Gastroesophageal Reflux Disease (GERD)
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This topic is about gastroesophageal reflux disease (GERD) in adults. For information on reflux in babies and children, see Gastroesophageal Reflux in Babies and Children. For information on reflux while pregnant, see Gastroesophageal Reflux Disease During Pregnancy. For information about occasional heartburn, see Heartburn.
What is gastroesophageal reflux disease (GERD)?
Reflux means that stomach acid and juices flow from the stomach back up into the tube that leads from the throat to the stomach (esophagus). This causes heartburn. When you have heartburn that bothers you often, it is called gastroesophageal reflux disease, or GERD.
Eating too much or bending forward after eating sometimes causes heartburn and a sour taste in the mouth. But having heartburn from time to time doesn't mean that you have GERD. With GERD, the reflux and heartburn last longer and come more often. If this happens to you, be sure to get it treated, because GERD can cause ulcers and damage to your esophagus.
What causes GERD?
Normally when you swallow your food, it first travels down the food pipe (esophagus). A valve opens to let the food pass into the stomach, and then the valve closes. With GERD, the valve doesn't close tightly enough. Stomach acid and juices from the stomach flow back up (reflux) into the esophagus.
What are the symptoms?
The main symptom of GERD is heartburn. It may feel like a burning, warmth, or pain just behind the breastbone. It is common to have symptoms at night when you're trying to sleep.
If you have pain behind your breastbone, it is important to make sure that it isn't caused by a problem with your heart. The burning sensation caused by GERD usually occurs after you eat. Pain from the heart usually feels like heaviness, tightness, discomfort, or a dull ache. It occurs most often after you are active.
How is GERD diagnosed?
First, your doctor will do a physical exam and ask you questions about your health. You may or may not need further tests. Your doctor may just treat your symptoms by recommending medicines that reduce or block stomach acid. These include H2 blockers such as famotidine (Pepcid) and proton pump inhibitors such as omeprazole (Prilosec). If your heartburn goes away after you take the medicine, your doctor will likely diagnose GERD.
How is it treated?
For mild symptoms of GERD, you can try over-the-counter medicines. These include antacids (for example, Tums), H2 blockers (for example, Pepcid), and proton pump inhibitors (for example, Prilosec). Changing your diet, losing weight if needed, and making other lifestyle changes can also help. If you still have symptoms after trying lifestyle changes and over-the-counter medicines, talk to your doctor.
Your doctor may recommend surgery if medicine doesn't work or if you can't take medicine because of the side effects. Fundoplication surgery strengthens the valve between the esophagus and the stomach. But many people continue to need some medicine even after surgery.
GERD is common in pregnant women. Lifestyle changes and antacids are usually tried first to treat pregnant women who have GERD. Most nonprescription antacids are safe to use during pregnancy to treat symptoms. Antacids that contain sodium bicarbonate can cause fluid to build up, so they should not be taken by pregnant women. And do not use antacids that have magnesium trisilicate, because they may not be safe for your baby. But it is okay to use antacids that contain calcium carbonate (such as Tums). If lifestyle changes and antacids don't help control your symptoms, talk to your doctor about using other medicines. Most of the time, symptoms get better after the baby is born.
How can you manage GERD?
You may need to take medicine for many years to help control the symptoms. But you can also make changes to your lifestyle to help relieve your symptoms of GERD. Here are some things to try:
- Change your eating habits.
- It's best to eat several small meals instead of two or three large meals.
- After you eat, wait 2 to 3 hours before you lie down. Late-night snacks aren't a good idea.
- Chocolate, mint, and alcohol can make GERD worse. They relax the valve between the esophagus and the stomach.
- Spicy foods, foods that have a lot of acid (like tomatoes and oranges), and coffee can make GERD symptoms worse in some people. If your symptoms are worse after you eat a certain food, you may want to stop eating that food to see if your symptoms get better.
- Don't smoke or chew tobacco.
- If you get heartburn at night, raise the head of your bed6 in. (15 cm) to8 in. (20 cm) by putting the frame on blocks or placing a foam wedge under the head of your mattress. (Adding extra pillows doesn't work.)
- Don't wear tight clothing around your middle.
- Lose weight if you need to. Losing just 5 to 10 pounds can help.
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Gastroesophageal reflux disease (GERD) happens when stomach acid and juices back up, or reflux, into the esophagus, the tube that connects the throat to the stomach. This occurs when the valve between the lower end of the esophagus and the stomach (the lower esophageal sphincter) does not close tightly enough.
