GERD: Heartburn and more

Harvard Men's Health Watch

Doctors call it gastroesophageal reflux disease, or GERD. Millions of men call it heartburn, and many others have coughing, wheezing, or hoarseness without realizing that GERD is to blame. By any name, GERD is common, bothersome, and sometimes serious. It is also expensive, draining the American economy of more than $9 billion a year. But once you know you have GERD, you can control it and prevent complications.

Normal swallowing

A complex set of 29 muscles in your mouth and tongue get the process started. They close off your windpipe (trachea) to protect your lungs, and then move food into your esophagus, or food pipe. The esophagus is a narrow 10- to 13-inch-long tube leading from your throat to your stomach. But food doesn't just slide down the esophagus. Instead, muscles that encircle the food pipe contract in an orderly, wave-like fashion to propel food into the stomach. That's why an adventurous (and athletic) guy can perform the old parlor stunt of drinking while standing on his head (as they say on TV — don't attempt this at home).

Swallowing is normally a one-way affair. To prevent food from returning to the esophagus, the ring-like muscles of the lower esophagus pinch the tube closed. Doctors call these muscles the lower esophageal sphincter, or LES (see figure).

GERD: Acid on the rise

In GERD, stomach acid backs up into the esophagus, injuring sensitive tissues.

What is GERD?

Every time you swallow, the LES relaxes so food can enter your stomach. When your stomach is full, a tiny amount of food can sneak back into the esophagus when you swallow — that's normal. But in people with GERD, substantial amounts of stomach acid and digestive juices get into the esophagus. The stomach has a tough lining that resists acid, but the food pipe doesn't. Its sensitive tissues are injured by acid, and, if the acid makes it all the way to the mouth, other structures can be damaged.

Causes

Poor function of the LES is responsible for most cases of GERD. A variety of substances can make the LES relax when it shouldn't, and others can irritate the esophagus, exacerbating the problem. Other conditions can simply put too much pressure on the LES. Some of the chief culprits in GERD are shown below.

Common causes of GERD symptoms

Foods

  • Garlic and onions

  • Coffee, cola, and other carbonated beverages

  • Alcohol

  • Chocolate

  • Fried and fatty foods

  • Citrus fruits

  • Peppermint and spearmint

  • Tomato sauces

Medications

  • Alpha blockers (used for the prostate)

  • Nitrates (used for angina)

  • Calcium-channel blockers (used for angina and high blood pressure)

  • Tricyclics (used for depression)

  • Theophylline (used for asthma)

  • Bisphosphonates (used for osteoporosis)

  • Anti-inflammatories (used for arthritis, pain, and fever)

Other causes

  • Smoking

  • Obesity

  • Overeating

  • Tight clothing around the waist

  • Hiatus hernia (part of the stomach bulges through the diaphragm muscle into the lower chest)

  • Pregnancy

Symptoms

Heartburn and "acid indigestion" are the most common complaints. A burning pain is typical, and when it's accompanied by burping or bloating, it points to GERD as the cause. But GERD can sometimes cause belly pain that mimics an ulcer. And if acid in the food pipe triggers esophageal spasms, it can cause a heavy or constricting pain that may feel like a heart attack.

If the acid makes it all the way to the throat and mouth, it can cause other problems. And since these problems can occur in the absence of heartburn, they are often misdiagnosed. Here are some of the stealthy signs of GERD:

Mouth and throat symptoms

  • A sour or bitter taste in the mouth

  • Regurgitation of food or fluids

  • Hoarseness or laryngitis, especially in the morning

  • Sore throat or the need to clear the throat

  • Dental erosions

  • Feeling that there is a "lump in the throat."

Lung symptoms

  • Persistent coughing without apparent cause, especially after meals

  • Wheezing, asthma.

Complications

About 19 million Americans have GERD. Most have heartburn and many experience throat or lung symptoms. But a few go on to develop complications. The most common is esophagitis, inflammation of the food pipe. It produces consistent burning pain that can make swallowing and eating difficult. Left untreated, the inflammation can cause ulcers of the tube's lining, bleeding, or both. Repeated cycles of esophagitis and healing can lead to a scarring and narrowing of the tube (a stricture).

Severe esophagitis only strikes about 2% of people with GERD. An even smaller number develop Barrett's esophagus, a condition in which severe inflammation and acid conspire to produce premalignant changes in the cells that line the esophagus. Some 2% to 5% of people with Barrett's esophagus go on to develop cancer. To prevent that, people with severe esophagitis should take medications to suppress acid indefinitely. In addition, patients with Barrett's esophagus require regular endoscopies to detect any progression toward cancer.

Diagnosis

Most people with GERD don't need any tests at all. If your symptoms are typical and mild, you may even be able to treat yourself. Similarly, if doctors suspect you have uncomplicated GERD, they may recommend a trial of therapy as the next step; if you respond promptly, you probably won't be asked to have additional tests.

GERD can be puzzling, however, so if the diagnosis is uncertain, tests may be in order. The old standby is the barium swallow, or upper GI series. You'll be asked to swallow a paste-like solution of barium while a technician takes x-rays to look for ulcers, strictures, a hiatus (also called hiatal) hernia, abnormal contractions of the esophagus, or reflux of barium from the stomach into the food pipe.

Esophageal monitoring is a better way to diagnose GERD. One type, pH monitoring, measures the level of acid in the lower esophagus over a 24-hour period, while manometry measures the pressure in the esophagus during swallowing.

