What is GERD

Gastroesophageal reflux disease also called GERD, gastro-oesophageal reflux disease (GORD), acid reflux or heartburn, is a condition that develops when there is a backward flow or reflux of stomach contents (acid from the food and liquid in your stomach) back up into your throat and esophagus causing troublesome symptoms and/or complications ¹, ², ³, ⁴, ⁵. Gastroesophageal reflux disease can present as non-erosive reflux disease or erosive esophagitis. It can occur at any age, even in babies. Many times, you or your doctor can determine the triggers for your reflux. GERD can seriously damage your esophagus or lead to precancerous changes in the esophagus called Barrett’s esophagus.

The main symptoms of gastroesophageal reflux disease (GERD) are:

• Heartburn – a burning sensation in the middle of your chest, usually after eating, which might be worse after eating, when lying down or when bending over.
• An unpleasant sour taste in your mouth, caused by stomach acid

You may also have:

• Cough or hiccups that keep coming back
• Hoarse voice
• Bad breath
• Bloating and feeling sick

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

• An ongoing cough
• Inflammation of the vocal cords (laryngitis)
• New or worsening asthma

Gastroesophageal reflux disease is caused by a weakened muscle at the end of your esophagus where it connects to your stomach called the lower esophageal sphincter (LES). The lower esophageal sphincter (LES) muscle doesn’t close properly, which allows acid to back up into your throat. Typically, when food is swallowed, the lower esophageal sphincter (a band of muscle around the bottom of the esophagus) relaxes to allow food and liquid to flow down into the stomach. Then the muscle tightens again. If the lower esophageal sphincter isn’t working as it should, stomach acid can flow back up into the esophagus (acid reflux) and cause heartburn. The acid backup may be worse when you’re bent over or lying down.

Sometimes gastroesophageal reflux disease is caused or made worse by:

• certain food and drink – such as coffee, tomatoes, alcohol, chocolate and fatty or spicy foods
• being overweight
• smoking
• pregnancy
• stress and anxiety
• an increase in some types of hormones, such as progesterone and estrogen
• taking certain medicines such as anti-inflammatory painkillers like ibuprofen
• a hiatus hernia – when part of your stomach moves up into your chest
• a stomach ulcer
• a bacterial infection in your stomach

In the United States, 20% of the population experience gastroesophageal reflux disease-related symptoms weekly and 7% daily ⁶, ⁷. The prevalence of gastroesophageal reflux disease is slightly higher in men compared to women ⁸. Several studies have demonstrated that patients with gastroesophageal reflux disease (GERD) have reduced health-related quality of life and work productivity ⁹.

The danger of untreated gastroesophageal reflux disease (GERD) is that it can cause health problems such as inflammation of the esophagus (esophagitis), which is a risk factor for esophageal cancer. Gastroesophageal reflux disease (GERD) also may lead to breathing problems such as asthma, fluid in the lungs, chest congestion, as well as damaging teeth.

Not everyone who has an episode of acid reflux has gastroesophageal reflux disease (GERD). Your doctor may have you undergo testing to see if you have gastroesophageal reflux disease (GERD). Such tests could include:

• Ambulatory acid (pH) probe test: This test measures the acid in your stomach for 24 hours. Your doctor will insert a small, thin tube into your nose and down into your throat. The tube is connected to a small computer you strap around your waist. Another version of this involves a small probe placed in your throat. The probe transmits a signal for a period of time. After 2 days, the probe falls off and is passed in your stool.
• X-ray of the upper digestive system: The X-ray will look at the inside your upper digestive system (throat, stomach, and upper intestine). For this test, you will you be given a chalky liquid to swallow. This liquid coats your digestive tract to provide better views of the inside.
• Endoscopy or gastroscopy: This is where a thin tube with a camera inside it is passed down your throat and into your stomach. This allows your doctor to look inside your upper digestive tract. He or she may also take a sample of the tissue inside your tract for further testing, for example, tests to check for bacteria that can cause heartburn
• Esophageal motility test (manometry): This test measures the movement and pressure of your esophagus. It involves inserting small, thin tube through your nose and down your throat.

Based on endoscopic and histopathologic appearance, gastroesophageal reflux disease (GERD) is classified into three different types ¹⁰:

1. Non-erosive reflux disease (NERD). Non-erosive reflux disease (NERD) is a subcategory of gastroesophageal reflux disease (GERD). It is characterized by troublesome reflux symptoms with abnormally increased gastroesophageal reflux observed on 24-hour ambulatory pH-impedance monitoring in the absence of esophageal mucosal injury confirmed on endoscopy.
   
