academy of Pediatrics classified cimetidine as compatible with breastfeeding ⁷. Ranitidine and famotidine are also safe during breastfeeding, but nizatidine should be avoided based on adverse effects noted in the offsprings of lactating rats receiving this drug ². Little is known about proton pump inhibitor excretion in breast milk or infant safety in lactating women. Therefore these medications are not recommended if the mother is breastfeeding.

[Source ³]

Complications of GERD / heartburn

Over time, chronic inflammation in your esophagus can cause:

• Esophagitis. Esophagitis is inflammation in the esophagus. Adults who have chronic esophagitis over many years are more likely to develop precancerous changes in the esophagus.
• Narrowing of the esophagus (esophageal stricture). Damage to the lower esophagus from stomach acid causes scar tissue to form. The scar tissue narrows the food pathway, leading to problems with swallowing.
• An open sore in the esophagus (esophageal ulcer). Stomach acid can wear away tissue in the esophagus, causing an open sore to form. An esophageal ulcer can bleed, cause pain and make swallowing difficult.
• Precancerous changes to the esophagus (Barrett’s esophagus). Damage from acid can cause changes in the tissue lining the lower esophagus. These changes are associated with an increased risk of esophageal cancer. People with Barrett’s esophagus may develop a rare cancer called esophageal adenocarcinoma.

Other complications of GERD

With GERD you might breathe stomach acid into your lungs. The stomach acid can then irritate your throat and lungs, causing respiratory problems, such as

• Asthma —a long-lasting disease in your lungs that makes you extra sensitive to things that you’re allergic to
• Chest congestion, or extra fluid in your lungs
• A dry, long-lasting cough or a sore throat
• Hoarseness—the partial loss of your voice
• Laryngitis—the swelling of your voice box that can lead to a short-term loss of your voice
• Pneumonia—an infection in one or both of your lungs—that keeps coming back
• Wheezing—a high-pitched whistling sound when you breathe.

What causes GERD

Gastroesophageal reflux and GERD happen when your lower esophageal sphincter becomes weak or relaxes when it shouldn’t, causing stomach contents to rise up into the esophagus. The lower esophageal sphincter becomes weak or relaxes due to certain things, such as

• increased pressure on your abdomen from being overweight, obese, or pregnancy
• certain medicines, including
  • those that doctors use to treat asthma —a long-lasting disease in your lungs that makes you extra sensitive to things that you’re allergic to
  • calcium channel blockers—medicines that treat high blood pressure
  • antihistamines—medicines that treat allergy symptoms
  • painkillers
  • sedatives—medicines that help put you to sleep
  • antidepressants —medicines that treat depression
• smoking, or inhaling secondhand smoke

A hiatal hernia can also cause GERD. Hiatal hernia is a condition in which the opening in your diaphragm lets the upper part of the stomach move up into your chest, which lowers the pressure in the esophageal sphincter.

Risk factors for GERD

Conditions that can increase your risk of GERD include:

• Obesity
• Bulging of the top of the stomach up into the diaphragm (hiatal hernia)
• Pregnancy
• Connective tissue disorders, such as scleroderma
• Delayed stomach emptying

Factors that can aggravate acid reflux include:

• Smoking
• Eating large meals or eating late at night
• Eating certain foods (triggers) such as fatty or fried foods
• Drinking certain beverages, such as alcohol or coffee
• Taking certain medications, such as aspirin.

What does a heartburn or GERD feels like

If you have gastroesophageal reflux, you may taste food or stomach acid in the back of your mouth.

The most common symptom of gastroesophageal reflux disease (GERD) is regular heartburn, a painful, burning feeling in the middle of your chest (heartburn), behind your breastbone, and in the middle of your abdomen, usually after eating and might be worse at night. Not all adults with GERD have heartburn.

