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7. Gastroesophageal Reflux Disease |
v Heartburn, Hiatal Hernia, and Gastroesophageal Reflux Disease (GERD)
Gastroesophageal reflux disease, or GERD, occurs when the lower esophageal sphincter (LES) does not close properly and stomach contents leak back, or reflux, into the esophagus. The LES is a ring of muscle at the bottom of the esophagus that acts like a valve between the esophagus and stomach. The esophagus carries food from the mouth to the stomach.
When refluxed stomach acid touches the lining of the esophagus, it causes a burning sensation in the chest or throat called heartburn. The fluid may even be tasted in the back of the mouth, and this is called acid indigestion. Occasional heartburn is common but does not necessarily mean one has GERD. Heartburn that occurs more than twice a week may be considered GERD, and it can eventually lead to more serious health problems.
Anyone, including infants, children, and pregnant women, can have GERD.
What are the symptoms of GERD?
The main symptoms are persistent heartburn and acid regurgitation. Some people have GERD without heartburn. Instead, they experience pain in the chest, hoarseness in the morning, or trouble swallowing. You may feel like you have food stuck in your throat or like you are choking or your throat is tight. GERD can also cause a dry cough and bad breath.
GERD in Children
Studies* show that GERD is common and may be overlooked in infants and children. It can cause repeated vomiting, coughing, and other respiratory problems. Children’s immature digestive systems are usually to blame, and most infants grow out of GERD by the time they are 1 year old. Still, you should talk to your child’s doctor if the problem occurs regularly and causes discomfort. Your doctor may recommend simple strategies for avoiding reflux, like burping the infant several times during feeding or keeping the infant in an upright position for 30 minutes after feeding. If your child is older, the doctor may recommend avoiding
• sodas that contain caffeine
• chocolate and peppermint
• spicy foods like pizza
• acidic foods like oranges and tomatoes
• fried and fatty foods
Avoiding food 2 to 3 hours before bed may also help. The doctor may recommend that the child sleep with head raised. If these changes do not work, the doctor may prescribe medicine for your child. In rare cases, a child may need surgery.
*Jung AD. Gastroesophageal reflux in infants and children. American Family Physician. 2001;64(11):1853-1860.
What causes GERD?
No one knows why people get GERD. A hiatal hernia may contribute. A hiatal hernia occurs when the upper part of the stomach is above the diaphragm, the muscle wall that separates the stomach from the chest. The diaphragm helps the LES keep acid from coming up into the esophagus. When a hiatal hernia is present, it is easier for the acid to come up. In this way, a hiatal hernia can cause reflux. A hiatal hernia can happen in people of any age; many otherwise healthy people over 50 have a small one.
Other factors that may contribute to GERD include:
• alcohol use
• overweight
• pregnancy
• smoking
Also, certain foods can be associated with reflux events, including
• citrus fruits
• chocolate
• drinks with caffeine
• fatty and fried foods
• garlic and onions
• mint flavorings
• spicy foods
• tomato-based foods, like spaghetti sauce, chili, and pizza
How is GERD treated?
If you have had heartburn or any of the other symptoms for a while, you should see your doctor. You may want to visit an internist, a doctor who specializes in internal medicine, or a gastroenterologist, a doctor who treats diseases of the stomach and intestines. Depending on how severe your GERD is, treatment may involve one or more of the following lifestyle changes and medications or surgery.
Lifestyle Changes
• If you smoke, stop.
• Do not drink alcohol.
• Lose weight if needed.
• Eat small meals.
• Wear loose-fitting clothes.
• Avoid lying down for 3 hours after a meal.
• Raise the head of your bed 6 to 8 inches by putting blocks of wood under the bedposts—just using extra pillows will not help.
Medications
Your doctor may recommend over-the-counter antacids, which you can buy without a prescription, or medications that stop acid production or help the muscles that empty your stomach.
Antacids, such as Alka-Seltzer, Maalox, Mylanta, Pepto-Bismol, Rolaids, and Riopan, are usually the first drugs recommended to relieve heartburn and other mild GERD symptoms. Many brands on the market use different combinations of three basic salts—magnesium, calcium, and aluminum—with hydroxide or bicarbonate ions to neutralize the acid in your stomach. Antacids, however, have side effects. Magnesium salt can lead to diarrhea, and aluminum salts can cause constipation. Aluminum and magnesium salts are often combined in a single product to balance these effects.