2. Erosive esophagitis. Erosive esophagitis is characterized by erosions or ulcers of the esophageal mucosa ¹¹. Patients may be asymptomatic or can present with worsening symptoms of gastroesophageal reflux disease (GERD). The degree of esophagitis is endoscopically graded using the Los Angeles esophagitis classification system, which employs the A, B, C, D grading system based on variables that include length, location, and circumferential severity of mucosal breaks in the esophagus ¹².
   
3. Barrett’s esophagus. Barrett’s esophagus occurs as a result of chronic pathological acid exposure to the distal esophageal mucosa. It leads to a histopathological change of the distal esophageal mucosa, which is normally lined by stratified squamous epithelium to metaplastic columnar epithelium. Barrett’s esophagus is more commonly seen in Caucasian males above 50 years, obesity, and history of smoking and predisposes to the development of esophageal adenocarcinoma ¹¹. Current guidelines recommend the performance of periodic surveillance endoscopy in patients with a diagnosis of Barrett’s esophagus ¹³.

Non-erosive reflux disease (NERD) is the most prevalent type seen in 60-70% of patients followed by erosive esophagitis and Barrett’s esophagus seen in 30% and 6-12% of patients with gastroesophageal reflux disease (GERD), respectively ¹⁰, ⁹, ¹⁴.

If you have acid reflux, your doctor may prescribe a medicine called a proton pump inhibitor (PPI) or H-2 receptor blockers (Histamine-2 Receptor Antagonists) that reduces how much acid your stomach makes. You’ll usually need to take this type of medicine for 4 or 8 weeks, depending on how serious your acid reflux is.

Go back to your doctor if your symptoms return after stopping your medicine. You may need a long-term prescription.

In some cases, surgery may be required to treat acid reflux. This is when medicine doesn’t help, or if you want a long-term solution. Types of surgery may include:

• Nissen fundoplication: This surgery reinforces the lower muscle in the esophagus. A surgeon will wrap the very top of the stomach around the outside of the lower esophagus. This reduces reflux by putting pressure on your esophagus. This is a laparoscopic surgery. This means the surgeon makes three or four small cuts in the abdomen (stomach region). He or she will insert instruments, including a flexible tube with a tiny camera, through the cuts.
• Linx surgery: This surgery strengthens the muscle in the esophagus. The Linx device is a ring of tiny beads made of titanium. The surgery wraps the ring around the area between the stomach and esophagus. The magnetic attraction of the beads keeps the opening between the two closed. This helps keep acid from backing up into your throat. However, it’s weak enough to allow food to pass. The surgery is minimally invasive.
• Transoral incisionless fundoplication (TIF). This new procedure involves tightening the lower esophageal sphincter by creating a partial wrap around the lower esophagus using polypropylene fasteners. Transoral incisionless fundoplication (TIF) is performed through the mouth by using an endoscope and requires no surgical incision. Its advantages include quick recovery time and high tolerance. If you have a large hiatal hernia, transoral incisionless fundoplication (TIF) alone is not an option. However, transoral incisionless fundoplication (TIF) may be possible if it is combined with laparoscopic hiatal hernia repair.

The Esophagus

Esophagus is a hollow muscular tube that carries food from your throat (pharynx) to your stomach. The esophagus  lies behind the trachea (windpipe) and in front of the spine. In adults, the esophagus is usually between 10 and 13 inches (25 to 33 centimeters [cm]) long and is about ¾ of an inch (2cm) across at its smallest point ¹⁵. The esophagus starts with a special ring of muscle called the upper esophageal sphincter, formed in part by the cricopharyngeus muscle, and ends with the lower esophageal sphincter, surrounded by the crural diaphragm ¹⁶. When food enters your mouth, it mixes with saliva. The actions of salivary enzymes convert food into a mass called a food bolus. Once the food bolus reaches your throat (pharynx), swallowing starts, and relaxation of the upper esophageal sphincter ensues to allow passage of the food bolus into the esophagus ¹⁶. When you swallow, food and liquids travel through the inside of your esophagus called the lumen aided by peristaltic contractions of the esophageal muscles to reach your stomach. The lower part of your esophagus that connects to your stomach is called the gastroesophageal (GE) junction. A special ring of muscle near the gastroesophageal junction, called the lower esophageal sphincter (LES), controls the movement of food from the esophagus into the stomach. Between meals, it closes to keep the stomach’s acid and digestive juices out of the esophagus. When the food bolus finally reaches the distal end of the esophageal body, it triggers relaxation of the lower esophageal sphincter (LES), which in turn permits entry of the food bolus into your stomach.

Figure 1. Esophagus

Figure 2. Lower esophageal sphincter (LES)

Figure 3. lower esophageal sphincter (endoscopic view)

Figure 4. Gastroesophageal reflux disease (GERD)

Figure 5. Gastroesophageal reflux disease diagnostic algorithm

[Source ¹⁷ ]

What’s the best thing to do if you have chest pain and you’re not sure what’s causing it?