Most of the time, GERD happens when the valve relaxes at the wrong time and stays open too long. Normally, the valve is only open for a few seconds when you swallow. Some foods, like peppermint and chocolate, may relax the valve so it doesn't close tightly. Alcohol, tobacco, and some medicines can also relax the valve.
Some foods can make GERD worse. Avoiding them can help reduce heartburn. These include citrus fruits, fatty and fried foods, garlic and onions, spicy foods, and tomato-based foods like spaghetti sauce and pizza.
Other things can make stomach juices back up, such as:
- Hormonal changes during pregnancy. Heartburn is common during pregnancy, because hormones cause the digestive system to slow down.
- A weak lower esophageal sphincter. If this valve is weak, it won't close normally, and reflux will occur more often.
- Hiatal hernia. GERD is common among people who have hiatal hernias.
- Slow digestion. If food stays in your stomach too long before it goes to the small intestine, the stomach contents are more likely to get pushed up into the esophagus and cause heartburn.
- Overfull stomach. Having a very full stomach increases the chance that the valve will relax and let stomach juices back up into your esophagus.
The main symptoms of gastroesophageal reflux disease (GERD) include:
- Persistent heartburn. Heartburn is an uncomfortable feeling or burning pain behind the breastbone. It may occur after you eat, soon after you lie down, or when you bend forward. Some people have GERD without heartburn.
- A sour or bitter taste in the mouth. The backflow of stomach acid and juices into the esophagus may cause this sour or bitter taste.
Heartburn caused by GERD is usually felt within 2 hours after you eat. If your heartburn lasts for several hours—for example, all night—you may have severe GERD.
Other symptoms of GERD may include:
- Chest pain. This may be a dull, heavy discomfort that spreads across the chest. This chest pain may occur with heartburn and may be confused with the pain of a heart attack.
- Trouble swallowing. This is more common with advanced GERD.
- A feeling that you have something stuck in your throat.
- A cough.
- Having extra saliva.
Gastroesophageal reflux disease (GERD) may cause irritation or inflammation in the esophagus, the tube that connects the throat to the stomach. This condition is called esophagitis. GERD without esophagitis is sometimes called nonerosive reflux disease.
If you have mild GERD symptoms—an uncomfortable feeling of burning, warmth, heat, or pain just behind the breastbone—you may be able to treat yourself with nonprescription medicines that reduce or block acid.
Advanced GERD can cause complications such as:
- Severe inflammation of the lining of the esophagus (esophagitis), esophageal erosion, and ulcers.
- Narrowing of the esophagus.
- Barrett's esophagus, in which the cells that line the inside of the esophagus are replaced by cells similar to those that line the inside of the stomach and intestine. Barrett's esophagus is not common, but it can lead to cancer of the esophagus.
- Respiratory problems, such as a persistent cough, asthma, pneumonia, and laryngitis.
- The speeding up of tooth decay, because stomach acid gets into the mouth and wears away tooth enamel.
Some people who have GERD may be at increased risk for cancer of the esophagus.
What Increases Your Risk
Things that increase your risk for symptoms of gastroesophageal reflux disease (GERD) include your lifestyle and certain health conditions.
- Being overweight.
- Drinking alcohol.
- Eating certain foods, such as chocolate or peppermint, that may relax the valve between the stomach and esophagus.
- Being pregnant. Many pregnant women have symptoms of GERD during pregnancy. Most of the time, symptoms get better after the baby is born.
- Having a hiatal hernia.
- Taking certain medicines. If you think that a medicine you take may be causing your GERD symptoms, talk to your doctor.
When should you call your doctor?
The main symptom of gastroesophageal reflux disease (GERD) is an uncomfortable feeling of burning, warmth, heat, or pain just behind the breastbone, a feeling commonly referred to as heartburn. Sometimes heartburn can feel like the chest pain of a heart attack.
Call 911 or other emergency services immediately if:
- You have symptoms of a heart attack. These may include:
- Chest pain or pressure, or a strange feeling in the chest.
- Shortness of breath.
- Nausea or vomiting.
- Pain, pressure, or a strange feeling in the back, neck, jaw, or upper belly or in one or both shoulders or arms.
- Lightheadedness or sudden weakness.
- A fast or irregular heartbeat.
After you call 911, the operator may tell you to chew 1 adult-strength or 2 to 4 low-dose aspirin. Wait for an ambulance. Do not try to drive yourself.
