Gastroesophageal reflux disease

 | January 1, 2008

Gastroesophageal reflux disease

You enjoyed the meal, but now you're paying for it, big time. You've got heartburn — an uncomfortable burning sensation radiating up the middle of your chest. Heartburn, the most common gastrointestinal malady, can hit after you eat spicy foods, when you lie down to take a nap, or perhaps at bedtime. Many women experience this sensation during pregnancy. Sometimes the pain is so intense that you may think you are having a heart attack. Although heartburn can mimic a heart attack, it is not life-threatening.

About one-third of Americans have heartburn at least once a month, with 10% experiencing it nearly every day. One survey revealed that 65% of people with heartburn may have symptoms both during the day and at night, with 75% of the nighttime heartburn patients saying that the problem keeps them from sleeping, and 40% reporting that nighttime heartburn affects their job performance the following day. This epidemic leads people to spend nearly $2 billion a year on over-the-counter antacids alone. Clearly, it's a major problem.

Heartburn is an expression of a condition known as gastroesophageal reflux disease (GERD), often called "reflux," in which acid and pepsin rise from the stomach into the esophagus, much like water bubbling into a sink from a plugged drain.

The burning sensation is usually felt in the chest just behind the breastbone and often extends from the lower end of the rib cage to the root of the neck. It can last for hours and may be accompanied by the very unpleasant, stinging sensation of highly acidic fluid rushing into the back of the throat. There may also be a sour taste in the mouth.

But the heart of heartburn and GERD is the burning behind the sternum. A variety of foods; certain emotions such as anxiety, anger, or fear; and even particular positions, like reclining or bending forward, can aggravate it. While GERD — and its symptom, heartburn — can be difficult to cope with, many people manage them quite well. However, other people do spend countless hours and untold sums of money looking for a way to spell relief.

Figure 5: Reflux Gastroesophageal reflux disease is an often painful condition that occurs when the lower esophageal sphincter fails to do its job of keeping digestive juices in the stomach. When the sphincter relaxes too much, irritating stomach acids surge up into the esophagus, sometimes causing inflammation and a painful burning sensation behind the breastbone known as heartburn.

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Causes of GERD

GERD is a digestive disorder affecting the lower esophageal sphincter (LES), the muscle connecting the esophagus and stomach. The LES is a high-pressure zone that acts as a barrier to protect the esophagus against the backflow of gastric acid from the stomach.

Normally, the LES works something like a gate, opening to allow food to pass into the stomach and closing to keep food and acidic stomach juices from flowing back into the esophagus. Gastroesophageal reflux occurs when the LES relaxes when it shouldn't or becomes weak, allowing contents of the stomach to rise up into the esophagus (see Figure 5). Scientists aren't sure exactly why this happens. The LES is a complex segment of smooth muscle under the control of nerves and various hormones. As a result, dietary substances, drugs, and nervous system factors can impair its function.

Factors other than malfunction of the LES contribute to reflux. In one study, about half of reflux patients exhibited impaired motility of the stomach — the inability of the stomach muscles to contract in a normal fashion. This might lead to delayed emptying of the stomach, increasing the risk that acid will reflux back into the esophagus. A failure of peristaltic contractions to clear the esophagus of acid that has refluxed, a lessening of the esophageal lining's ability to resist damage, or a shortage of saliva (which has a neutralizing effect on acid) may play a part as well.

Episodes of reflux often go unnoticed, but when reflux is excessive, the gastric acid irritates the gullet and may produce pain, experienced as heartburn. Sometimes acid regurgitates as far as the mouth and may come up forcefully as vomit or as a "wet burp." Most symptoms of GERD are transient and only occur, for example, after a big meal or when a person bends over or lies down.

Overweight people and pregnant women may suffer more heartburn episodes because increased abdominal pressure contributes to reflux. Pregnant women are also more prone to heartburn because the LES relaxes in response to the high levels of the hormone progesterone that occur with pregnancy. Generally, though, GERD is uncommon in people under age 40.