If you have persistent chest pain and you aren’t sure it’s heartburn, call your local emergency services number for emergency medical help.

See your doctor if you had an episode of unexplained chest pain that went away within a few hours and you did not seek medical attention. Both heartburn and a developing heart attack can cause symptoms that subside after a while. The pain doesn’t have to last a long time to be a warning sign.

Is acid reflux, GERD and heartburn the same?

These terms are often used interchangeably, but they actually have very different meanings. GERD (gastroesophageal reflux disease) is the disease or diagnosis defined as regular symptoms caused by the flow of gastric contents into the esophagus. Heartburn is one of the symptoms of GERD. Acid reflux is the reason why patients have GERD. There is actually reflux that can be non-acidic that can be seen in GERD as well.

What can make my heartburn worse?

Many things can make heartburn worse. Heartburn is most common after overeating, when bending over or when lying down. Pregnancy, stress, and certain foods can also make heartburn worse.

Things that can make heartburn worse:

• Cigarette smoking
• Certain drinks, including coffee (both regular and decaffeinated), other drinks that contain caffeine, alcohol, and carbonated drinks
• Citrus fruits
• Tomato products
• Chocolate, mints, or peppermints
• Fatty foods or spicy foods (such as pizza, chili, and curry)
• Lying down too soon after eating
• Being overweight or obese
• Certain medicines (such as sedatives and some medicines for high blood pressure)

What food to avoid if you have GERD?

Some people who have GERD find that certain foods or drinks trigger symptoms or make symptoms worse. Avoid eating or drinking the following foods that may make acid reflux or GERD worse ¹⁸:

• acidic foods, such as citrus fruits, tomatoes and tomato products
• chocolate
• coffee and other sources of caffeine
• peppermint
• high-fat foods
• spicy foods
• alcoholic drinks
• mint

Talk with your doctor about your diet and foods or drinks that seem to increase your symptoms. Your doctor may recommend reducing or avoiding certain foods or drinks to see if GERD symptoms improve.

What can I eat if I have 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.

Stock your kitchen with foods from these foods that help prevent acid reflux:

High-fiber foods

High-fiber foods make you feel full so you’re less likely to overeat, which may contribute to heartburn. So, load up on healthy fiber from these foods:

• Whole grains such as oatmeal, couscous and brown rice.
• Root vegetables such as sweet potatoes, carrots and beets.
• Green vegetables such as asparagus, broccoli and green beans.

Alkaline foods

Foods fall somewhere along the pH scale (an indicator of acid levels). Those that have a low pH are acidic and more likely to cause reflux. Those with higher pH are alkaline and can help offset strong stomach acid.

Alkaline foods include:

• Bananas
• Melons
• Cauliflower
• Fennel
• Nuts
• Ginger is one of the best digestive aids because of its medicinal properties. It’s alkaline in nature and anti-inflammatory, which eases irritation in the digestive tract. Try sipping ginger tea when you feel heartburn coming on.

Watery foods

Eating foods that contain a lot of water can dilute and weaken stomach acid. Choose foods such as:

• Celery
• Cucumber
• Lettuce
• Watermelon
• Broth-based soups
• Herbal tea

Heartburn during pregnancy

Heartburn or acid reflux is one of the most commonly reported complaints among pregnant women, being reported by 30% to 80% of pregnant women ¹⁹, ²⁰, ²¹. Heartburn can occur in all trimesters of pregnancy and occurs in approximately two-thirds of all pregnancies reaching 80% in some populations ²², ²³, ²⁴, ²⁵, ²², ²⁰. Most women begin their symptoms late in the first trimester or in the second trimester and these symptoms become more frequent and severe in the final months of pregnancy ²⁶, ²¹. The symptoms of heartburn in pregnancy may be frequent, severe and distressing, but serious complications are rare, symptoms are generally limited to the pregnancy period without long-term effects ²⁶, ²⁷. Gestational acid reflux symptoms typically resolve with delivery, women may still experience reflux symptoms post-partum that require ongoing medical therapy.

Pregnancy hormone called estrogen and progesterone appear to weaken the lower esophageal sphincter (LES) muscle and 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 ²⁸ by the American College of Gastroenterology ²⁹. You’re more likely to get heartburn during pregnancy if you’ve had a baby before or if you get heartburn when you’re not pregnant ²¹. Generally, if there has not been too much weight gain during the pregnancy, a woman’s heartburn improves after delivery.

The diagnosis of heartburn is based on clinical history. Upper endoscopy and other diagnostic tests are infrequently performed ³⁰, ²¹, ³¹.

What might help for acid reflux during pregnancy:

• Eat several small meals instead of three large meals — eat slowly.
• Drink fluids between meals — not with meals.
• Don’t eat greasy and fried foods.
• Avoid citrus fruits or juices and spicy foods.
• Do not eat or drink within a few hours of bedtime.
• Do not lie down right after meals.

