GERD- GastroEsophageal Reflux Disease (See Zoom Teleclinic Aug 13, 2020, 3:30 Pacific Time)

by | Aug 12, 2020

Gastroesophageal Reflux Disease

Also indexed as: Acid Reflux, GERD

Businessman Suffering From GERD.

Gastroesophageal reflux disease (GERD) is a disorder of the esophagus that causes frequent symptoms of heartburn and gas often resulting in hiatal hernia. The esophagus is the tube connecting the mouth to the stomach. GERD occurs when a muscular ring called the lower esophageal sphincter (LES) is weakened, which permits irritating stomach contents to pass through the diaphragm hiatus up into the esophagus, resulting in heartburn.

Sometimes regurgitation of acid and food as high as the mouth can occur. Chronic irritation of the esophagus by stomach acid can eventually cause ulceration and scarring and might lead to cancer of the esophagus, especially in people who smoke and/or consume large amounts of alcohol.1

What are the symptoms of GERD?

People with GERD have heartburn, which usually feels like a burning pain that begins in the chest and may travel upward to the throat. Many people also feel a regurgitation of stomach contents into the mouth, leaving an acid or bitter taste. Some people with GERD may also have coughing while lying down, increased production of saliva, and difficulty sleeping after eating.

Medical treatments

Over the counter antacids, such as magnesium hydroxide (Phillips’ Milk of Magnesia®), aluminum hydroxide (Amphojel®), calcium carbonate (Tums®), and the combination magnesium-aluminum hydroxide (Mylanta®, Maalox®), help relieve the symptoms of GERD. The histamine H2 antagonists, such as cimetidine (Tagamet®), ranitidine (Zantac®), and famotidine (Pepcid®), are also beneficial.

Medications may be used to control stomach acidity, including prescription strength histamine H2 inhibitors, such as cimetidine (Tagamet®), ranitidine (Zantac®), and famotidine (Pepcid®), as well as the proton pump inhibitors omeprazole (Prilosec®), lansoprazole (Prevacid®), pantoprazole (Protonix®), and rabeprazole (Aciphex®).  Long term use of OTC or prescribed medications often results in food sensitivities due to maldigestion and malabsorption.

Individuals with GERD should avoid stomach acid stimulants (e.g., coffee, alcohol), certain drugs (e.g., anticholinergics), specific foods (e.g., fats, chocolate, sugar), and smoking. 

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Dietary changes that may be helpful

Whether lowering dietary fat is important for people with GERD is somewhat unclear. Historically, low-fat diets have been recommended to patients with GERD because fatty foods appeared to be associated with increased heartburn and fatty foods had been shown to weaken the LES in both healthy people and people with GERD.2 3 A number of recent studies, however, have found no correlation between the fat content of a meal and subsequent symptoms of heartburn and reflux.4 5 Another study found that hospitalizations due to GERD were no more likely for people who ate high-fat diets than for those on low-fat diets.6 One study compared different fast foods for their likelihood to cause reflux symptoms and found that chili and red wine caused more symptoms than higher-fat foods such as hamburgers and French fries.7

Eating foods or drinking beverages flavored with spearmint, peppermint, or other spices with strong aromatic oils causes relaxation of the LES and can contribute to symptoms in people with GERD.8 Chocolate also relaxes the LES and can cause heartburn.9 10 Acidic beverages like juices, coffee, and tea have also been linked to increased heartburn pain, as have carbonated drinks, alcohol, and milk.11

Infants who suffer from GERD may have a true allergy to cows’ milk.12 Some small studies estimate that milk allergy is a cause in about 20% of infants with GERD,13 14 15 but a larger study of 204 infants with GERD diagnosed cows’ milk allergies in 41%.16 For these infants, reflux symptoms improved with elimination of milk products from the diet. Some researchers advise a trial of cows’ milk-elimination in all infants suffering from GERD.17 18 Infants with a condition known as multiple food protein intolerance in infancy (MFPI) have been shown to have a high incidence of GERD and may only improve when amino-acid based formula is used in place of other formulas.19 20

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Lifestyle changes that may be helpful

Smoking weakens the LES and is a strong risk factor for GERD.21 22 23 A study of infants with GERD found that exposure to cigarette smoke in the environment is associated with reflux, leading the authors conclude that secondhand smoke contributes directly to GERD in infants.24 No similar studies on environmental smoke have been done with adults. Psychological stress and alcohol have also been shown to be associated with the weakening of the LES and symptoms of GERD.25 26 27 28