Other medical conditions can also contribute to GERD. As many as 70% of asthma patients also have reflux. It's not clear, however, whether asthma is a cause or effect (see "Asthma and reflux"). Still, asthma may improve when GERD is treated. Other illnesses that may contribute to reflux include diabetes, peptic ulcers, and some types of cancer.

Functional GERD can occur without specific anatomical malfunction in which case it is called functional. For example, some evidence suggests that people with functional heartburn have lower pain thresholds than their healthy counterparts.

Foods that cause reflux. Diet can contribute to LES dysfunction. For example, alcohol can loosen the LES (and irritate the esophageal lining), as can coffee and other caffeine-containing products. Coffee, tea, cocoa, and cola drinks are all powerful stimulants of gastric acid production. Mints and chocolate, often served to cap off a meal to aid in digestion, can actually make things worse. Both relax the LES and can induce heartburn, as can fried and fatty foods. Some people say that onions and garlic give them heartburn. Others have trouble with citrus fruits or tomato products, which are irritating to the esophageal lining. High-fat foods may also trigger symptoms. If you notice that a particular food leads to episodes of heartburn, by all means, stay away from it.

Eating patterns. How you eat can also be as important as what you eat. Skipping breakfast or lunch and then consuming a huge meal at day's end can increase gastric pressure and the possibility of reflux. Lying down right after eating will only make the problem worse. It is best to wait three hours after eating before going to bed. And stay away from late-night snacks, too.

Smoking. Smoking can irritate the entire GI tract. In addition, frequent sucking on a cigarette can cause you to swallow air, increasing stomach pressure and encouraging reflux. Smoking sometimes also relaxes the LES.

Overweight and obesity. Research has linked GERD to being overweight or obese. A 2006 study in The New England Journal of Medicine found that weight gain increases the risk of frequent GERD symptoms — even if the person's body mass index (a ratio of weight to height) remains in the normal range. The additional weight may increase pressure on the stomach, pushing its contents up. Hormones may also play a role. Even a modest weight gain may induce heartburn, so avoiding weight gain is a good idea for many reasons.

Medications that cause heartburn. Some prescription drugs can exacerbate heartburn (see Table 1). Oral contraceptives or postmenopausal hormone preparations containing progesterone are known culprits. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin) and naproxen (Aleve, Naprosyn) may also pose problems. A prescription NSAID known as a COX-2 inhibitor, celecoxib (Celebrex), is widely used to relieve pain because it is designed to be easier on the stomach than standard NSAIDs. Celebrex carries a warning, however, because it has been linked to an increased risk for heart attacks and strokes, and it may still cause GI symptoms in some people. Corticosteroids, used to treat a variety of medical conditions, are also known to cause heartburn. Other drugs — such as alendronate (Fosamax), used to prevent and treat osteoporosis — can irritate the esophagus. And some antidepressants, tranquilizers, and calcium-channel blockers can contribute to reflux by relaxing the LES. The asthma medication theophylline may initiate or aggravate reflux in some people, thereby causing chest pain. In an interesting twist, however, studies have found that theophylline can improve chest pain that is not caused by reflux or heart disease.

The hiatal hernia connection. Hiatal hernia is a common condition in which there is an opening, or hiatus, in the diaphragm, the muscle that separates the chest from the abdomen and helps with breathing. This hiatus permits part of the stomach to protrude into the chest (see Figure 6). The resulting protrusion changes the angle at which the esophagus joins the stomach, weakening the ligaments that hold these organs in proper alignment and impairing the LES's ability to prevent reflux. Studies indicate that a hiatal hernia, particularly if large, promotes retention of acid above the hiatus and reflux of acid into the esophagus, causing irritation and pain.

Figure 6: Hiatal hernia One possible cause of heartburn is a common condition called hiatal hernia in which a portion of the stomach protrudes through the opening in a weak diaphragm, the band of muscle that separates the chest from the abdomen.