Common signs and symptoms of GERD include:

• Chest pain (after meals)
• Difficulty swallowing or painful swallowing
• Regurgitation of food or sour liquid
• Sensation of a lump in your throat
• Bad breath
• Nausea
• Respiratory problems
• Vomiting
• The wearing away of your teeth

If you have nighttime acid reflux, you might also experience:

• Chronic cough
• Laryngitis
• New or worsening asthma
• Disrupted sleep

Some symptoms of GERD come from its complications, including those that affect your lungs.

GERD Diagnosis

Your doctor might be able to diagnose GERD based on a physical examination and history of your signs and symptoms.

If your gastroesophageal reflux symptoms don’t improve, if they come back frequently, or if you have trouble swallowing, your doctor may recommend testing you for gastroesophageal reflux disease (GERD).

To confirm a diagnosis of GERD, or to check for complications, your doctor might recommend:

• Upper endoscopy. An intravenous (IV) needle will be placed in your arm to provide a sedative. Sedatives help you stay relaxed and comfortable during the procedure. In some cases, the procedure can be performed without sedation. You will be given a liquid anesthetic to gargle or spray anesthetic on the back of your throat. Your doctor carefully feeds the endoscope down your esophagus and into your stomach and duodenum. A small camera mounted on the endoscope sends a video image to a monitor, allowing close examination of the lining of your upper GI tract. The endoscope pumps air into your stomach and duodenum, making them easier to see. Test results can often be normal when reflux is present, but an endoscopy may detect inflammation of the esophagus (esophagitis) or other complications. An endoscopy can also be used to collect a sample of tissue (biopsy) to be tested for complications such as Barrett’s esophagus.
• Ambulatory acid (pH) probe test. The most accurate procedure to detect acid reflux is esophageal pH and impedance monitoring. Esophageal pH and impedance monitoring measures the amount of acid in your esophagus while you do normal things, such as eating and sleeping.A gastroenterologist performs this procedure at a hospital or an outpatient center as a part of an upper GI endoscopy. Most often, you can stay awake during the procedure.A gastroenterologist will pass a thin tube through your nose or mouth into your stomach. The gastroenterologist will then pull the tube back into your esophagus and tape it to your cheek. The end of the tube in your esophagus measures when and how much acid comes up your esophagus. The other end of the tube attaches to a monitor outside your body that records the measurements.You will wear a monitor for the next 24 hours. You will return to the hospital or outpatient center to have the tube removed.This procedure is most useful to your doctor if you keep a diary of when, what, and how much food you eat and your GERD symptoms are after you eat. The gastroenterologist can see how your symptoms, certain foods, and certain times of day relate to one another. The procedure can also help show whether acid reflux triggers any respiratory symptoms.
• Bravo wireless esophageal pH monitoring. Bravo wireless esophageal pH monitoring also measures and records the pH in your esophagus to determine if you have GERD. A doctor temporarily attaches a small capsule to the wall of your esophagus during an upper endoscopy. The capsule measures pH levels in the esophagus and transmits information to a receiver. The receiver is about the size of a pager, which you wear on your belt or waistband.You will follow your usual daily routine during monitoring, which usually lasts 48 hours. The receiver has several buttons on it that you will press to record symptoms of GERD such as heartburn. The nurse will tell you what symptoms to record. You will be asked to maintain a diary to record certain events such as when you start and stop eating and drinking, when you lie down, and when you get back up.To prepare for the test talk to your doctor about medicines you are taking. He or she will tell you whether you can eat or drink before the procedure. After about seven to ten days the capsule will fall off the esophageal lining and pass through your digestive tract.
• Esophageal manometry. Esophageal manometry measures muscle contractions in your esophagus. A gastroenterologist may order this procedure if you’re thinking about anti-reflux surgery.The gastroenterologist can perform this procedure during an office visit. A health care professional will spray a liquid anesthetic on the back of your throat or ask you to gargle a liquid anesthetic.The gastroenterologist passes a soft, thin tube through your nose and into your stomach. You swallow as the gastroenterologist pulls the tube slowly back into your esophagus. A computer measures and records the pressure of muscle contractions in different parts of your esophagus.The procedure can show if your symptoms are due to a weak sphincter muscle. A doctor can also use the procedure to diagnose other esophagus problems that might have symptoms similar to heartburn. A health care professional will give you instructions about eating, drinking, and taking your medicines after the procedure.
• X-ray of your upper digestive system (upper GI series). During the procedure, you will stand or sit in front of an x-ray machine and drink barium to coat the inner lining of your upper GI tract. The x-ray technician takes several x-rays as the barium moves through your GI tract. The upper GI series can’t show GERD in your esophagus; rather, the barium shows up on the x-ray and can find problems related to GERD, such as:
  • hiatal hernias
  • esophageal strictures
  • ulcers