See your doctor if symptoms don’t improve after trying these suggestions. Ask your doctor about using an antacid.

If your heartburn doesn’t improve by changing how you eat, your doctor may suggest that you take medicine for it. Antacids are the first type of medicine to try. They can relieve your symptoms quickly. Antacids are safe in pregnancy as long as you don’t take more than the recommended dose. There are many different types — talk to your pharmacist to find one that’s most suitable for you.

If antacids don’t control your symptoms, speak to your doctor about other medicines you can take.

Figure 6. Acid reflux during pregnancy treatment algorithm

Footnote: Step-up approach towards management of gastroesophageal reflux disease (GERD) during pregnancy.

Abbreviations: GERD = gastroesophageal reflux disease, H2RA = histamine-2 receptor antagonist, PPI = proton pump inhibitor.

[Source ¹⁹ ]

Can acid reflux during pregnancy hurt my baby?

Acid reflux during pregnancy usually won’t cause any problems for your baby, but it’s uncomfortable for you.

A healthy diet is important for both your and your baby’s health. If heartburn is making it hard to eat healthy food, it’s best to treat it.

Heartburn during pregnancy causes

The cause of heartburn during pregnancy is multifactorial, involving both hormonal and mechanical factors. Pregnancy hormones called estrogen and progesterone, can relax the the lower esophageal sphincter (LES) muscle that usually holds your esophagus closed where it meets your stomach ²⁰, ³², ³³. The lowest lower esophageal sphincter pressure occurs at 36 weeks gestation ³³. This allows food and acid from your stomach to go back up your esophagus. Pregnancy hormones also slow down the muscles of your digestive tract. So food tends to move more slowly and digestion is sluggish. This causes many pregnant women to feel bloated.

Other factors that may also play a part in heartburn during pregnancy are increased intragastric pressure secondary to the enlarging uterus and changes in gastrointestinal motility through ineffective esophageal motility, with prolonged clearance time ²⁰, ³⁴.

Abnormal gastric emptying or delayed small bowel transit might also contribute to heartburn in pregnancy ²¹.

Heartburn becomes more common as your pregnancy progresses. This can happen when your uterus (womb) pushes up against your stomach as your baby grows. This also pushes the contents of your stomach up into your esophagus.

Risk factors for heartburn in pregnancy include advancing gestational age, heartburn symptom before getting pregnant and women who have previously had one or more babies ²¹.

Heartburn can also be triggered by what you eat and drink, such as:

• a big meal
• high-fat foods
• spicy foods
• chocolate
• citrus fruit juices
• drinks containing caffeine, including coffee, tea and cola
• alcohol (which is not recommended in pregnancy)

Other things that may trigger heartburn include:

• doing exercise soon after eating
• lying down after eating
• feeling anxious

Because mothers are different, it’s a good idea to take note of the particular foods, drinks or activities that give you heartburn while you are pregnant.

Heartburn during pregnancy prevention

If your symptoms are mild, changing how you eat may help prevent heartburn. You could try:

• eating smaller meals more often and eating slowly
• avoiding eating for 2 or 3 hours before exercise or going to bed
• avoiding foods and drinks that give you heartburn
• avoiding eating and drinking at the same time, which can make your stomach more full
• sitting up straight while eating and not lying down after a meal
• raising the head of your bed or sleeping on at least 2 pillows
• sleeping on your left side

You might find it helpful to chew gum, which makes you produce more saliva to help neutralize the acid from your stomach. Drinking milk can also help neutralize acid.

Heartburn during pregnancy treatment

If your heartburn doesn’t improve by changing how you eat, your doctor may suggest that you take medicine for it. Antacids are the first type of medicine to try. They can relieve your symptoms quickly. Antacids are safe in pregnancy as long as you don’t take more than the recommended dose. There are many different types — talk to your pharmacist to find one that’s most suitable for you.

If antacids don’t control your symptoms, speak to your doctor about other medicines you can take.

The common drugs used for the treatment of heartburn in pregnancy include antacids, sucralfate, H2 receptor blockers (histamine-2 receptor antagonists), prokinetic drugs (drugs that stimulate the muscles of the gastrointestinal tract to prevent acids from staying in the stomach too long), proton pump inhibitors (PPIs), and alginate-based reflux suppressants such as Liquid Gaviscon and Gaviscon Advance ³⁵, ³⁶, ²¹. Traditional Chinese Medicine such as acupuncture has been used in treatment of heartburn in pregnancy in one study ³⁷. There are insufficient data to assess acupuncture versus no treatment ³⁸. More research is needed on acupuncture and other complimentary therapies as treatments for heartburn in pregnancy ³⁸.