A number of studies have found that obesity increases the risk of GERD,29 30 though one study found no association between severe obesity and GERD.31 Obese people tend to have weaker sphincters,32 and they more often develop a condition related to GERD called hiatal hernia, in which the upper part of the stomach protrudes above the diaphragm, resulting in a deformed LES.33 It has been suggested that obesity may contribute to GERD by increasing abdominal pressure, but this mechanism has not been proven.34 The benefit of weight loss for obese patients with GERD is controversial. Some researchers have found that symptoms of GERD are reduced with weight loss,35 while others have seen no change with weight loss and even increased symptoms in patients with massive weight loss.36

Lying down prevents gravity from keeping the stomach contents well below the opening from the esophagus. For this reason, many authorities recommend that people with GERD avoid lying down sooner than three hours after a meal, and suggest elevating the head of the bed to prevent symptoms during sleep.37 38

GERD occurs more frequently during exercise than at rest, and can be a cause of chest pain or abdominal pain during exertion.39 One study found that increased intensity of exercise resulted in increased reflux in both trained athletes and untrained people.40 In another study, running produced more reflux than less jarring activities, such as bicycling, while weight training produced few reflux symptoms.41 Eating just before exercise has been found to further aggravate GERD.42 43 On the other hand, a recent survey found that people who participate in little recreational activity were more likely than active people to be hospitalized for GERD.44 It makes sense for people with GERD to use exercise as part of a healthy lifestyle, perhaps choosing activities that are less likely to cause reflux symptoms.

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Nutritional supplements that may be helpful

Hydrochloric acid and digestive enzymes are sometimes recommended by practitioners of natural medicine in the hope improved digestion will help prevent reflux.45 However, these therapies have not been researched for their effectiveness.  Gastric analysis by radio-telemetry should be done to measure hydrochloric acid production before supplementation is advised.

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Herbs that may be helpful

Licorice, particularly as chewable deglycyrrhizinated licorice (DGL), has been shown to be an effective treatment for the healing of stomach and duodenal ulcers;46 47 48 in an uncontrolled trial, licorice was effective as a treatment for aphthous ulcers (canker sores).49 A synthetic drug similar to an ingredient of licorice has been used as part of an effective therapy for GERD in both uncontrolled50 and double-blind51 52 trials. In a comparison trial, this combination proved to be as effective as cimetidine (Tagamet®), a common drug used to treat GERD.53 However, licorice itself remains unexamined as a treatment for GERD.

Other herbs traditionally used to treat reflux and heartburn include digestive demulcents (soothing agents) such as aloe vera, slippery elm, bladderwrack, and marshmallow.54 None of these have been scientifically evaluated for effectiveness in GERD. However, a drug known as Gaviscon®, containing magnesium carbonate (as an antacid) and alginic acid derived from bladderwrack, has been shown helpful for heartburn in a double-blind trial.55 It is not clear whether whole bladderwrack would be as useful as its alginic acid component.

References:

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2. Nebel OT, Castell DO. Lower esophageal pressure changes after food ingestion. Gastroenterology 1972;63:778–83.

3. Becker DJ, Sinclair J, Castell DO, Wu WC. A comparison of high and low fat meals on postprandial esophageal acid exposure. Am J Gastroenterol 1989;84:782–6.

4. Penagini R, Mangano M, Bianchi PA. Effect of increasing the fat content but not the energy load of a meal on gasto-oesophageal reflux and lower oesophageal sphincter motor function. Gut 1998;42:330–3.

5. Pehl C, Waizenhoefer A, Wendl B, et al. Effect of low and high fat meals on lower esophageal sphincter motility and gastroesophageal reflux in healthy subjects. Am J Gastroenterol 1999;94:1192–6.

6. Ruhl CE, Everhart JE. Overweight, but not high dietary fat intake, increases risk of gastroesophageal reflux disease hospitalization: the NHANES I Epidemiologic Followup Study. First National Health and Nutrition Examination Survey. Ann Epidemiol 1999;9:424–35.

