Gastroesophageal reflux disease (GERD) is a condition in which contents of the stomach or small intestine repeatedly move back up into the esophagus (the tube connecting the throat to the stomach). This regurgitating action is called reflux. Reflux causes heartburn, and although most people have an attack of heartburn at some point in their lives, persistent reflux and severe heartburn may indicate GERD.

Heartburn -- a burning sensation under the sternum in the chest -- is the primary symptom of GERD. Heartburn often occurs after a meal and worsens at night, when you are lying flat. It is more likely to occur following a heavy meal, or if you bend, lift, or lie down just after eating.

Other symptoms of GERD include:

• Regurgitation of food
• Belching
• Nausea and vomiting
• Chronic cough, wheezing
• Sore throat, hoarseness or change in voice, difficulty swallowing
• Chest pain

GERD is common in infants and young children, but is generally mild. If an infant has the following symptoms, however, call a doctor as soon as possible:

• Ongoing coughing
• Wheezing, gasping
• Severe vomiting
• Frequent burping

Normally when a person swallows, the muscular walls of the esophagus move in waves to push the food down into the stomach. Right after the food enters the stomach, a band of muscle (the lower esophageal sphincter, or LES) closes off the esophagus. If the muscle fails to close tightly enough or weakens over time, the stomach contents can back up into the esophagus, causing heartburn and other symptoms of GERD.

Substances in the digestive juices from the stomach (such as acid, pepsin, and bile) can damage the inner lining of the esophagus, causing inflammation ulcers (open sores), and, possibly, precancerous changes to cells (called Barrett's esophagus).

Any of the following may compromise the LES:

• Pregnancy
• Obesity
• Hiatal hernia (a condition in which a portion of the stomach protrudes through an opening in the diaphragm where the esophagus normally fits snuggly and passes into the stomach)
• Recurrent or persistent vomiting
• Nasogastric tubes (these are inserted through the nose and into the stomach for a variety of medical reasons)
• Smoking cigarettes
• Some medicines, including calcium channel blockers (a class of meds used for high blood pressure such as amlodipine, diltiazem, felodipine, nifedipine, nisoldipine, and verapamil), anticholinergic drugs (including benztropine, biperiden, dicyclomine, hyoscyamine, isopropamide, and scopolamine), iron pills, non-steroidal anti-inflammatory drugs (NSAIDs including aspirin and ibuprofen), potassium, dopamine (for Parkinson's disease), sedatives, bisphosphonates (alendronate and risedronate for osteoporosis), and beta blockers (such as atenolol, labetalol, metoprolol, nadolol, pindolol, and propranolol, for high blood pressure or heart disease)

• Heavy meals
• Lying down or bending after a meal
• Eating immediately prior to exercise
• Prior esophageal surgery
• Esophageal stricture (narrowing of the esophagus)
• Cigarette smoking
• Alcohol intake
• Psychological stress

Children with the following conditions are at particular risk for GERD:

• Neurologic impairment
• Food allergies
• Scoliosis
• Frequent vomiting
• Cystic fibrosis
• Digestive disorders

GERD is generally not difficult to diagnose. Your symptoms, what you eat and drink, medications you are taking, and your lifestyle are usually enough to make a clear diagnosis. If the diagnosis is unclear to your doctor, one or more tests may be performed:

• Upper endoscopy, called esophageal gastroduodenoscopy (EGD), which involves the insertion of a tube down your throat into the esophagus to look for signs of reflux, inflammation, ulcers, or other changes in the esophagus.
• A barium swallow, which involves visualization of the esophagus through a series of x-rays following the swallowing of a substance called barium. This looks at the movement of the esophagus and whether any fluid comes back from the stomach into the esophagus.
• Manometry measures the pressure of the sphincter muscle. If the pressure is low, this is consistent with GERD.

The primary goals of treatment are to reduce the reflux (regurgitation), stop the harmful effect of the stomach's materials by reducing its acid content, improve the clearance of food through to the stomach, and protect the walls of the esophagus.

For mild cases, these goals can be accomplished by making lifestyle changes (such as avoiding certain foods) and by taking over-the-counter medication. Health care professionals may recommend herbs such as DGL-licorice (Glycyrrhiza glabra ) for their soothing properties. Prescription medicines may be recommended as needed.

For moderate-to-severe cases, prescription medication may be used more regularly, and the condition may be monitored more closely. If these measures fail, surgery may ultimately be required.

Lifestyle

Making changes to or avoiding certain habits can go a long way to relieving or preventing your symptoms of GERD.