Table 1. GERD medication used in pregnancy

[Source ²⁸]

Table 2. GERD medication used during lactation (breastfeeding)

Footnotes: 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 ³⁹. 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 ⁴⁰. 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 ²⁸]

Strategies to Ease Heartburn Symptoms during Pregnancy

According to the American College of Gastroenterology ²⁹, 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. 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 ⁴¹

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 ⁴²

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.

What causes GERD?

Currently, there is no known cause to explain the development of gastroesophageal reflux disease ⁵. Over the years, several risk factors have been identified and implicated in the pathogenesis of gastroesophageal reflux disease ⁴³. Gastroesophageal reflux disease is caused by frequent acid reflux or reflux of nonacidic content from the stomach. When you swallow, a circular band of muscle around the bottom of your esophagus called the lower esophageal sphincter relaxes to allow food and liquid to flow into your stomach. Then the sphincter closes again. If the lower esophageal sphincter does not relax as it should or it weakens, stomach acid can flow back into your esophagus. This constant backwash of acid irritates the lining of your esophagus, often causing it to become inflamed.

A meta-analysis by Hampel H et al. ⁴⁴ concluded that obesity was associated with an increased risk of developing gastroesophageal reflux disease (GERD) symptoms, erosive esophagitis, and esophageal cancer. The study by Malfertheiner et al. ⁴⁵ evaluated the predictive factors for erosive reflux disease in more than 6000 patients with GERD and noted that the odds ratio for the erosive disease increased with the body mass index (BMI). Several other risk factors have been independently associated with the development of GERD symptoms that include age ≥50 years, low socioeconomic status, tobacco use, consumption of excess alcohol, connective tissue disorders, pregnancy, postprandial supination, and different classes of drugs which include anticholinergic drugs, benzodiazepines, NSAID or aspirin use, nitroglycerin, albuterol, calcium channel blockers, antidepressants, and glucagon ⁴⁶, ⁴⁷, ⁴.

Risk factors for GERD

The following factors can lead to the onset of gastroesophageal reflux disease or aggravate acid reflux:

• Certain diseases, such as Zollinger-Ellison syndrome or scleroderma.
• Increased abdominal pressure due to obesity or pregnancy.
• Increased production of gastrin, a hormone that regulates the release of stomach acid.
• Hiatal hernia, a condition where the upper part of the stomach moves up into the chest through an opening in the diaphragm. This condition lowers the pressure in the esophageal sphincter.
• Certain medications, including asthma medicine, calcium channel blockers, antihistamines, painkillers, sedatives, and antidepressants.
• Certain foods and beverages, such as fried, spicy, or fatty foods, chocolate, peppermint, coffee, or alcoholic beverages.
• Smoking or inhaling second-hand smoke.
• 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, ibuprofen and naproxen.

Gastroesophageal reflux disease prevention

There are ways to prevent gastroesophageal reflux disease and acid reflux. To start, you need to know your body and how it reacts to different food and drinks. Spicy and acidic foods and carbonated drinks can trigger acid reflux. Try to avoid those things when possible. Eat smaller meals throughout the day, and don’t eat too late at night. Don’t lie down too soon after eating. Limit the use of alcohol. If you use tobacco, try to quit. Stress and lack of sleep also can worsen symptoms.

There are many dietary and lifestyle changes you can make to reduce or eliminate acid reflux, including:

• Not drinking alcohol
• Not smoking
• Avoid these foods and drinks that are commonly known to be heartburn triggers
  • Fried foods
  • Fast foods
  • Pizzas
  • Potato chips and other processed snacks
  • Chili powder and pepper (white, black, cayenne)
  • Fatty meats such as bacon and sausage
  • Cheese
  • Alcohol
  • Carbonated beverages
  • Caffeine
  • Acidic foods
  • Peppermints
• Not eating too close to bedtime
• Losing weight
• Not wearing tight clothing
• Eating smaller meals or avoiding overeating

Foods that help prevent acid reflux

Ginger is one of the best digestive aids because of its medicinal properties. Ginger is alkaline in nature and anti-inflammatory, which eases irritation in the digestive tract. Try sipping ginger tea when you feel heartburn coming on.

High-fiber foods

Fibrous foods make you feel full so you’re less likely to overeat, which may contribute to heartburn. So, load up on healthy fiber from these foods:

• Whole grains such as oatmeal, couscous and brown rice.
• Root vegetables such as sweet potatoes, carrots and beets.
• Green vegetables such as asparagus, broccoli and green beans.