While people with small hiatal hernias (less than 3 centimeters, or about 1.2 inches) often have no symptoms, others report significant heartburn discomfort. Almost all people with large hiatal hernias have reflux. And hiatal hernias are almost always present in people with GERD who have moderate or severe esophagitis (inflammation of the esophagus). While the hiatal hernias and reflux occur independently, there is strong evidence that the two are related.

Eosinophilic esophagitis. Eosinophilic esophagitis is a disease characterized by the presence of eosinophils, a type of white blood cell, in the wall of the esophagus. Eosinophils, which are associated with allergic reactions, stimulate inflammation. One symptom of the condition is heartburn, although episodes of dysphagia, the feeling of food or pills sticking in the esophagus, is more characteristic. The disease often occurs in children and young adults, many of whom also have allergies or asthma. Eosinophilic esophagitis often responds to a course of the steroid fluticasone (Flovent), although in some cases symptoms may also improve with a proton pump inhibitor (PPI) such as omeprazole (Prilosec) or lansoprazole (Prevacid).

Table 1: Medications that may cause or worsen reflux
DRUG CLASS	BRAND NAME(S)		USE
Bronchodilators*
theophylline	Aerolate, Uniphyl, and others		Relieves wheezing
Calcium-channel blockers*
amlodipine	Norvasc		Lower blood pressure and improve coronary artery blood flow
diltiazem	Cardizem
nifedipine	Adalat, Procardia
verapamil	Calan, Isoptin
Nonsteroidal anti-inflammatory drugs (NSAIDs)*
aspirin	Bufferin, Ecotrin, and others		Relieve pain and inflammation
ibuprofen	Advil, Motrin
naproxen	Aleve, Anaprox, Naprosyn
Osteoporosis drugs*
alendronate	Fosamax		Build bone density
ibandronate	Boniva
risedronate	Actonel
Progestins*
medroxyprogesterone acetate		Provera, Depo-Provera	Relieve symptoms of menopause; used in oral contraceptives
norethindrone acetate		Aygestin, Micronor
Tricyclic antidepressants*
amitriptyline	Elavil, Endep		Relieve depression; occasionally used for long-term pain
nortriptyline	Pamelor, Aventyl
protriptyline	Vivactil
*Not all available drugs are listed.

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Diagnosing reflux

Many people can manage heartburn without seeking medical care, through dietary changes, over-the-counter medications (see "Self-help for reflux"), and relaxation therapy. A doctor may be helpful if your symptoms don't respond to self-help techniques and if they interfere with sleep or daily life. If you do seek your physician's advice, providing a detailed account of your symptoms will help him or her make the diagnosis.

The doctor will review your medical history and ask detailed questions about the nature of the pain and its pattern of onset. For example, he or she may ask whether symptoms are worse after you eat a heavy meal or known dietary troublemakers such as high-fat foods or dairy products. Your doctor will want to know if bending over to tie your shoelaces or lying down aggravates the symptoms and whether the pain seems linked to anxiety or stress.

For typical reflux symptoms, doctors usually forgo diagnostic tests and proceed straight to treatment, starting with a proton pump inhibitor such as omeprazole or lansoprazole. If this provides relief, the odds are that the diagnosis of GERD was correct. Once the symptoms are under control, the patient may either continue with the PPI or switch to a less powerful medication. That might be an H₂ -receptor antagonist (H₂ blocker) such as cimetidine (Tagamet), ranitidine (Zantac), or famotidine (Pepcid), or an antacid like Tums.

Asthma and reflux. Your doctor will be alert for other symptoms, such as frequent nonburning chest pain, bleeding into the gastrointestinal tract, dysphagia (difficulty in swallowing), hoarseness, or constant coughing and wheezing. Such symptoms may be associated with GERD, but could have other causes and might warrant tests to gain more information (see "Is this test necessary?").

For example, GERD is sometimes accompanied by respiratory problems such as asthmatic wheezing, coughing, or hoarseness. When asthma strikes adult nonsmokers with no history of lung disease or allergies, pH-monitoring studies sometimes suggest that GERD is the culprit. As many as 70% of patients with asthma experience reflux.