The following are typical suggestions for people with GERD:

• Avoid behavior that does not allow food to easily move down into and through the stomach. This includes bending, lying down, or participating in jarring exercises soon after a meal.
• Don't eat heavy meals.
• Avoid acidic foods and drinks. These include caffeinated beverages, decaffeinated coffee, and orange juice.
• Avoid alcohol, chocolate, spearmint, and peppermint. These can relax the lower esophageal sphincter.
• Avoid carbonated beverages.
• Avoid eating fatty foods, including full-fat milk, which also may relax the lower esophageal sphincter tone. Take medication with plenty of water.
• Lose weight if you are overweight.
• Quit smoking.
• Avoid medications that provoke symptoms. These include smooth-muscle relaxants, such as calcium channel blockers (including amlodipine, diltiazem, felodipine, nifedipine, nisoldipine, and verapamil, which are used for high blood pressure), anticholinergic drugs (including benztropine, biperiden, dicyclomine, hyoscyamine, isopropamide, and scopolamine), iron pills, non-steroidal anti-inflammatory drugs (NSAIDs including aspirin and ibuprofen), potassium, dopamine (for Parkinson's disease), sedatives, bisphosphonates (alendronate and risedronate for osteoporosis), and beta blockers (such as atenolol, labetalol, metoprolol, nadolol, pindolol, and propranolol, for high blood pressure or heart disease).

If you experience more frequent symptoms at night, you may be relieved by:

• Raising the head of your bed about 6 inches.
• Avoiding bedtime snacks.

Stress may worsen symptoms. Therefore, relaxation, such as yoga, tai chi, or meditation, is worth considering as part of your treatment plan.

Medications

The main aim of drug treatment is to control the acidity of the stomach. This can be achieved with either nonprescription or prescription drugs, depending on the severity and frequency of your reflux. Your doctor will determine which medicine is best for you.

There are several different types of medications used for GERD, and each works in a different way. Over-the-counter antacids neutralize the stomach acids. Histamine H2 blockers interfere with the production of acid, and proton pump inhibitors suppress molecules in the glands responsible for the release of acid. Avoid taking other medications within 3 hours of an antacid because antacids may limit the absorption of other drugs.

• Antacids, available over the counter, may relieve heartburn or indigestion. Antacids include aluminum hydroxide (Amphojel, AlternaGEL), magnesium hydroxide (Phillips' Milk of Magnesia), aluminum hydroxide and magnesium hydroxide (Maalox, Mylanta), calcium carbonate (Rolaids, Titralac, Tums), and sodium bicarbonate (Alka-Seltzer). Antacids may block medications from being absorbed and thereby decrease the medicine's effectiveness. It is recommended to take antacids at least 1 hour before or 2 hours after taking medications. Ask your pharmacist or doctor for more information.
• H2 blockers, such as cimetidine (Tagemet), ranitidine (Zantac), nizatidine (Axid), and famotidine (Pepcid), reduce gastric acid secretion.
• Proton-pump inhibitors, including esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix), and rabeprazole (Aciphex), decrease gastric acid production.
• Sucralfate (Carafate) makes a coating over the ulcer crater, protecting it from further damage.
• Prokinetic agents, specifically metoclopramide (Reglan), promote movement of stomach acids along the gastrointestinal tract, rather than backing up into the esophagus.

Surgery and Other Procedures

For a small number of people, diet, medication, and lifestyle changes are not enough to relieve symptoms of GERD. In such cases, a surgical procedure called fundoplication may be performed to prevent reflux and repair a hiatal hernia (a condition that may cause GERD). As many as 90% of people who have had this operation report no longer having heartburn.

Nutrition and Dietary Supplements

Nutritional therapy is one of the first treatments recommended for GERD.

Doctors used to recommend eating bland foods with milk and only small amounts of food with each meal. Following these nutritional tips may help reduce symptoms:

• Eat antioxidant foods, including fruits (such as blueberries, cherries, and tomatoes), and vegetables (such as squash and bell peppers).
• Eat foods high in B-vitamins and calcium, such as almonds, beans, whole grains (if no allergy), dark leafy greens (such as spinach and kale), and sea vegetables.
• Avoid refined foods, such as white breads, pastas, and especially sugar.
• Eat fewer red meats and more lean meats, cold-water fish, tofu (soy, if no allergy) or beans for protein.
• Use healthy oils, such as olive oil or vegetable oil.
• Reduce or eliminate trans-fatty acids, found in commercially baked goods such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
• Avoid beverages that can irritate the lining of the stomach or increase acid production including coffee (with or without caffeine), alcohol, and carbonated beverages.
• Drink 6 - 8 glasses of filtered water daily.
• Exercise at least 30 minutes daily, 5 days a week.