Alkaline foods

Foods that have a low pH are acidic and more likely to cause reflux. Those with higher pH are alkaline and can help offset strong stomach acid. Alkaline foods include:

• Bananas
• Melons
• Cauliflower
• Fennel
• Nuts

Watery foods

Eating foods that contain a lot of water can dilute and weaken stomach acid. Choose foods such as:

• Celery
• Cucumber
• Lettuce
• Watermelon
• Broth-based soups
• Herbal tea

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 main symptom of gastroesophageal reflux disease (GERD) is heartburn, often described as a burning feeling in the back of your throat, in the middle of your chest, or behind the sternum (breastbone), and regurgitating sour or bitter liquid to the throat or mouth ⁵, ¹¹. The combination of heartburn and regurgitation is such a common characteristic of gastroesophageal reflux disease (GERD) that formal testing may be unnecessary ⁴⁸.

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

Other symptoms of gastroesophageal reflux disease include ⁴⁹, ⁵⁰, ⁵¹:

• An acid taste in your mouth.
• A dry cough, asthma, and difficulty swallowing (these may occur without the burning sensation)
• Excessive saliva and a sore throat that doesn’t go away

You may also have:

• Non-burning chest pain, which is usually located in the middle of the chest and radiates to the back
• Difficulty swallowing (dysphagia)
• Atypical reflux symptoms relating to the throat, larynx or lungs:
  • Sore throat
  • Coughing or hiccups that keep coming back
  • Increased salivation
  • Shortness of breath
  • A hoarse voice
  • Bad breath
• Bloating and feeling sick

Symptoms are often worse after eating, when lying down or when bending over.

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

GERD / heartburn complications

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.

GERD Diagnosis

A diagnosis of gastroesophageal reflux disease (GERD) starts with a thorough medical history during which you describe your signs and symptoms and physical examination. If the typical symptoms of acid reflux disease are present, including heartburn and regurgitation, your doctor may begin treatment without performing specific diagnostic tests.

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).

Tests may be performed if:

• Your symptoms are atypical
• The severity of acid reflux raises concerns about esophageal damage
• Symptoms do not respond to initial treatment
• Your doctor is considering anti-reflux surgery.

To confirm a diagnosis of gastroesophageal reflux disease (GERD) or to check for complications, your doctor might recommend:

• Upper endoscopy or gastroscopy. Your doctor inserts a thin, flexible tube equipped with a light and camera (endoscope) down your throat. The endoscope helps your provider see inside your esophagus and stomach. Test results may not show problems 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 esophagus. In some instances, if a narrowing is seen in the esophagus, it can be stretched or dilated during this procedure. This is done to improve trouble swallowing (dysphagia).
• Transnasal esophagoscopy. This test is done to look for any damage in your esophagus. A thin, flexible tube with a video camera is put through your nose and moved down your throat into the esophagus. The camera sends pictures to a video screen.
• Reflux testing (wireless pH/pH impedance). Ambulatory acid (pH) probe is placed in your esophagus to identify when, and for how long, stomach acid regurgitates there. The monitor connects to a small computer that you wear around your waist or with a strap over your shoulder. The monitor might be a thin, flexible tube (catheter) that’s threaded through your nose into your esophagus. Or it might be a clip that’s placed in your esophagus during an endoscopy. The clip passes into your stool after about two days.
  • Wireless pH Testing. Wireless pH testing allows your doctor to evaluate your reflux activity over a 48-hour period while you continue your normal activities. To perform wireless pH testing:
    • Your doctor performs an endoscopy and places a small chip in your lower esophagus
    • The chip records the acid level in your esophagus for 48 hours.
    • The chip transmits your acid level to a wireless recording device that you wear around your belt.
    • The data from the recording device can gauge your reflux severity.
  • 24-Hour pH Impedance. Your doctor may order this procedure to evaluate your reflux. This procedure monitors your pH level (level of acidity) for a prolonged period. During pH impedance:
    • Your doctor places a thin, flexible catheter with an acid-sensitive tip through your nose into your esophagus. The catheter is placed in separate recording spots to evaluate the flow of liquid from your stomach into your esophagus.
    • The catheter stays in your nose for a period of 24 hours.
    • Your doctor is able to evaluate whether you have GERD, the severity of your reflux, the presence of non-acid reflux and the correlation between your reflux and symptoms. This procedure helps in the design of a course of treatment for you.
• X-ray of the upper digestive system. X-rays are taken after you drink a chalky liquid that coats and fills the inside lining of your digestive tract. The coating allows your doctor to see a silhouette of your esophagus and stomach. This is particularly useful for people who are having trouble swallowing. You may also be asked to swallow a barium pill that can help diagnose a narrowing of the esophagus that may interfere with swallowing.
• Esophageal manometry also known as esophageal motility (movement) studies. This test measures the rhythmic muscle contractions in your esophagus when you swallow. Esophageal manometry also measures the coordination and force exerted by the muscles of your esophagus. This is typically done in people who have trouble swallowing. An esophageal manometry is an essential part of the assessment process prior to anti-reflux surgery.
  • During an esophageal manometry your doctor places a pressure-sensitive catheter into the esophagus. This may be performed right before esophageal pH impedance studies, as it determines where your doctor should place the catheter. The catheter evaluates the strength and coordination of your muscle contractions. It also tests the strength and relaxation function of the lower esophageal sphincter.
• Barium esophagram also called barium swallow,  is an imaging test that checks for problems in your upper gastrointestinal tract. Your upper gastrointestinal tract includes your mouth, back of the throat, esophagus, stomach, and first part of your small intestine. The test uses a special type of x-ray called fluoroscopy. Fluoroscopy is a kind of X-ray “movie.” A barium esophagram also evaluates the coordination of your esophageal motor function. While it does not test for the presence of reflux, it is useful for evaluating injury to your esophagus.
  • During barium contrast radiography:
    • You swallow a contrast solution called barium.
    • The barium coats your esophagus and gastrointestinal tract, making it easier for the doctor to detect abnormalities.
    • An X-ray is taken.
    • During the X-ray, your doctor looks for a narrowing in the esophagus called a stricture.
    • 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. Your doctor will give you instructions about eating, drinking, and taking your medicines after the procedure.

