Heartburn Or Gastroesophageal Reflux Disease (GERD)

What is GERD?
Gastroesophageal reflux is the phrase used to describe the backward flow or regurgitation of stomach contents passing up into the esophagus. The typical symptom of GERD is a burning discomfort behind the breast bone. Some describe heartburn as indigestion, a "sour" stomach, pain in the upper abdomen or chest, regurgitation of food or bitter liquid into the mouth or excessive production of saliva. GERD is a common condition and symptoms of heartburn are experienced at least once a month by more than 60 million Americans.

For women, the first experience with heartburn is often during pregnancy. Studies suggest that over 50% of pregnant women will experience heartburn during pregnancy. This is due to hormones of pregnancy and pressure from the growing fetus. Symptoms of heartburn resolve in most of these women after delivery of the baby.

What causes GERD?
Acid is produced in the stomach every day. Normally, a small amount of acid passes into the esophagus through a valve between the esophagus and stomach called the lower esophageal sphincter. When the frequency or amount of acid in contact with your esophagus increases, symptoms and damage to your esophagus can occur.

Common Causes or Triggers of Heartburn
Eating a large, especially fatty meal
Tomato sauces (spaghetti & pizza)
Lying down after a meal
Chocolate, peppermint
Coffee and tea
Alcohol and carbonated beverages
Some muscle relaxers and blood pressure medicines
Excess weight

The diagnosis of heartburn or GERD is based on the presence of typical infrequent symptoms that may be relieved by antacids or other acid blocking medicines--some available over-the-counter or stronger prescription acid suppressants. As frequency and severity of symptoms increase, the condition is more likely to (1) be referred to as GERD, (2) cause more serious health problems if left untreated, and (3) require treatment and monitoring by your physician and use of prescription medication. If you have heartburn two more times a week, or don’t get lasting relief on the medication you are taking, you need to see your physician.

Occasionally GERD will cause unusual symptoms. If you suffer from unexplained cough, asthma, or laryngitis (hoarseness & sore throat) ask your doctor if it could be caused by acid reflux.

What can you do to treat heartburn?
Many women with infrequent heartburn can easily control symptoms with diet and lifestyle modifications and limited use of over the counter acid-blocking medicines.

Diet and Lifestyle Modifications
Eat more frequent, but smaller meals
Avoid: - fatty food, coffee & tea, chocolate, peppermint, alcohol, smoking, carbonated beverages.
Maintain a normal weight
Avoid eating 2-3 hrs before bedtime
Elevate the head of the bed 4-6 inches

Over-the-Counter (OTC)Medicines*
(liquid or tablets):
Tums®, Rolaids®, Mylanta®, Maalox®, Gaviscon®, and many others.
OTC Acid Blockers: Pepcid AC® , Tagamet HB® , Zantac AC® ., Prilosec OTC®
*Important Note: If you are pregnant or nursing a baby, seek the advice of a doctor before using OTC acid blockers.

Medications Requiring Prescription
Proton Pump Inhibitors: esomeprazole, Nexium®; or
lansoprazole, Prevacid®; or
pentaprazole, Protonix®; or
rabeprazole, Aciphex®;
Pro-motility Drugs: cisapride, Propulsid®
Prescription Strength Antacids: sucralfate, Carafate®
Prescription Strength H2 Blockers: cimetidine, Tagamet® , ranitidine, Zantac® , famotidine, Pepcid® , nizatadine, Axid®

Can longstanding GERD cause serious problems?
Yes. In severe cases, acid reflux may cause esophageal ulcers, strictures and a pre-cancerous disorder called Barrett’s esophagus. Recent studies show that chronic heartburn which is not effectively treated and resolved over several years, can greatly increase your risk of cancer of the esophagus.

When should you see a doctor about symptoms of heartburn?
If you have any of the following:

  • Symptoms of heartburn two or more times a week
  • Don’t get lasting relief on medication you are taking
  • Difficulty swallowing, especially solids
  • Choking, wheezing, hoarseness caused by regurgitation of acid into the throat
    Signs of bleeding (vomiting dark coffee ground-like material or passage of tarry black bowel movements)
  • Unexplained weight loss
  • Reflux symptoms over more than one year

When and what test(s) should be performed to evaluate GERD?
When symptoms are frequent, severe, or not controlled with modification in diet and lifestyle plus use of acid blocking medicines, further testing may be indicated.

EGD (esophagogastroduodenoscopy): this test involves passage of a lighted flexible tube through the mouth into the esophagus, stomach, and upper intestines. Doctors will often spray the back of the throat with an anesthetic and give intravenous sedatives to make the test more comfortable. The EGD is the single best test to evaluate the esophagus for damage from GERD. When necessary, EGD can be safely performed by doctors during pregnancy.

Esophageal Manometry and pH Tests: these tests involve insertion of small catheters (plastic tubes) through the nose into the esophagus to measure pressures and the amount of acid refluxed into the esophagus. These tests are reserved for persons with atypical and/or severe symptoms of GERD.

Surgical Options for Chronic, Severe Heartburn
Generally, there appears to be some relationship between success in reflux surgery and success with medical treatment, for instance, those who have had good results on medical therapy seem to have better results from surgery. Conversely, the intractable reflux patients -- those who have been unsuccessful in resolving their symptoms using medical therapy with prescription acid suppressing medicines -- do not seem to be very good candidates for surgery.

The physician who has been treating your heartburn/GERD with medications should be involved in any consideration of surgery. While there are many patients who have experienced good results through surgery, there is limited, long-term information on continuous relief many years after surgery, and results can vary significantly depending upon the type of hospital and the experience of the specific surgeon.

"Open" fundoplication. This classic surgery requires an incision in the abdomen and/or chest. The surgeon will create an artificial valve using the top of the stomach to prevent further acid reflux into the esophagus. Recovery from surgery requires a week or more in the hospital.

"Laparoscopic" fundoplication: This newer method of surgery uses a lighted tube inserted through a tiny incision in the abdomen to create a valve from the top of the stomach to prevent acid reflux into the chest. Many experienced surgeons have excellent results with this new and safe procedure. Recovery from laparoscopic surgery often requires only a few days in the hospital.

What treatments for heartburn are safe during pregnancy?
During pregnancy, the medical treatment of reflux should be balanced to alleviate the mother’s symptoms of heartburn, while protecting the developing fetus.

Step 1: Modification of diet & lifestyle

Step 2: Antacids are probably safe. Sodium bicarbonate can cause a condition known as metabolic acidosis and should be avoided during pregnancy. Magnesium containing antacids may interfere with uterine contractions during labor and should be avoided during the last trimester of pregnancy.

Step 3: sucralfate (Carafate® ) has a good record for safety and results with pregnant patients. Acid blockers can probably be administered safely, but require a doctor’s supervision.

Step 4: Other medical therapy should only be used when the benefit of the medicine for the mother outweighs the risk of the medicine to the developing fetus.