Calcium carbonate antacids, such as Tums, Titralac, and Alka-2, can also be a supplemental source of calcium. They can cause constipation as well.
Foaming agents, such as Gaviscon, work by covering your stomach contents with foam to prevent reflux. These drugs may help those who have no damage to the esophagus.
H2 blockers, such as cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR), and ranitidine (Zantac 75), impede acid production. They are available in prescription strength and over the counter. These drugs provide short-term relief, but over-the-counter H2 blockers should not be used for more than a few weeks at a time. They are effective for about half of those who have GERD symptoms. Many people benefit from taking H2 blockers at bedtime in combination with a proton pump inhibitor.
Proton pump inhibitors include omeprazole (Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex), and esomeprazole (Nexium), which are all available by prescription. Proton pump inhibitors are more effective than H2 blockers and can relieve symptoms in almost everyone who has GERD.
Another group of drugs, prokinetics, helps strengthen the sphincter and makes the stomach empty faster. This group includes bethanechol (Urecholine) and metoclopramide (Reglan). Metoclopramide also improves muscle action in the digestive tract, but these drugs have frequent side effects that limit their usefulness.
Because drugs work in different ways, combinations of drugs may help control symptoms. People who get heartburn after eating may take both antacids and H2 blockers. The antacids work first to neutralize the acid in the stomach, while the H2 blockers act on acid production. By the time the antacid stops working, the H2 blocker will have stopped acid production. Your doctor is the best source of information on how to use medications for GERD.
What if symptoms persist?
If your heartburn does not improve with lifestyle changes or drugs, you may need additional tests.
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A barium swallow radiograph uses x rays to help spot abnormalities such as a hiatal hernia and severe inflammation of the esophagus. With this test, you drink a solution and then x rays are taken. Mild irritation will not appear on this test, although narrowing of the esophagus—called stricture--ulcers, hiatal hernia, and other problems will. |
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Upper endoscopy is more accurate than a barium swallow radiograph and may be performed in a hospital or a doctor’s office. The doctor will spray your throat to numb it and slide down a thin, flexible plastic tube called an endoscope. A tiny camera in the endoscope allows the doctor to see the surface of the esophagus and to search for abnormalities. If you have had moderate to severe symptoms and this procedure reveals injury to the esophagus, usually no other tests are needed to confirm GERD. |
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The doctor may use tiny tweezers (forceps) in the endoscope to remove a small piece of tissue for biopsy. A biopsy viewed under a microscope can reveal damage caused by acid reflux and rule out other problems if no infecting organisms or abnormal growths are found. |
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In an ambulatory pH monitoring examination, the doctor puts a tiny tube into the esophagus that will stay there for 24 hours. While you go about your normal activities, it measures when and how much acid comes up into your esophagus. This test is useful in people with GERD symptoms but no esophageal damage. The procedure is also helpful in detecting whether respiratory symptoms, including wheezing and coughing, are triggered by reflux. |
Surgery
Surgery is an option when medicine and lifestyle changes do not work. Surgery may also be a reasonable alternative to a lifetime of drugs and discomfort.
Fundoplication, usually a specific variation called Nissen fundoplication, is the standard surgical treatment for GERD. The upper part of the stomach is wrapped around the LES to strengthen the sphincter and prevent acid reflux and to repair a hiatal hernia.
This fundoplication procedure may be done using a laparoscope and requires only tiny incisions in the abdomen. To perform the fundoplication, surgeons use small instruments that hold a tiny camera. Laparoscopic fundoplication has been used safely and effectively in people of all ages, even babies. When performed by experienced surgeons, the procedure is reported to be as good as standard fundoplication. Furthermore, people can leave the hospital in 1 to 3 days and return to work in 2 to 3 weeks.
In 2000, the U.S. Food and Drug Administration (FDA) approved two endoscopic devices to treat chronic heartburn. The Bard EndoCinch system puts stitches in the LES to create little pleats that help strengthen the muscle. The Stretta system uses electrodes to create tiny cuts on the LES. When the cuts heal, the scar tissue helps toughen the muscle. The long-term effects of these two procedures are unknown.
Implant
Recently the FDA approved an implant that may help people with GERD who wish to avoid surgery. Enteryx is a solution that becomes spongy and reinforces the LES to keep stomach acid from flowing into the esophagus. It is injected during endoscopy. The implant is approved for people who have GERD and who require and respond to proton pump inhibitors. The long-term effects of the implant are unknown.