Is this test necessary? Doctors ordinarily don't put heartburn patients through costly diagnostic evaluations. However, more serious reflux symptoms, such as bleeding from the esophagus, swallowing problems, or severe symptoms that fail to respond to standard treatment for GERD, may warrant further investigation. Common tests include the following: Barium studies. The patient drinks a liquid barium mixture and then undergoes an x-ray examination of the chest and upper abdomen. The barium, a contrast medium, defines the esophagus on the x-ray image and can help the physician identify problems such as a hiatal hernia, esophageal ulcers, or a stricture (narrowing) of the esophagus. This test is called an upper GI series when the stomach and first part of the small intestine are also examined. Upper GI endoscopy. The physician inserts a flexible tube down the throat, after having first sedated the patient and depressed the gag reflex with a local anesthetic spray. The tube contains a light and camera, which allow the doctor to inspect the lining of the esophagus, assess injuries such as ulcers or strictures, and take a biopsy (a tissue sample), if necessary. Trans-nasal esophagoscopy. This diagnostic imaging technique employs a scope that is smaller than a standard endoscope. The scope is inserted through the nose (rather than the mouth) and into the esophagus. No sedation is needed, and patients can see the images and learn the results immediately. This test is not yet widely available, but may become more useful for screening patients with GERD for Barrett's esophagus (see "Complications of reflux") right in the doctor's office. pH monitoring. Used less frequently, this test monitors an individual's reflux episodes over 24 hours via a thin, acid-sensing probe inserted through the nose and positioned just above the LES. This is the best method for documenting reflux in patients who have unexplained chest pain, coughing, wheezing, or hoarseness. It's also used to assess the adequacy of acid-suppressing therapy when symptoms persist. A wireless form of the pH monitor is contained in a capsule and looks like a pill (see "Diagnosing IBS"). It is placed in the esophagus and can be used to monitor pH levels for 48 hours, during periods while the patient is both on and off acid-suppressing therapy. The wireless pH system is particularly useful in patients who do not respond to PPIs. Impedance testing. This test, approved in the United States in 2002 and becoming more readily available in clinical practice, can be done at the same time as pH monitoring. Probes equipped for this test include a pair of metallic rings that measure changes in electrical resistance that occur as food and gas pass through the esophagus.

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Complications of reflux

Although simple reflux is uncomfortable, it doesn't usually pose a danger to healthy individuals. From half to three-quarters of people with reflux disease have mild symptoms that generally clear up in response to simple measures. Over time, however, serious problems can develop when frequent relapses associated wih persistent GERD go untreated. These complications can include narrowing (stricture) of the esophagus, erosion of its lining, precancerous changes in its cells, and esophageal ulcers.

One complication, known as reflux esophagitis, is inflammation that occurs when acid and pepsin, released from the stomach, erode areas of the mucosa, the surface layer of cells that line the esophagus. Besides the burning sensation of simple heartburn, patients with esophagitis may also complain of pain behind the breastbone spreading into the back or up to the neck, jaw, or even the ears. The pain can be so intense that you may have trouble swallowing and may even think you are having a heart attack.

With esophagitis, food may feel as if it sticks in your throat before going down the gullet. Hot drinks are unpleasant to swallow, and you may have some nausea. You may also regurgitate some acid fluid into your throat, resulting in a cough. The inflammation of the esophagus can even lead to bleeding. Endoscopy is necessary to confirm the diagnosis of esophagitis and locate any associated ulcers or strictures. Bleeding ulcers in an inflamed esophagus may require aggressive treatment, such as blood transfusions and, to stop the bleeding, a probe passed through an endoscopic tube to apply electricity or heat, or to inject blood vessel–constricting agents into the bleeding site. Strictures may need to be dilated through endoscopy, using a balloon or other special dilator. About one-third of patients who need this procedure require a series of treatments to fully open the passageway.

