Acid Reflux (GERD)

Gastroesophageal reflux disease, or GERD, occurs when the lower esophageal sphincter (LES) does not close properly and stomach contents leak back, or reflux, into the esophagus. The LES is a ring of muscle at the bottom of the esophagus that acts like a valve between the esophagus and stomach.

When refluxed stomach acid touches the lining of the esophagus, it causes a burning sensation in the chest or throat called heartburn. The fluid may even be tasted in the back of the mouth. Occasional heartburn is common but does not necessarily mean one has GERD. Heartburn that occurs more than twice a week may be considered GERD, and it can eventually lead to more serious health problems.

Anyone, including infants, children, and pregnant women, can have GERD.

What are the symptoms of GERD?

The main symptoms are heartburn and acid regurgitation. Some people have GERD without heartburn. Instead, they experience pain in the chest, hoarseness in the morning, or trouble swallowing. You may feel like you have food stuck in your throat or like you are choking or your throat is tight. GERD can also cause a dry cough and bad breath.

What causes GERD?

GERD occurs when the lower esophageal sphincter relaxes inappropriately, allowing acid to enter the esophagus. Having a hiatal hernia may also lead to the development of GERD. A hiatal hernia occurs when the upper part of the stomach is above the diaphragm, the muscle wall that separates the stomach from the chest. The diaphragm helps the LES keep acid from coming up into the esophagus. When a hiatal hernia is present, it is easier for the acid to come up.

Other factors that may contribute to GERD include:

alcohol use
obesity
pregnancy
smoking

Also, certain foods can be associated with reflux events, including

citrus fruits
chocolate
drinks with caffeine
fatty and fried foods
garlic and onions
mint flavorings
spicy foods
tomato-based foods, like spaghetti sauce, chili, and pizza

How is GERD treated?

If you have had heartburn or any other symptom of GERD, you should see your doctor. You may want to visit an internist, a doctor who specializes in internal medicine, or a gastroenterologist, a doctor who treats diseases of the stomach and intestines. Depending on how severe your GERD is, treatment may involve one or more of the following: lifestyle changes and medications or surgery.

Lifestyle Changes

If you smoke, stop.
Do not drink alcohol.
Lose weight if needed.
Eat small meals.
Wear loose-fitting clothes.
Avoid lying down for 3 hours after a meal.
Raise the head of your bed 6 to 8 inches by putting blocks of wood under the bedposts—just using extra pillows will not help.

Medications

Your doctor may recommend over-the-counter antacids, which you can buy without a prescription, or medications that stop acid production.

Antacids, such as Alka-Seltzer, Maalox, Mylanta, Pepto-Bismol, Rolaids, and TUMS, are usually the first drugs recommended to relieve heartburn and other mild GERD symptoms. Many brands on the market use different combinations of three basic salts—magnesium, calcium, and aluminum—with hydroxide or bicarbonate ions to neutralize the acid in your stomach. Antacids, however, have side effects. Magnesium salt can lead to diarrhea, and aluminum salts can cause constipation. Aluminum and magnesium salts are often combined in a single product to balance these effects.

Calcium carbonate antacids, such as Tums, Titralac, and Alka-2, can also be a supplemental source of calcium. They can cause constipation as well.

Foaming agents, such as Gaviscon, work by covering your stomach contents with foam to prevent reflux.

H₂ blockers, such as cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR), and ranitidine (Zantac 75), impede acid production. They are available in prescription strength and over the counter. They are effective for about half of those who have GERD symptoms. Many people benefit from taking H₂ blockers at bedtime in combination with a proton pump inhibitor.

Proton pump inhibitors include omeprazole (Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex), and esomeprazole (Nexium), which are all available by prescription. Proton pump inhibitors are more effective than H₂ blockers and can relieve symptoms in almost everyone who has GERD.

Because drugs work in different ways, combinations of drugs may help control symptoms. People who get heartburn after eating may take both antacids and H₂ blockers. The antacids work first to neutralize the acid in the stomach, while the H₂ blockers and proton pump inhibitors stop acid production. By the time the antacid stops working, the H₂ blocker will have stopped acid production. Your doctor is the best source of information on how to use medications for GERD.

What if symptoms persist?

If your heartburn does not improve with lifestyle changes or drugs, you may need additional tests.

Upper endoscopy - After anesthesia is administered, the doctor will slide a thin, flexible tube called an endoscope through the mouth into your esophagus and stomach. A tiny camera in the endoscope allows the doctor to see the surface of the esophagus and to search for abnormalities. If you have had moderate to severe symptoms and this procedure reveals injury to the esophagus, usually no other tests are needed to confirm GERD. The doctor may use tiny tweezers (forceps) placed through the endoscope to remove a small piece of tissue for biopsy. A biopsy viewed under a microscope can reveal damage caused by acid reflux.
In an ambulatory pH monitoring examination, the doctor places a tiny capsule (a “Bravo” capsule) into the lining of the esophagus during endoscopy. This capsule stays attached to the esophageal lining for approximately 72 hours. While you go about your normal activities, the capsule measures when and how much acid comes up into your esophagus. Acid levels are measured for 48 hours. The capsule will subsequently detach from the lining of the esophagus and pass through the digestive tract, ultimately passing with stool. This test is useful in people with GERD symptoms but no esophageal damage. The procedure is also helpful in detecting whether symptoms such as a chronic sore throat, wheezing, or coughing, are due to acid reflux.

Surgery
Surgery is an option when medicine and lifestyle changes do not work. Surgery may also be a reasonable alternative to a lifetime of drugs and discomfort.

Fundoplication, usually a specific variation called Nissen fundoplication, is the standard surgical treatment for GERD. 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.

What are the long-term complications of GERD?

Sometimes GERD can cause serious complications. Inflammation of the esophagus from stomach acid can cause bleeding or ulcers. In addition, scarring from tissue damage can narrow the esophagus and make swallowing difficult. Some people develop Barrett's esophagus, where cells in the esophageal lining take on an abnormal appearance, which over time can lead to cancer.

Also, studies have shown that asthma, chronic cough, and pulmonary fibrosis may be aggravated or even caused by GERD.

For information about Barrett's esophagus, please see the Barrett's Esophagus fact sheet.

Points to Remember

Heartburn, also called acid indigestion, is the most common symptom of GERD. Anyone experiencing heartburn twice a week or more may have GERD.
You can have GERD without having heartburn. Your symptoms could be excessive clearing of the throat, problems swallowing, the feeling that food is stuck in your throat, burning in the mouth, or pain in the chest.
If you have been using antacids for more than 2 weeks, it is time to see a doctor. Most doctors can treat GERD. You may want to visit an internist—a doctor who specializes in internal medicine—or a gastroenterologist—a doctor who treats diseases of the stomach and intestines.
Doctors usually recommend lifestyle and dietary changes to relieve heartburn. Many people with GERD also need medication. Surgery may be an option.

Information obtained and edited from The National Digestive Diseases Information Clearinghouse. The U.S. Government does not endorse or favor any specific commercial product or company. Trade, proprietary, or company names appearing in this document are used only because they are considered necessary in the context of the information provided. If a product is not mentioned, the omission does not mean or imply that the product is unsatisfactory.