7. Rodriguez S, Miner P, Robinson M, et al. Meal type affects heartburn severity. Dig Dis Sci 1998;14:157–9.

8. Sigmund CJ, McNally EF. The action of a carminitive on the lower esophageal sphincter. Gastroenterology 1969;56:13–8.

9. Wright LE, Castell DO. The adverse effect of chocolate on lower esophageal sphincter pressure. Dig Dis 1975;20:703–7.

10. Murphy DW, Castell DO. Chocolate and heartburn: Evidence of increased esophageal acid exposure after chocolate ingestion. Am J Gastroenterol 1988;83:633–6.

11. Feldman M, Barnett C. Relationships between the acidity and osmolality of popular beverages and reported postprandial heartburn. Gastroenterology 1995;108:125–31.

12. Moneret-Vautrin DA. Cow’s milk allergy. Allerg Immunol (Paris) 1999;31:201–10 [review].

13. McLain BI, Cameron DJ, Barnes GL. Is cow’s milk protein intolerance a cause of gastro-oesophageal reflux in infancy? J Paediatr Child Health 1994;30:316–8.

14. Forget P, Arends JW. Cow’s milk protein allergy and gastro-oesophageal reflux. Eur J Pediatr 1985;144:298–300.

15. Staiano A, Troncone R, Simeone D, et al. Differentiation of cow’s milk intolerance and gastro-oesophageal reflux. Arch Dis Child 1995;73:439–42.

16. Iacono G, Carroccio A, Cavataio F, et al. Gastroesophageal reflux and cow’s milk allergy in infants: a prospective study. J Allergy Clin Immunol 1996:97:822–7.

17. Staiano A, Troncone R, Simeone D, et al. Differentiation of cow’s milk intolerance and gastro-oesophageal reflux. Arch Dis Child 1995;73:439–42.

18. Forget P, Arends JW. Cow’s milk protein allergy and gastro-oesophageal reflux. Eur J Pediatr 1985;144:298–300.

19. Hill DJ, Cameron DS, Catto-Smith A, et al. Multiple food protein intolerance (MFPI) as a cause of reflux oesophagitis in infancy: results of a pilot study. J Allergy Clin Immunol 1998;101:S89 [abstract].

20. Hill DJ, Hosking CS, Heine RG. Clinical spectrum of food allergy in children in Australia and South-East Asia: identification and targets for treatment. Ann Med 1999;31:272–81 [review].

21. Castell DO. Physiology and pathophysiology of the lower esophageal sphincter. Ann Otol Rhinol Laryngol 1975;84:569–75 [review].

22. Stanghellini V. Relationship between gastrointestinal symptoms and lifestyle, psychosocial factors and comorbidity in the general population: results from the Domestic/International Gastroenterology Surveillance Study (DIGEST). Scand J Gastroenterol Suppl 1999:231:29–37.

23. Locke GR 3rd, Talley NJ, Fett SL, et al. Risk factors associated with symptoms of gastroesophageal reflux. Am J Med 1999;106:642–9.

24. Alaswad B, Toubas PL, Grunow JE. Environmental tobacco smoke exposure and gastroesophageal reflux in infants with apparent life-threatening events. J Okla State Med Assoc 1996;89:233–7.

25. Castell DO. Physiology and pathophysiology of the lower esophageal sphincter. Ann Otol Rhinol Laryngol 1975;84:569–75 [review].

26. Stanghellini V. Relationship between gastrointestinal symptoms and lifestyle, psychosocial factors and comorbidity in the general population: results from the Domestic/International Gastroenterology Surveillance Study (DIGEST). Scand J Gastroenterol Suppl 1999:231:29–37.

27. Rodriguez S, Miner P, Robinson M, et al. Meal type affects heartburn severity. Dig Dis Sci 1998;14:157–9.

28. Locke GR 3rd, Talley NJ, Fett SL, et al. Risk factors associated with symptoms of gastroesophageal reflux. Am J Med 1999;106:642–9.

29. Halsted CH. Obesity: effects on the liver and gastrointestinal system. Curr Opin Clin Nutr Metab Care 1999;2:425–9 [review].

30. Locke GR 3rd, Talley NJ, Fett SL, et al. Risk factors associated with symptoms of gastroesophageal reflux. Am J Med 1999;106:642–9.

31. Lundam L, Ruth M, Sandberg N, Bove-Nielson M. Does massive obesity promote abnormal gastroesophageal reflux? Dig Dis Sci 1995;40:1632–5.