You may have bloating and nausea for a short time after the procedure. For several days afterward, you may have white or light-colored stools from the barium. A health care professional will give you instructions about eating, drinking, and taking your medicines after the procedure.

How to get rid of heartburn

GERD treatment

Your doctor is likely to recommend that you first try lifestyle modifications and over-the-counter medications. If you don’t experience relief within a few weeks, your doctor might recommend prescription medication or surgery.

Heartburn medicine over-the-counter

The options include:

• Antacids that neutralize stomach acid. Antacids, such as Mylanta, Rolaids and Tums, may provide quick relief. But antacids alone won’t heal an inflamed esophagus damaged by stomach acid. Overuse of some antacids can cause side effects, such as diarrhea or sometimes kidney problems.
• Medications to reduce acid production. These medications — known as H-2-receptor blockers — include cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR) and ranitidine (Zantac). H-2-receptor blockers don’t act as quickly as antacids, but they provide longer relief and may decrease acid production from the stomach for up to 12 hours. Stronger versions are available by prescription.
• Medications that block acid production and heal the esophagus. These medications — known as proton pump inhibitors — are stronger acid blockers than H-2-receptor blockers and allow time for damaged esophageal tissue to heal. Over-the-counter proton pump inhibitors include lansoprazole (Prevacid 24 HR) and omeprazole (Prilosec OTC, Zegerid OTC).

Heartburn medicine prescription

Prescription-strength treatments for GERD include:

• Prescription-strength H-2-receptor blockers. These include prescription-strength famotidine (Pepcid), nizatidine and ranitidine (Zantac). These medications are generally well-tolerated but long-term use may be associated with a slight increase in risk of vitamin B-12 deficiency and bone fractures.
• Prescription-strength proton pump inhibitors. These include esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec, Zegerid), pantoprazole (Protonix), rabeprazole (Aciphex) and dexlansoprazole (Dexilant). Although generally well-tolerated, these medications might cause diarrhea, headache, nausea and vitamin B-12 deficiency. Chronic use might increase the risk of hip fracture.
• Medication to strengthen the lower esophageal sphincter. Baclofen may ease GERD by decreasing the frequency of relaxations of the lower esophageal sphincter. Side effects might include fatigue or nausea.
• Prokinetics. Prokinetics help your stomach empty faster. Prokinetics can cause problems if you mix them with other medicines, so tell your doctor about all the medicines you’re taking. Prescription prokinetics include:
  • bethanechol (Urecholine)
  • metoclopramide (Reglan)
  • Both of these medicines have side effects, including:
    • nausea
    • diarrhea
    • fatigue, or feeling tired
    • depression
    • anxiety
    • delayed or abnormal physical movement
• Antibiotics. Antibiotics, including erythromycin, can help your stomach empty faster. Erythromycin has fewer side effects than prokinetics; however, it can cause diarrhea.