How to get rid of heartburn

GERD treatment

If your symptoms are mild, treatment may not be necessary. Your doctor is likely to recommend that you first try lifestyle changes and nonprescription medications. If you don’t experience relief within a few weeks, your doctor might recommend prescription medication and additional testing.

Heartburn medicine over-the-counter

Over-the-counter medicine is effective for treating mild cases of acid reflux. These medicines include:

• Antacids that neutralize stomach acid. Antacids such as Mylanta, Rolaids and Tums neutralize stomach acid and may provide quick relief. Unfortunately, antacids alone won’t heal the damage stomach acid causes in your esophagus. Overuse of some antacids can cause side effects, such as diarrhea or constipation or sometimes kidney problems.
• Medications to reduce acid production. These medications — known as H-2 receptor blockers (Histamine-2 Receptor Antagonists) — include cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR) and ranitidine (Zantac). H-2 receptor blockers (Histamine-2 Receptor Antagonists) reduce acid production, but don’t act as quickly as antacids. However, they provide longer relief and may decrease acid production from the stomach for up to 12 hours. Stronger versions of these medications are available by prescription from your doctor.
• Medications that block acid production and heal the esophagus. These medications known as Proton pump inhibitors (PPIs) 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).

If these medicines are not providing relief after a few weeks, contact your doctor. Your doctor may give you a prescription version of H2 receptor blockers or proton pump inhibitors. Additionally, your doctor may prescribe medicine to strengthen the lower esophageal sphincter. The medicine may decrease the number of times your muscle relaxes. It is often used for severe reflux. Side effects include fatigue or confusion. Another medicine your doctor may prescribe helps your stomach empty faster. This will cause the food to move along the digestive tract and not back up into your throat. Your doctor may combine more than one medicine, depending upon the severity of your reflux.

Heartburn medicine prescription

Prescription-strength drugs 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. In some cases, surgery may be required to treat acid reflux. This is when medicine doesn’t help, or if you want a long-term solution. Types of surgery may include:

• Nissen fundoplication: Fundoplication is the most common surgery for GERD. This surgery reinforces the lower muscle in the esophagus. In most cases, it leads to long-term reflux control. A surgeon will wrap the very top of your stomach around the outside of your lower esophagus around the lower esophageal sphincter (LES) to tighten the muscle and prevent reflux. The wrapping of the top part of the stomach can be partial or complete. This reduces reflux by putting pressure on your esophagus. This is a laparoscopic surgery. This means the surgeon makes three or four small cuts in your abdomen (stomach region). He or she will insert instruments, including a flexible tube with a tiny camera, through the cuts. 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: LINX device strengthens the muscle in the esophagus. The Linx device is a ring of tiny beads made of titanium. The surgery wraps the ring around the area between the stomach and esophagus. The magnetic attraction of the beads keeps the opening between the two closed. This helps keep acid from backing up into your throat. However, it’s weak enough to allow food to pass. The Linx device can be implanted using minimally invasive surgery.
• Transoral incisionless fundoplication (TIF). This new procedure involves tightening the lower esophageal sphincter by creating a partial wrap around the lower esophagus using polypropylene fasteners. Transoral incisionless fundoplication (TIF) is performed through the mouth by using an endoscope and requires no surgical incision. Its advantages include quick recovery time and high tolerance. If you have a large hiatal hernia, transoral incisionless fundoplication (TIF) alone is not an option. However, transoral incisionless fundoplication (TIF) may be possible if it is combined with laparoscopic hiatal hernia repair.
• Bariatric surgery (weight-loss surgery). If you have GERD and obesity, your doctor may recommend weight-loss surgery, also called bariatric surgery, most often gastric bypass surgery. Bariatric surgery can help you lose weight and reduce GERD symptoms.