Another complication of chronic esophageal inflammation is Barrett's esophagus, an abnormality in which taller cells resembling those that line the small intestine replace the squamous or flat cells that normally line the lower esophagus. The condition, a potential consequence of longstanding GERD, is caused by long-term and severe exposure to acid from the stomach and bile from the small intestine. Barrett's esophagus can, over time, develop into cancer, so patients are urged to have regular endoscopic evaluations (including biopsies) to identify very early malignant changes. Persons most at risk are those — usually middle-aged white men — who developed GERD at an early age and have had it for many years.

One study reported a higher risk for esophageal cancer in GERD patients, whether or not they have Barrett's esophagus. Fortunately, only a very small percentage of patients with GERD will develop esophageal cancer. Some experts think it's the reflux of bile, in addition to acid, that heightens the risk for esophageal cancer.

GERD can also result in dental problems, including loss of tooth enamel. And it can cause spasms of the vocal cords (larynx), blocking the flow of air to the lungs. One study has reported that such spasms may cause sleep apnea, a condition in which breathing frequently stops for brief moments during sleep.

ROME III: Diagnosing GI disorders Doctors diagnose functional gastrointestinal disorders (including functional heartburn) based on a patient's symptoms. To make diagnosis as consistent as possible, a group of more than 100 international experts created the Rome criteria. Rome III, published in 2006, provides the most current diagnostic criteria for all of the functional gastrointestinal disorders presented in this report.

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Self-help for reflux

Modifying diet and lifestyle remains the foundation for treating the symptoms of reflux. Your goal is to prevent the problem by keeping stomach contents where they belong and staying away from foods that loosen the LES.

Here are some prevention tips for people troubled by symptoms.

Eat smaller meals. A large meal remains in the stomach for several hours, increasing the chances for gastroesophageal reflux. Therefore, anyone who suffers from this problem should distribute his or her daily food intake over three, four, or five smaller meals.

Relax when you eat. Stress increases the production of stomach acid, so make meals a pleasant, relaxing experience. Sit down. Eat slowly. Chew completely. Play soothing music.

Relax between meals. Relaxation therapies such as deep breathing, meditation, massage, tai chi, or yoga may help prevent and relieve heartburn.

Remain upright after eating. You should maintain postures that reduce the risk for reflux for at least three hours after eating. For example, don't bend over or strain to lift heavy objects.

Avoid eating within three hours of going to bed. Do not eat bedtime snacks.

Lose weight. Excess pounds increase pressure on the stomach and can push acid into the esophagus.

Loosen up. Avoid tight belts, waistbands, and other clothing that puts pressure on your stomach.

Avoid foods that burn. Abstain from food or drink that increases gastric acid secretion, decreases LES pressure, or slows the emptying of the stomach. Known offenders include high-fat foods, spicy dishes, tomatoes and tomato products, citrus fruits, garlic, onions, milk, carbonated drinks, coffee (including decaf), tea, chocolate, mints, and alcohol. The list is long, but you're likely to see a substantial improvement if you cut out such foods.

Stop smoking. Nicotine stimulates stomach acid and impairs LES function.

Chew gum. It can increase saliva production, soothing the esophagus and washing acid back down to the stomach.

Consult your doctor about your medications. Drugs that can predispose you to reflux include aspirin and other NSAIDs, oral contraceptives, hormone replacement therapy, narcotics, certain antidepressants, and some asthma medications (see Table 1).

Raise your bed's head at night. If you're bothered by nighttime heartburn, elevate the head of your bed by placing a wedge (available in medical supply stores) under your upper body. But don't elevate your head with extra pillows. That makes reflux worse by bending you at the waist and compressing your stomach.

Exercise wisely. Wait at least two hours after a meal before engaging in vigorous physical activity, giving your stomach time to empty.

Do you have functional heartburn? According to the Rome III criteria for a diagnosis of functional heartburn, a patient must have experienced all of the following for the past three months, with symptoms starting at least six months before diagnosis: burning discomfort or pain behind the breastbone no evidence that symptoms are caused by acid reflux from the stomach or esophagus absence of structural disorders that interfere with the movement of food down the esophagus.