Call your doctor immediately if you:
- Vomit blood.
- Have bloody, black, or maroon-colored stools.
Call your doctor if your GERD symptoms:
- Do not improve after 2 weeks of home treatment, are different or are getting worse, or are interfering with normal activities.
- Occur with choking or difficulty swallowing.
- Occur with a lot of weight loss when you are not trying to lose weight.
- Have occurred frequently over several years and are only partially relieved with lifestyle changes and nonprescription medicines that reduce or block acid.
Watchful waiting is a wait-and-see approach. Occasional mild heartburn can often be relieved by making lifestyle changes and taking nonprescription medicines that reduce or block acid. Contact a doctor if you have any of the symptoms listed above.
Who to see
The following health professionals can evaluate symptoms of GERD:
- Family medicine doctor
- General practice doctor
- Physician assistant (PA)
- Nurse practitioner (NP)
- Pediatrician, if you think your child has GERD symptoms
- Obstetrician or gynecologist, if you are pregnant
You may be referred to a doctor who specializes in diseases of the digestive tract (gastroenterologist) to check severe GERD symptoms or to get an opinion on whether surgery is needed. If you are thinking about having surgery, you may also be referred to a general surgeon who has experience treating stomach and esophagus problems.
Exams and Tests
To find out if you have gastroesophageal reflux disease (GERD), your doctor may first ask you questions about your symptoms, such as whether you have a frequent uncomfortable feeling of burning, warmth, heat, or pain just behind the breastbone (heartburn). If you have heartburn often, your doctor may prescribe medicines to treat GERD without doing any other tests.
If medicines don't help, you may have other tests. These may include:
- An upper gastrointestinal endoscopy. This allows your doctor to look at the inner lining of your esophagus, your stomach, and the first part of your small intestine (duodenum) through a thin, flexible viewing tool called an endoscope.
- Esophageal tests. These may be done to find out how well the muscles in the esophagus move food, or to monitor how often acid gets into the esophagus and how long it stays there.
- An upper gastrointestinal series. These X-ray pictures of the esophagus and stomach may help find other problems that may be causing GERD symptoms.
Treatment for gastroesophageal reflux disease (GERD) is aimed at:
- Reducing backflow, or reflux, of stomach acid and juices into the esophagus.
- Preventing damage to the lining of the esophagus, or helping to heal the lining if damage has occurred.
- Keeping GERD from coming back.
- Preventing health problems that can occur because of GERD.
Treatment starts with changing habits, avoiding things that trigger your symptoms, and taking nonprescription medicines that reduce or block acids. If you still have symptoms after taking medicines for a few weeks, you may need prescription medicines. You may need to keep up with treatment over the long term to prevent GERD symptoms from coming back. If GERD keeps coming back or gets worse, you may need to think about surgery.
Making lifestyle changes is an important part of treating symptoms of GERD. Quitting smoking, losing weight if you need to, and changing your eating habits can all help you feel better.
If you have been using nonprescription medicines to treat your symptoms for longer than 2 weeks, talk to your doctor. Stomach acid could be causing damage to your esophagus. If you have GERD symptoms often, or if they are very bad, your doctor may recommend that you use prescription medicines.
Be sure to continue to take medicines as instructed by your doctor, because stopping treatment will often bring symptoms back.
Avoid your triggers
An important part of treating GERD is avoiding triggers. These things can include:
- Spicy foods.
- Fatty foods.
- Drinks that contain caffeine or alcohol.
- Certain medicines.
If you think that your symptoms are worse after you eat a certain food, you can stop eating that food to see if it helps.
If you think a medicine is making your symptoms worse, talk to your doctor.
Watch for changes
If your symptoms don't get better with treatment, or if they get worse, your doctor may suggest that you take your medicine more often. Or you may be switched to a higher dose or a stronger medicine.
Your doctor may also refer you to a specialist for an upper gastrointestinal endoscopy. Sometimes, GERD leads to other health problems, such as Barrett's esophagus. Part of your treatment may involve more endoscopies and other tests to monitor your health.
Sometimes surgery is needed, such as when medicines don't relieve symptoms or if you're unable to take medicines over a long period of time. Surgery can have benefits but can also cause problems with swallowing and burping. Some people still need to take medicines after surgery. And some people need to have surgery again.