What are the long-term complications of GERD?
Sometimes GERD can cause serious complications. Inflammation of the esophagus from stomach acid causes bleeding or ulcers. In addition, scars from tissue damage can narrow the esophagus and make swallowing difficult. Some people develop Barrett’s esophagus, where cells in the esophageal lining take on an abnormal shape and color, which over time can lead to cancer.
Also, studies have shown that asthma, chronic cough, and pulmonary fibrosis may be aggravated or even caused by GERD.
Points to Remember
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Heartburn, also called acid indigestion, is the most common symptom of GERD. Anyone experiencing heartburn twice a week or more may have GERD. |
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You can have GERD without having heartburn. Your symptoms could be excessive clearing of the throat, problems swallowing, the feeling that food is stuck in your throat, burning in the mouth, or pain in the chest. |
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In infants and children, GERD may cause repeated vomiting, coughing, and other respiratory problems. Most babies grow out of GERD by their first birthday. |
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If you have been using antacids for more than 2 weeks, it is time to see a doctor. Most doctors can treat GERD. Or you may want to visit an internist—a doctor who specializes in internal medicine—or a gastroenterologist—a doctor who treats diseases of the stomach and intestines. |
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Doctors usually recommend lifestyle and dietary changes to relieve heartburn. Many people with GERD also need medication. Surgery may be an option. |
Hope Through Research
No one knows why some people who have heartburn develop GERD. Several factors may be involved, and research is under way on many levels. Risk factors—what makes some people get GERD but not others—are being explored, as is GERD’s role in other conditions such as asthma and bronchitis.
The role of hiatal hernia in GERD continues to be debated and explored. It is a complex topic because some people have a hiatal hernia without having reflux, while others have reflux without having a hernia.
Much research is needed into the role of the bacterium Helicobacter pylori. Our ability to eliminate H. pylori has been responsible for reduced rates of peptic ulcer disease and some gastric cancers. At the same time, GERD, Barrett’s esophagus, and cancers of the esophagus have increased. Researchers wonder whether having H. pylori helps prevent GERD and other diseases. Future treatment will be greatly affected by the results of this research.
v Gastroesophageal Reflux in Children and Adolescents
Gastroesophageal reflux (GER) occurs when stomach contents back up into the esophagus (the tube that connects the mouth to the stomach) during or after a meal. A ring of muscle at the bottom of the esophagus opens and closes to allow food to enter the stomach. This ring is called the lower esophageal sphincter (LES). Reflux can occur when the LES opens, allowing stomach contents and acid to come back up into the esophagus.
GER often begins in infancy, but only a small number of infants continue to have GER as older children. Evaluation by a physician is advised for anyone with persistent symptoms of GER.
Symptoms
Almost all children and adults have a little bit of reflux, without being aware of it. When refluxed material rapidly returns to the stomach, it causes no damage to the esophagus. In some children, the stomach contents remain in the esophagus and cause damage to the esophagus lining. In other children, the stomach contents go up to the mouth (regurgitation) and are swallowed again. When the refluxed material passes into the back of the mouth or enters the airways, the child may become hoarse or have a raspy voice or a chronic cough. Other symptoms include recurrent pneumonia, wheezing, and difficult or painful swallowing.
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Diagnosis
The doctor or nurse can talk with you about your child’s symptoms, examine your child, and recommend tests to determine if reflux is the cause of the symptoms. These tests check the esophagus, stomach, and small intestine to see if there are any problems. However, treatment is sometimes started without tests.
The most common tests used to diagnose GER are
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Upper GI series x ray: Barium (a chalky drink) is swallowed so x rays will show the shape of the esophagus and stomach. This test can find a hiatal hernia, blockage, and other problems. |
| • |
Endoscopy: After a sedative medication is given so the patient will fall asleep, a small flexible tube with a very tiny camera is inserted through the mouth and down into the esophagus and stomach. The lining of the esophagus, stomach, and part of the small intestine is examined and biopsies (small pieces of the lining) can be painlessly obtained. The biopsies are later examined with a microscope for signs of inflammation and other problems. |
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Esophageal pH probe: A thin light wire with an acid sensor at its tip is inserted through the nose into the lower part of the esophagus. The probe detects and records the amount of stomach acid coming back up into the esophagus, and can tell if acid is in the esophagus when the child has symptoms such as crying, arching the back, or coughing. |
Speak with your child’s health care provider if any of the following occur:
| • | increased amounts of vomiting or persistent projectile (forceful) vomiting |
| • | vomiting of fluid that is green or yellow in color or looks like coffee grounds or blood |
| • | difficulty breathing after vomiting or spitting up |
| • | pain related to eating, or food refusal causing weight loss or poor weight gain |
| • | difficult or painful swallowing |
Treatment
The treatment of reflux depends on the child’s symptoms and age. When a child or teenager is uncomfortable, has difficulty sleeping or eating, or fails to grow, the doctor or nurse may first suggest a trial of medication to decrease the amount of acid made in the stomach. One class of medications called H2-blockers includes cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid), and nizatidine (Axid).