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Antireflux drug therapy

How do you spell relief? Nonstop advertising has acquainted most people with antacids, the least expensive treatment for heartburn. These work by reducing the acidity of refluxed material. Almost as well known are H₂ -receptor antagonists (H₂ blockers) and proton pump inhibitors (PPIs). The former cost a little more than antacids, but are generally more convenient, and some can be purchased over the counter. PPIs are more effective than either antacids or H₂ blockers, but tend to be costly. In severe cases, physicians may favor combining various antireflux drugs, such as over-the-counter antacids and H₂ blockers or PPIs and prokinetic drugs that increase gastric emptying. However, PPIs without additional medications are generally preferable to combinations.

Let's look at them in the order in which physicians typically recommend or prescribe their use.

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Proton pump inhibitors

PPIs are more effective than H₂ blockers at lowering the production of gastric acid. PPIs, also known as acid pump inhibitors, work by inactivating a specific enzyme responsible for the final step of acid release in the stomach. They can reduce gastric acid secretion by more than 95% without causing systemic side effects.

One PPI, omeprazole (Prilosec), is available over the counter, and it is the only one approved by the FDA for repeated courses of treatment for erosive esophagitis. PPIs available by prescription include lansoprazole (Prevacid), rabeprazole (Aciphex), pantoprazole (Protonix), omeprazole (Zegerid), and esomeprazole (Nexium). Omeprazole sold as Zegerid is an immediate-release medication in contrast to others, which are delayed-release.

Erosive esophagitis usually recurs when drug treatment is stopped, so long-term treatment is often necessary. All these medications effectively heal esophagitis and alleviate heartburn.

Although they have numerous advantages, PPIs are expensive. In addition, they may make the GI tract more susceptible to bacterial infections and vitamin B₁₂ deficiency and have been reported to increase the long-term risk of hip fractures. Despite these concerns, PPIs have become the preferred medication for reflux esophagitis and for patients with unremitting GERD-derived respiratory symptoms. Doctors often recommend them first for frequent, uncomplicated heartburn, but once symptoms recede, a less expensive medication such as an H₂ blocker can be effective.

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Histamine H₂ -receptor antagonists

For chronic reflux, histamine H₂ -receptor antagonists (H₂ blockers) are now widely available either by prescription or, in smaller doses, over the counter. They are often effective for GERD symptoms that don't respond to antacids or changes in eating habits.

H₂ blockers work by countering the effect of histamine (which stimulates gastric acid), thereby decreasing the amount of acid that the stomach produces. They act directly on the stomach's acid-secreting cells to stop them from making hydrochloric acid, particularly at night when acid gathers in the stomach and can wash back into the esophagus. Cimetidine (Tagamet) was the first H₂ blocker on the market. Others available in the United States include ranitidine (Zantac), famotidine (Pepcid), and nizatidine (Axid).

For people whose heartburn is troublesome only at night, a single dose taken in the evening may suffice, but if symptoms occur during the day and night, more frequent treatments will be needed. All the H₂ blockers are equally effective, so switching to another if one fails to work is likely to be fruitless. Increasing the dose, however, may be helpful.

While considered relatively safe, H₂ blockers can have side effects (see Table 2). If you use an over-the-counter H₂ blocker for heartburn, be aware that this may mask the symptoms of more serious conditions, so discuss your symptoms with your doctor.

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Antacids

These inexpensive over-the-counter remedies neutralize digestive acids in the stomach and esophagus, at least in mild cases of heartburn. While many people find tablets more convenient, liquids provide faster relief. Tablets must be chewed thoroughly in order to be effective. The best time to take an antacid is after a meal or when symptoms occur. The usual recommended dosage is 1 to 2 tablespoons each time.

There are three basic salts used in antacids: magnesium, aluminum, and calcium. A major side effect of magnesium hydroxide is diarrhea, while the most common side effect of antacids containing aluminum hydroxide is constipation.

Antacids high in calcium (Tums, Rolaids, Titralac, and Alka-2) are probably the strongest. Calcium carbonate products have been used for centuries in the form of chalk powder and ground oyster shell. They, too, can be constipating if consumed in sufficient quantities.