Endoscopy is the best way to detect the complications of GERD, including inflammation, ulcers, strictures, and abnormal or malignant cells. After giving you sedatives and numbing your throat, your doctor will pass a fiber-optic tube through your mouth into your esophagus and stomach. Endoscopy allows the physician to inspect and photograph your tissues and to perform biopsies on any suspicious areas.

Endoscopy is an important test, but it's not risk-free, so it shouldn't be done unless necessary. Here are some warning symptoms that may call for endoscopy:

  • Longstanding or severe GERD

  • GERD that does not respond to therapy

  • GERD that begins after age 50

  • GERD that is accompanied by loss of appetite or weight, vomiting, bleeding or anemia, difficulty swallowing, or the sensation of food sticking in the esophagus.

Therapy: Lifestyle

You can control many symptoms of GERD with simple lifestyle modifications. Here are some tips:

  • Don't smoke. It's the first rule of preventive medicine, and it's as important for GERD as for heart and lung disease.

  • Avoid foods that trigger GERD (see "Common causes of GERD symptoms").

  • If you are taking certain painkillers, antibiotics, or other medications that can irritate the esophagus or contribute to GERD, ask your doctor about alternatives, but don't stop treatment on your own.

  • Avoid large meals and try to be up and moving around for at least 30 minutes after eating. (It's a good time to help with the dishes.) Don't lie down for two hours after you eat, even if it means giving up that bedtime snack.

  • Use gravity to keep the acid down in your stomach at night. Propping up your head with an extra pillow won't do it. Instead, place four- to six-inch blocks under the legs at the head of your bed. A simpler (and very effective) approach is to sleep on a large, wedge-shaped pillow. Your bedding store may not carry one, but many maternity shops will, since GERD is so common during pregnancy. And because GERD is also so common in general, you won't be the only man looking for a pillow in a maternity shop.

  • Chew gum, which will stimulate acid-neutralizing saliva.

  • Lose weight.

  • Avoid tight belts and waistbands.

Treatment: Medications

If you doubt that GERD is a big problem in the U.S., just check out your local drug store. You'll find a vast array of over-the-counter (OTC) products to treat it, plus numerous prescription medications behind the pharmacist's counter. Here is a look at the five types of medication that can help:

Proton-pump inhibitors (PPIs). PPIs are the most effective medications for GERD. That's because they are the best at shutting down the stomach's acid production. They act rapidly, but even after you feel better, it may take four to eight weeks to heal an inflamed food pipe. Because GERD tends to recur, patients usually need prolonged therapy, and those with severe esophagitis or Barrett's esophagus may need high-dose, lifelong treatment. Fortunately, side effects are uncommon, with diarrhea, rash, or headache in fewer than 3% of people taking the medications. Long-term use, particularly at high doses, can increase the risk of osteoporosis ("thin bones") and fractures. One PPI, omeprazole, is available OTC and by prescription. The others — lansoprazole (Prevacid), rabeprazole (AcipHex), pantoprazole (Protonix), and esomeprazole (Nexium) — are prescription medications.

H2-receptor blockers. These popular drugs were the first to reduce the production of stomach acid. They are widely available OTC in low doses and by prescription in full doses. H2 blockers can provide temporary relief for mild GERD, but are less effective than PPIs. Examples include cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid), and nizatidine (Axid).

Antacids. Antacids do not reduce the amount of acid produced by the stomach, but they do neutralize some of it. Many are available over the counter. They reduce acid faster than acid-suppressing medications but provide only temporary relief for mild heartburn. In general, liquid forms work faster than chewable tablets. Antacids that contain magnesium can produce loose stools. Those with calcium can be used as dietary supplements to build stronger bones, but men should not overdo it since they can cause constipation, and high doses of calcium (above 1,200 mg a day) may increase the risk of advanced prostate cancer.

Coating agent. Sucralfate (Carafate) is a prescription drug that protects the esophagus and stomach by forming a protective film on the surface. It is very safe, but long-term benefits are unclear.

Motility agent. Metoclopramide (Reglan), another prescription drug, promotes normal contractions of the esophagus and helps the stomach empty faster. Side effects such as drowsiness, agitation, and tremors limit its usefulness, but it can help some patients with GERD.

Treatment: Surgery

Lifestyle modifications and medications — particularly the PPIs — have produced such good results that surgery for GERD is recommended much less often than it used to be. But surgery has improved, too, and it can be very beneficial for patients with severe GERD who don't respond fully to medical therapy and, perhaps, in young people who are leery of lifelong medication.

The major advance is the introduction of laparoscopic surgery for GERD. While the patient is under general anesthesia, the surgeon makes several small incisions in the abdomen that are used to introduce a fiber-optic tube and tiny surgical instruments. The most popular GERD operation is the Nissen fundoplication, in which the upper portion of the stomach is wrapped around the lower esophagus to prevent reflux. New approaches include using radiofrequency energy to tighten the LES (the Stretta procedure) and tightening the LES with sutures (the Bard system).

Getting the better of GERD

GERD is a problem of modern life. Smoking, poor eating habits, obesity, alcohol abuse, and stress all fuel the fire of heartburn. A little heartburn from time to time is no big deal — but persistent GERD can lead to serious complications. Fortunately, this modern problem can be solved with old-fashioned lifestyle changes, modern drug therapy with PPIs or other agents, and new surgical options.