A recent meta-analysis by Gerson et al. ⁵² that included data from 233 patients demonstrated that subjects who underwent Transoral Incisionless Fundoplication (TIF 2.0) procedure had improved esophageal pH, decreased need for proton pump inhibitors (PPIs) and significant improvement in the quality of life at three years after TIF 2.0 procedure. Another prospective study by Testoni et al. ⁵³ demonstrated Transoral Incisionless Fundoplication (TIF) with EsophyX (EndoGastric Solutions, Redmond, WA, United States) as an effective long-term treatment option for patients with symptomatic GERD with associated hiatal hernia less than 2 cm. A meta-analysis comparing Nissen fundoplication and magnetic sphincter augmentation that included data from 688 patients with 415 who underwent MSA and the rest who were treated with Nissen fundoplication concluded that MSA was an effective therapeutic option for GERD as short-term outcomes with magnetic sphincter augmentation appeared to be comparable to Nissen fundoplication ⁵⁴.

Figure 7. GERD surgery – Nissen fundoplication

Footnote: 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.

What are the disadvantages of anti-reflux surgery?

Every surgical procedure carries certain risks. Quite a lot of people have symptoms such as flatulence (“passing wind” or “farting”) and regurgitation after having anti-reflux surgery. But these symptoms could also be caused by the disease itself, and not by the surgery ⁵⁵. Surgery causes swallowing problems in some people, or makes existing swallowing problems worse. Up to 23 out of 100 people in the studies had symptoms like these after fundoplication surgery.

Possible serious complications of surgery include severe bleeding, organ injury and infections. Up to 2 out of 100 people have severe bleeding, and the digestive tract is injured in about 1 out of 100 people.

Home remedies for heartburn

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

• Maintain a healthy weight. Lose weight if you’re overweight. 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, peppermint, garlic, onion, and caffeine.
• Avoid tight-fitting clothing that are tight around your waist or abdomen. Clothes that fit tightly around your waist put pressure on your abdomen and the lower esophageal sphincter.
• Try to find ways to relax
• Don’t eat within 3 or 4 hours before bed. Wait at least three hours after eating before lying down or going to bed.
• Don’t smoke or use tobacco. Smoking decreases the lower esophageal sphincter’s ability to function properly.
• Don’t drink alcohol
• Don’t stop taking any prescribed medicine without speaking to a doctor first

Elevate the head of your bed. You may find that using wood, bricks or books under the feet at the head end of your bed to raise the head of your bed by around 10 to 20 cm, so your chest and head are above your waist, helps relieve symptoms. This can help stop stomach acid traveling up towards your throat. 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 as this can increase pressure on your abdomen and make your symptoms worse. When you go to bed, start by lying on your left side to help make it less likely that you will have reflux.

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

Diet plays a major role in controlling acid reflux symptoms and is the first line of therapy used for people with GERD. 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.

Foods commonly known to be heartburn triggers cause the lower esophageal sphincter to relax and delay the digestive process, letting food sit in the stomach longer. Foods that are high in fat, salt or spice such as:

• Fried food
• Fast food
• Pizza
• Potato chips and other processed snacks
• Chili powder and pepper (white, black, cayenne)
• Fatty meats such as bacon and sausage
• Cheese

Other foods that can cause the same problem include:

• Tomato-based sauces
• Citrus fruits
• Chocolate
• Peppermint
• Carbonated beverages

Moderation is key since many people may not be able to or want to completely eliminate these foods. But try to avoid eating problem foods late in the evening closer to bedtime, so they’re not sitting in your stomach and then coming up your esophagus when you lay down at night. It’s also a good idea to eat small frequent meals instead of bigger, heavier meals and avoid late-night dinners and bedtime snacks.

Stock your kitchen with foods from these foods that help prevent acid reflux:

High-fiber foods

High-fiber foods make you feel full so you’re less likely to overeat, which may contribute to heartburn. So, load up on healthy fiber from these foods:

• Whole grains such as oatmeal, couscous and brown rice.
• Root vegetables such as sweet potatoes, carrots and beets.
• Green vegetables such as asparagus, broccoli and green beans.

Alkaline foods

Foods fall somewhere along the pH scale (an indicator of acid levels). Those that have a low pH are acidic and more likely to cause reflux. Those with higher pH are alkaline and can help offset strong stomach acid.

Alkaline foods include:

• Bananas
• Melons
• Cauliflower
• Fennel
• Nuts
• Ginger is one of the best digestive aids because of its medicinal properties. It’s alkaline in nature and anti-inflammatory, which eases irritation in the digestive tract. Try sipping ginger tea when you feel heartburn coming on.

Watery foods

Eating foods that contain a lot of water can dilute and weaken stomach acid. Choose foods such as:

• Celery
• Cucumber
• Lettuce
• Watermelon
• Broth-based soups
• Herbal tea

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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