Sodium bicarbonate, or baking soda, which is less powerful than other antacids, is the active ingredient in many seltzer antacids (Alka-Seltzer, Bromo-Seltzer) and is present in mineral water.

Because no single agent is perfect, many antacids combine several ingredients that are designed to balance their respective side effects.

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Prokinetic agents

Prokinetics — or gastrokinetics, as they're occasionally called — help empty the stomach of acids and fluids. They can also improve LES muscle tone. These medications are used only for occasional cases of GERD, either with or in place of H₂ blockers, particularly when the stomach appears to empty slowly.

Cisapride (Propulsid) was pulled from the U.S. market in 2000 after it was linked to more than 300 reports of heart rhythm abnormalities, including more than 80 deaths. Its predecessor, metoclopramide (Reglan) is available by prescription, but has a variety of side effects (see Table 2).

Fast fact GERD carries an annual economic burden in the United States of almost $10 billion.

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Herbal remedies

Some people have found herbs and other natural remedies to be helpful in the treatment of heartburn symptoms.

Chamomile. A cup of chamomile tea may have a soothing effect on the digestive tract. People with ragweed allergy should avoid chamomile.

Ginger. The root of the ginger plant is another well-known herbal digestive aid and has been a folk remedy for heartburn for centuries.

Licorice. This remedy has proved effective in several studies. Licorice is said to increase the mucous coating of the esophageal lining, helping it resist the irritating effects of stomach acid. Deglycyrrhizinated licorice, or DGL, is available in pill or liquid form. It is considered safe to take indefinitely.

Other herbs. A variety of other remedies have been used over the centuries, but scientific evidence to confirm their effectiveness is insufficient. Catnip, fennel, marshmallow root, and papaya tea have all been said to aid in digestion and act as a buffer to stop heartburn. Some people eat fresh papaya as a digestive aid. Others swear by raw potato juice, three times a day. Naturopathic followers also tout a homeopathic remedy with the unappetizing name of vomit nut as a heartburn fix. However, these herbal remedies do not undergo testing for safety and effectiveness by the federal government and are not approved by the FDA.

How to distinguish GERD discomfort from a heart attack It's important to consider the possibility that chest pain may mean a heart attack instead of heartburn. Symptoms associated with GERD can mimic the pain of a myocardial infarction (heart attack) or angina (chest pain caused by diminished blood flow through the coronary arteries), especially when the sensation is constricting rather than burning in nature. It can be dangerous to assume that your chest pain is caused by reflux. People with known reflux disease should always seek medical attention if they experience chest discomfort brought on by exercise, which may signal either angina or a heart attack. How can you be sure that you have heartburn, not a heart attack? The main thing to determine is the severity and length of your chest pain. If it's a severe, pressing, or squeezing discomfort, it may be a heart attack. And heart attack pain lasts awhile. If it goes away in five to 10 minutes, it's probably not a heart attack. It could be angina, however, which does require a visit to the doctor — and treatment. It's important not to dismiss chest tightness, especially if it follows physical exercise.

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Surgical options for reflux

Medication and lifestyle changes can successfully control 95% of GERD cases, but for a few patients, surgery is the best option. For example, surgery may be preferable for young patients who find the prospect of taking PPIs for life unappealing. Other indications for surgery are occasional cases of erosive esophagitis that do not improve with drug therapy, strictures that recur despite treatment, or pneumonia or recurrent respiratory problems due to acid reflux that don't improve with drug therapy.

The goal of surgery is to tighten the LES. The operations are generally effective and may eliminate the need for all GERD medications.

Fast fact About 90% of patients are free of heartburn in the months following reflux surgery. But a follow-up study showed that within 10 to 13 years, many such patients eventually needed to start taking heartburn medications again.

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Fundoplication

The most common antireflux operation is the Nissen (360-degree) fundoplication. Also known as a stomach wrap, the operation creates a vacuum effect that prevents stomach acid from surging upward into the esophagus. Partial fundoplication, in which the stomach is wrapped only partway around the esophagus, is another option.