32. Fisher BL, Pennathur A, Mutnick JL, Little AG. Obesity correlates with gastroesophageal reflux. Dig Dis Sci 1999;44:2290–4.

33. Wilson LJ, Ma W, Hirschowitz BI. Association of obesity with hiatal hernia and esophagitis. Am J Gastroenterol 1999;94:2840–4.

34. Merced CD, Rue C, Hanelin L, Hill LD. Effect of obesity on esophageal transit. Am J Surg 1985;149:177–81.

35. Fraser-Moody CA, Norton B, Gornall C, et al. Weight loss has an independent beneficial effect on symptoms of gastro-oesophageal reflux in patients who are overweight. Scand J Gastroenterol 1999;34:337–40.

36. Kjellin A, Ramel S, Rossner S, Thor K. Gastroesophageal reflux in obese patients is not reduced by weight reduction. Scand J Gastroenterol 1996;31:1047–51.

37. Kitchin LI, Castell DO. Rationale and efficacy of conservative therapy for gastroesophageal reflux disease. Arch Intern Med 1991;151:448–54. [review]

38. Galmiche JP, Letessier E, Scarpignato C. Treatment of gastro-oesophageal reflux disease in adults. BMJ 1998;316:1720–3.

39. Shawdon A. Gastro-oesophageal reflux and exercise. Important pathology to consider in the athletic population. Sports Med 1995;20:109–16. [review]

40. Soffer EE, Wilson J, Duethman G, et al. Effect of graded exercise on esophageal motility and gastroesophageal reflux in nontrained subjects. Dig Dis Sci 1994;39:193–8.

41. Clark CS, Kraus BB, Sinclair J, Castell DO. Gastroesophageal reflux induced by exercise in healthy volunteers. JAMA 1989;261:3599–601.

42. Yazaki E, Shawdon A, Beasley I, Evans DF. The effect of different types of exercise on gastro-oesophageal reflux. Aust J Sci Med Sport 1996;28:93–6.

43. Clark CS, Kraus BB, Sinclair J, Castell DO. Gastroesophageal reflux induced by exercise in healthy volunteers. JAMA 1989;261:3599–601.

44. Ruhl CE, Everhart JE. Overweight, but not high dietary fat intake, increases risk of gastroesophageal reflux disease hospitalization: the NHANES I Epidemiologic Followup Study. First National Health and Nutrition Examination Survey. Ann Epidemiol 1999;9:424–35.

45. Golan R. Optimal Wellness. New York: Ballantine Books, 1995, 373–4.

46. Morgan AG, Pacsoo C, McAdam WA. Maintenance therapy: A two year comparison between Caved-S and cimetidine treatment in the prevention of symptomatic gastric ulcer. Gut 1985;26:599–602.

47. Kassir ZA. Endoscopic controlled trial of four drug regimens in the treatment of chronic duodenal ulceration. Ir Med J 1985;78:153–6.

48. Glick L. Deglycyrrhinated licorice in peptic ulcer. Lancet 1982;ii:817 [letter].

49. Das SK, Das V, Gulati AK, Singh VP. Deglycyrrhizinated liquorice in aphthous ulcers. J Assoc Physicians India 1989;37:647.

50. Markham C, Reed PI. Pyrogastrone treatment of peptic oesophagitis: analysis of 104 patients treated during a 3 1/2-year period. Scand J Gastroenterol Suppl 1980;65:73–82.

51. Reed PI, Davies WA. Controlled trial of a carbenoxolone/alginate antacid combination in reflux oesophagitis. Curr Med Res Opin 1978;5:637–44.

52. Young GP, Nagy GS, Myren J, et al. Treatment of reflux oesophagitis with a carbenoxolone/antacid/alginate preparation. A double-blind controlled trial. Scand J Gastroenterol 1986;21:1098–104.

53. Maxton DG, Heald J, Whorwell PJ, Haboubi NY. Controlled trial of pyrogastrone and cimetidine in the treatment of reflux oesophagitis. Gut 1990;31:351–4.

54. Golan R. Optimal Wellness. New York: Ballantine Books, 1995, 373–4.

55. Chevrel B. A comparative crossover study on the treatment of heartburn and epigastric pain: Liquid Gaviscon and a magnesium-aluminum antacid gel. J Int Med Res 1980;8:300–3.

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