Nutritional deficiencies may be addressed with the following supplements:

• A multivitamin daily, containing the antioxidant vitamins A, C, E, the B-vitamins, and trace minerals, such as magnesium, calcium, zinc, and selenium.
• Omega-3 fatty acids, such as fish oil, 1 - 2 capsules or 1 tablespoonful oil 2 - 3 times daily, to help decrease inflammation and improve immunity. Cold-water fish, such as salmon or halibut, are good sources, but supplementation is recommended.
• Probiotic supplement (containing Lactobacillus acidophilus), 5 - 10 billion CFUs (colony forming units) a day, for maintenance of gastrointestinal and immune health. Some probiotic supplements may need to be refrigerated for best results. Your child may also take probiotic supplements. Consult with your health care provider before giving your child any dietary supplements.
• Alpha-lipoic acid, 25 - 50 mg twice daily, for antioxidant support.
• Melatonin, 2 - 6 mg at bedtime, for immune support and gastric protection.
• Vitamin C, 500 - 1,000 mg one to three times daily, as an antioxidant and for immune support.
• L-glutamine, 500 - 1,000 mg 3 times daily, for support of gastrointestinal health and immunity.
• Grapefruit seed extract (Citrus paradisi), 100 mg capsule or 5 - 10 drops (in favorite beverage) 3 times daily when needed, for antibacterial, antifungal, and antiviral activity, and for immunity.
• Resveratrol (from red wine), 50 - 200 mg daily, to help decrease inflammation and for antioxidant effects.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider to get your problem diagnosed before starting any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, you should make teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink 2 - 4 cups per day. You may use tinctures alone or in combination as noted.

• Green tea (Camelia sinensis) standardized extract, 250 - 500 mg daily, for antioxidant, anti-inflammatory, and heart health effects. Use caffeine-free products. You may also prepare teas from the leaf of this herb.
• Cat's claw (Uncaria tomentosa) standardized extract, 20 mg 3 times a day, for inflammation and antibacterial or antifungal activity.
• Reishi mushroom (Ganoderma lucidum), 150 - 300 mg 2 - 3 times daily, for inflammation and for immunity. You may also take a tincture of this mushroom extract, 30 - 60 drops 2 - 3 times a day.
• Olive leaf (Olea europaea) standardized extract, 250 - 500 mg 1 - 3 times daily, for antibacterial or antifungal activity and immunity. You may also prepare teas from the leaf of this herb.
• DGL-licorice (Glycyrrhiza glabra) standardized extract, 250 - 500 mg 3 times daily, chewed either 1 hour before or 2 hours after meals. Glycyrrhizin is a chemical found in licorice that causes side effects and drug interactions. DGL is deglycyrrhizinated licorice, or licorice with the glycyrrhizin removed.
• Mastic (Pistacia lentiscus) standardized extract, 1,000 - 2,000 mg daily in divided dosages, for activity against H. Pylori.
• Tumeric (Curcuma longa) standardized extract, 300 mg 3 times a day, for pain and inflammation.

Homeopathy

Although few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider the following remedies for the treatment of GERD symptoms based on their knowledge and experience. Before prescribing a remedy, homeopaths take into account your constitutional type - your physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each individual.

• Pulsatilla -- for heartburn, queasiness, a bad taste in the mouth brought on by eating rich foods and fats (especially ice cream); symptoms may include vomiting partly digested food. This remedy is most appropriate for an individual whose tongue is coated with a white or yellow substance.
• Ipecacuahna -- for persistent and severe nausea, with or without vomiting and diarrhea, caused by an excess of rich or fatty foods.
• Carbo vegetabilis -- for bloating and indigestion, especially with flatulence and fatigue.
• Nux vomica -- for heartburn, nausea, retching without vomiting, and sour burps caused by overeating, alcohol use, or coffee drinking. This remedy is most appropriate for individuals who also feel irritable and sensitive to noise and light.

Pregnancy

GERD is quite common during pregnancy, particularly in the third trimester.

Warnings and Precautions

Contact your health care provider if the medication recommended does not help or if you experience side effects, such as cramping or diarrhea.

Prognosis and Complications

The acidic contents of the stomach can damage the esophagus, causing narrowing, ulcers, erosion, and precancerous changes to cells known as Barrett's esophagus. GERD can also result in respiratory diseases, ear, nose, throat conditions, and tooth decay. Most people can effectively manage their symptoms with lifestyle modifications and medications.

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