Nissen fundoplication involves grabbing a portion of the top of the stomach and looping it around the lower end of the esophagus and LES to create an artificial sphincter or pinch valve. It prevents stomach acid from backing up into the esophagus (see Figure 7). The wrap must be tight enough to prevent the acid from coming back up, but not so tight that food can't enter and a satisfying belch can't escape. In addition to curing heartburn and GERD-induced respiratory symptoms, the procedure may enhance stomach emptying and improve abnormal peristalsis in some patients.

Over time, however, the stomach wrap can loosen. When that happens, the patient may need to resume medications and, in a small number of cases, undergo surgery to redo the procedure. A study in the Journal of the American Medical Association found that 62% of patients who had undergone the Nissen fundoplication procedure 10 years earlier were regularly using medications to control reflux.

An increasing number of surgeons are performing fundoplication as a laparoscopic procedure, in which special instruments and cameras are inserted into tiny incisions in the upper abdomen. Patients recover much faster from laparoscopy than from open surgery.

An even newer approach is endoscopic surgery, in which a specialist uses an endoscope inserted down the esophagus to perform the surgery. No abdominal incision is necessary. The number of surgeons trained in this procedure is limited, however, and the long-term results are unknown.

Figure 7: Surgery for GERD Most cases of GERD can be managed successfully with medications. But in a few cases, a surgical procedure called fundoplication may be used to fold the top of the stomach around itself to create a high-pressure zone that functions as a lower esophageal sphincter.

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Endoscopic suturing and plicating systems

Endoscopic treatments, which are carried out via a tube placed down the throat rather than through an incision, provide a middle-ground alternative to long-term acid-suppressing therapy and surgical intervention.

One endoscopic procedure, known as the Bard EndoCinch endoscopic suturing system, tightens the LES with stitches. The procedure uses a thin, flexible endoscopic tube with a device that resembles a miniature sewing machine at its tip. The endoscope is inserted down the patient's throat and is used to place stitches on either side of the LES. The doctor then ties the stitches together to tighten the valve.

In a similar technique, called plication, a pleat is made in the tissue to tighten the LES. Early plication devices had trouble maintaining their effects over time, but innovations in the technology have led to renewed interest. A newer device known as a plicator creates a single, full-thickness pleat in the upper stomach, about 1 centimeter below the gastroesophageal junction, to restructure the antireflux barrier. Although long-term data are limited, one small study found that this approach continued to effectively reduce GERD symptoms and medication use three years after the procedure was performed.

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Radiofrequency catheter ablation

The FDA approved radiofrequency catheter ablation to treat reflux in 2000. Also known as the Stretta procedure, it involves applying controlled radiofrequency energy through a flexible catheter that extends to the LES. The procedure, which takes less than an hour, "zaps" the LES and the upper part of the stomach, causing the lining of the lower esophagus to swell slightly. As a result, the valve tightens, creating a more effective barrier between the esophagus and stomach. Patients undergoing this procedure can expect to get back to their regular activities the next day.

Studies show that the Stretta procedure works well for most patients who have not had success with medication. In a 2003 study in The Lancet, 94 patients were followed for a year after they had the procedure. The percentage of patients requiring PPIs fell from 98% to 30% after surgery. Complications from the procedure have occurred in no more than 10% of patients and have generally not been serious.

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Injections

A final technique involves injection of inert materials into the muscles lining the end of the esophagus, to create a mechanical barrier that blocks reflux. Initial results with collagen and Teflon were not very encouraging because particles sometimes moved from the injection site or dissolved. In 2003, the FDA approved Enteryx, a liquid chemical polymer designed to be injected into the wall of the lower esophagus. The polymer solidified into a spongy material that helped prevent reflux by strengthening the muscle separating the lower esophagus from the stomach. However, Enteryx was pulled from the market in 2005 because of serious adverse effects, including death, which resulted when Enteryx was unknowingly injected into structures surrounding the esophagus. For the moment, at least, injections are not being used to treat GERD.

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Review Date: 2008-01-01

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