Surgery and other procedures

GERD can usually be controlled with medication. But if medications don’t help or you wish to avoid long-term medication use, your doctor might recommend:

• Fundoplication. Fundoplication is the most common surgery for GERD. In most cases, it leads to long-term reflux control. The surgeon wraps the top of your stomach around the lower esophageal sphincter, to tighten the muscle and prevent reflux. Fundoplication is usually done with a minimally invasive (laparoscopic) procedure. The wrapping of the top part of the stomach can be partial or complete. A surgeon performs fundoplication using a laparoscope, a thin tube with a tiny video camera. The surgeon performs the operation at a hospital. You receive general anesthesia and can leave the hospital in 1 to 3 days. Most people return to their usual daily activities in 2 to 3 weeks.
• LINX device. A ring of tiny magnetic beads is wrapped around the junction of the stomach and esophagus. The magnetic attraction between the beads is strong enough to keep the junction closed to refluxing acid, but weak enough to allow food to pass through. The Linx device can be implanted using minimally invasive surgery.

Figure 4. GERD surgery – Nissen fundoplication

Note: Surgery for GERD may involve a procedure to reinforce the lower esophageal sphincter called Nissen fundoplication. In this procedure, the surgeon wraps the top of the stomach around the lower esophagus. This reinforces the lower esophageal sphincter, making it less likely that acid will back up in the esophagus.

Home remedies for heartburn

Lifestyle changes may help reduce the frequency of acid reflux. Try to:

• Maintain a healthy weight. Excess pounds put pressure on your abdomen, pushing up your stomach and causing acid to reflux into your esophagus.
• Stop smoking. Smoking decreases the lower esophageal sphincter’s ability to function properly.
• Elevate the head of your bed. If you regularly experience heartburn while trying to sleep, place wood or cement blocks under the feet of your bed so that the head end is raised by 6 to 9 inches. If you can’t elevate your bed, you can insert a wedge between your mattress and box spring to elevate your body from the waist up. Raising your head with additional pillows isn’t effective.
• Don’t lie down after a meal. Wait at least three hours after eating before lying down or going to bed.
• Eat food slowly and chew thoroughly. Put down your fork after every bite and pick it up again once you have chewed and swallowed that bite.
• Avoid foods and drinks that trigger reflux. Common triggers include fatty or fried foods, tomato sauce, alcohol, chocolate, mint, garlic, onion, and caffeine.
• Avoid tight-fitting clothing. Clothes that fit tightly around your waist put pressure on your abdomen and the lower esophageal sphincter.

Alternative medicine

No alternative medicine therapies have been proved to treat GERD or reverse damage to the esophagus. Some complementary and alternative therapies may provide some relief, when combined with your doctor’s care.

Talk to your doctor about what alternative GERD treatments may be safe for you. The options might include:

• Herbal remedies. Licorice and chamomile are sometimes used to ease GERD. Herbal remedies can have serious side effects and might interfere with medications. Ask your doctor about a safe dosage before beginning any herbal remedy.
• Relaxation therapies. Techniques to calm stress and anxiety may reduce signs and symptoms of GERD. Ask your doctor about relaxation techniques, such as progressive muscle relaxation or guided imagery.

GERD diet

You can prevent or relieve your symptoms from gastroesophageal reflux or gastroesophageal reflux disease (GERD) by changing your diet. You may need to avoid certain foods and drinks that make your symptoms worse. Other dietary changes that can help reduce your symptoms include:

• decreasing fatty foods
• eating small, frequent meals instead of three large meals

What should I avoid eating if I have gastroesophageal reflux or gastroesophageal reflux disease (GERD)?

Avoid eating or drinking the following items that may make gastroesophageal reflux or GERD worse:

• chocolate
• coffee
• peppermint
• greasy or spicy foods
• tomatoes and tomato products
• alcoholic drinks

What can I eat if I have gastroesophageal reflux or gastroesophageal reflux disease (GERD)?

Eating healthy and balanced amounts of different types of foods is good for your overall health.

If you’re overweight or obese, talk with your doctor or a dietitian about dietary changes that can help you lose weight and decrease your GERD symptoms.

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