Another class is proton-pump inhibitors such as esomeprazole (Nexium), omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), and pantoprazole (Protonix).*
* The authors of this fact sheet do not specifically endorse the use of drugs for children that have not been tested in children (“off label” use). Such a determination can only be made under the recommendation of the treating health care provider.
If the child continues to have symptoms despite the initial treatment, tests may be ordered to help find better treatments. It is rare for children to require surgery for GER. However, surgery may be the best option for children who have severe symptoms that do not respond to any treatment.
Your child’s doctor or nurse can discuss the treatment options with you and help your child feel well again.
Additional suggestions are
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Have your child or teenager eat smaller meals more often. |
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Avoid eating 2 to 3 hours before bed. |
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Elevate the head of the bed 30 degrees. |
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Avoid carbonated drinks, chocolate, caffeine, and foods that are high in fat or contain a lot of acid (citrus fruits) or spices. |
Points to Remember
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GER occurs when stomach contents back up into the esophagus. |
| • |
GER is common in infants but most children grow out of it. |
| • |
GER may cause vomiting, coughing, hoarseness, or painful swallowing. |
| • |
Treatment depends on the child’s symptoms and age, and may include changes in eating habits and medications. Surgery may be an option. |
Hope Through Research
Researchers are studying the risk factors for developing GER and what causes the LES to open, with the aim of improving future treatment for GER.
v Gastroesophageal Reflux in Infants
Gastroesophageal reflux (GER) occurs when stomach contents come back up into the esophagus (the tube that connects the mouth to the stomach) during or after a meal. A ring of muscle at the bottom of the esophagus opens and closes to allow food to enter the stomach.
This ring of muscle is called the lower esophageal sphincter (LES). This sphincter opens to release gas (burping) after meals in normal infants, children, and adults. When the sphincter opens in infants, the stomach contents often go up the esophagus and out the mouth (spitting up or vomiting). GER can also occur when babies cough, cry, or strain. Most infants with GER are happy and healthy even though they spit up or vomit.
Symptoms
GER occurs often in normal infants. More than half of all babies experience reflux in the first 3 months of life. An infant with GER may experience
| • | spitting |
| • | vomiting |
| • | coughing |
| • | irritability |
| • | poor feeding |
| • | blood in the stools |
Only a small number of infants have severe symptoms due to GER. Most infants stop spitting up between the ages of 12 to 18 months.
In a small number of babies, GER may result in symptoms that are of concern. These include problems such as
| • | poor growth due to an inability to hold down enough food |
| • | irritability or refusing to feed due to pain |
| • | blood loss from acid burning the esophagus |
| • | breathing problems |
These problems can be caused by disorders other than GER. Your health care provider needs to determine if GER is causing your child’s symptom(s).
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Diagnosis
An infant who spits or vomits may have GER. The doctor or nurse will talk with you about your child’s symptoms and will examine your child. If the infant is healthy, happy, and growing well, no tests or treatment may be needed. Tests may be ordered to help determine whether your child’s symptoms are related to GER. Sometimes, treatment is started without tests.
Treatment
The treatment of reflux depends on the infant’s symptoms and age. Some babies may not need treatment, because GER often resolves by itself. Healthy, happy babies may only need their feedings thickened with cereal and to be kept upright after they are fed. Overfeeding can aggravate reflux, so your health care provider may suggest different ways of handling feedings. For example, smaller quantities with more frequent feeding can help decrease the chances of regurgitating. If a food allergy is suspected, you may be asked to change the baby’s formula, or to modify your diet if you are breastfeeding, for 1 to 2 weeks. If a child is not growing well, feedings with higher calorie content or tube feeding may be recommended.