Some medicines may cause gastroesophageal reflux disease (GERD) as a side effect. If any medicines you take seem to be the cause of your heartburn, talk with your doctor. Don't stop taking a prescription medicine until you talk with your doctor.
If you have been using nonprescription medicines to treat your symptoms for longer than 2 weeks, talk to your doctor. If you have gastroesophageal reflux disease (GERD), the stomach acid could be causing damage to your esophagus. Your doctor can help you find the right treatment. Making lifestyle changes is still an important part of the treatment of GERD when you are using medicine.
Antacids, H2 blockers, and proton pump inhibitors—either prescription or nonprescription—are usually tried first. Medicines can:
- Relieve symptoms (heartburn, sour taste, or pain).
- Allow the esophagus to heal.
- Prevent complications of GERD.
- Antacids, such as Mylanta and Tums. Antacids neutralize stomach acid and relieve heartburn. If you want to take medicine only when your symptoms bother you, antacids are a good choice. Be careful when you take over-the-counter antacid medicines. Many of these medicines have aspirin in them. Read the label to make sure that you are not taking more than the recommended dose. Too much aspirin can be harmful.
- Acid reducers. These include:
- H2 blockers, such as cimetidine (Tagamet) and famotidine (Pepcid). H2 blockers reduce the amount of acid in the stomach. Most are available in both nonprescription and prescription strength. If nonprescription H2 blockers don't relieve your symptoms, talk to your doctor about trying prescription-strength medicine.
- Proton pump inhibitors, such as lansoprazole (Prevacid) and omeprazole (Prilosec). Proton pump inhibitors (PPIs) reduce the amount of acid in the stomach. Some are available without a prescription.
Medicine may not prevent all of your GERD symptoms all the time. Even if you're taking an acid reducer every day, you may still have heartburn from time to time. It's okay to take antacids when you have heartburn like this. But if you feel like your daily medicine isn't working to control your GERD symptoms, talk with your doctor. You may need to try a different medicine.
Be sure to keep taking medicines as instructed by your doctor, because stopping treatment will often bring symptoms back.
What to think about
Doctors usually try to choose a treatment that uses enough medicine to control your symptoms but not so much that side effects become a serious problem.
Surgery may be used to treat gastroesophageal reflux disease (GERD) symptoms that have not been well controlled by medicines.
Surgery may be an option when:
- Medicines don't completely relieve symptoms, and the remaining symptoms are caused by reflux of stomach juices.
- A person doesn't want or, because of side effects, is not able to take medicines over an extended period of time to control GERD symptoms.
- Along with reflux, a person has symptoms such as asthma, hoarseness, or cough that do not adequately improve when treated with medicines.
The benefits of surgery need to be compared to the possible complications and new symptoms you may have after surgery. Surgery for GERD can cause problems with swallowing and burping. It can also cause extra gas in the digestive tract, which leads to bloating and passing gas (flatulence).
After surgery, you may need to have other procedures to fix these problems. Some people still have to take medicine to control their symptoms, even after surgery. And some people need to have surgery again.
Fundoplication surgery is the most common surgery used to treat GERD. This surgery strengthens the valve between the esophagus and stomach (lower esophageal sphincter) to keep acid from backing up into the esophagus as easily. It relieves GERD symptoms and inflammation of the esophagus (esophagitis).
Other types of surgery for gastroesophageal reflux disease may include:
- Partial fundoplication. Partial fundoplication involves wrapping the stomach only partway around the esophagus. Full fundoplication involves wrapping the stomach around the esophagus so that it completely encircles it. Most fundoplication surgery uses the full fundoplication method.
- Gastropexy. A gastropexy attaches the stomach to the diaphragm so that the stomach cannot move through the opening in the diaphragm into the chest. Gastropexy is done less often than fundoplication.
Other Works Consulted
- Agency for Healthcare Research and Quality (2011). Comparative Effectiveness of Management Strategies for Gastroesophageal Reflux Disease: Update (AHRQ Publication No. 11-EHC049-EF). Rockville, MD: Agency for Healthcare Research and Quality. Also available online: http://www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=781.
- American Gastroenterological Association (2008). American Gastroenterological Association medical position statement on the management of gastroesophageal reflux disease. Gastroenterology, 135(4): 1383–1391.
- Saltzman JR, Poneros JM (2009). Gastroesophageal reflux disease. In NJ Greenberger et al., eds., Current Diagnosis and Treatment: Gastroenterology, Hepatology, and Endoscopy, pp. 139–147. New York: McGraw-Hill.
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