Speak with your child’s health care provider if any of the following occur:
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vomiting large amounts or persistent projectile (forceful) vomiting, particularly in infants under 2 months of age |
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vomiting fluid that is green or yellow in color or looks like coffee grounds or blood |
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difficulty breathing after vomiting or spitting up |
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excessive irritability related to feeding, or refusing food, which seems to cause weight loss or poor weight gain |
| • |
difficult or painful swallowing |
Other treatments include the following:
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When a child is uncomfortable, has difficulty sleeping or eating, or does not grow, the doctor or nurse may suggest a medication. Different types of medicine can be used to treat reflux by decreasing the acid secreted by the stomach. One class of medications, called H2-blockers, includes cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid), and nizatidine (Axid). Another type of medication is the proton-pump inhibitors, such as esomeprazole (Nexium), omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), and pantoprazole (Protonix).* |
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Very rarely infants have severe GER that prevents them from growing or causes breathing problems. In some of these infants, surgery may be the best option. |
Your child’s doctor or nurse will discuss GER with you and suggest treatment if needed. The potential complications of the medications will be explained. Most infants don’t need medications and will outgrow reflux by 1 or 2 years of age.
* The authors of this fact sheet do not specifically endorse the use of drugs for children that have not been tested in children (“off label” use). Such a determination can only be made under the recommendation of the treating health care provider.
Specific Instructions for Infants With GER
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If the baby is bottle fed, add up to one tablespoon of rice cereal to 2 ounces of infant milk (including expressed breast milk). If the mixture is too thick for your infant to take easily, you can change the nipple size or cross cut the nipple. |
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Burp your baby after 1 or 2 ounces of formula are taken. For breastfed infants, burp after feeding on each side. |
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Do not overfeed. Talk to your child’s doctor or nurse about the amounts of formula or breast milk that your baby is taking. |
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When possible, hold your infant upright in your arms for 30 minutes after feeding. |
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Infants with GER should usually sleep on their backs, as is suggested for all infants. Rarely, a physician may suggest other sleep positions. |
Points to Remember
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GER occurs when stomach contents back up into the esophagus. |
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GER is common in infants but most children grow out of it. |
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In infants, GER may cause spitting up, vomiting, coughing, poor feeding, or blood in the stools. |
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Treatment depends on the infant’s symptoms and age, and may include changes in eating and sleeping habits. Medication may also be an option, or surgery in severe cases. |
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The main symptoms are watery diarrhea and vomiting. |
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Anyone can get viral gastroenteritis through unwashed hands, close contact with an infected person, or food and beverages that contain the virus. |
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Diagnosis is based on the symptoms and a physical examination. Currently only rotavirus can be rapidly detected in a stool test. |
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Viral gastroenteritis has no specific treatment; antibiotics are not effective against viruses. Treatment focuses on reducing the symptoms and preventing dehydration. |
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The symptoms of dehydration are excessive thirst, dry mouth, dark yellow urine or little or no urine, decreased tears, severe weakness or lethargy, and dizziness or light-headedness. |
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Infants, young children, the elderly, and people with weak immune systems have a higher risk of developing dehydration due to vomiting and diarrhea. |
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People with viral gastroenteritis should rest, drink clear liquids, and eat easy-to-digest foods. |
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For infants and young children, oral rehydration solutions can replace lost fluids, minerals, and salts. |
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Avoid viral gastroenteritis by washing hands thoroughly after using the bathroom or changing diapers, disinfecting contaminated surfaces, and avoiding foods or liquids that might be contaminated. |
For more information
American College of Gastroenterology (ACG)
4900-B South 31st Street
Arlington, VA 22206-1656
Phone: (703) 820-7400
Fax: (703) 931-4520
Internet: www.acg.gi.org
American Gastroenterological Association (AGA)
National Office
4930 Del Ray Avenue
Bethesda, MD 20814
Phone: (301) 654-2055
Fax: (301) 652-3890
Email: webinfo@gastro.org
Internet: www.gastro.org
North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN)
P.O. Box 6
Flourtown, PA 19031
Phone: (215) 233-0808
Fax: (215) 233-3939
Email: naspghan@naspghan.org
Internet: www.naspghan.org
Pediatric/Adolescent Gastroesophageal Reflux Association Inc. (PAGER)
P.O. Box 1153
Germantown, MD 20875-1153
Phone: (301) 601-9541
Email: gergroup@aol.com
Internet: www.reflux.org