Gastroesophageal reflux disease (GERD) occurs when stomach acid and stomach contents regurgitate from the stomach into the esophagus (swallowing tube). When this occurs, it can cause symptoms of heartburn but many patients will have no heartburn symptoms and instead will have cough, hoarseness, or difficulty controlling their asthma. Gastroesophageal reflux is common and in most patients can be treated with intermittent antacids or acid blockers (such as Zantac, Pepcid, or Tagamet). For patients with more severe symptoms or daily symptoms, more aggressive therapy is needed.
Gastroesophageal reflux is particularly common in patients with asthma and can be documented to occur in approximately 90% of asthmatics. In many asthmatics, the gastroesophageal reflux will actually make the asthma worse.
Gastroesophageal reflux can also stimulate a condition called vocal cord dysfunction (see Web file on vocal cord dysfunction) and not only can trigger this disease but make its control quite difficult.
Although most people have heartburn occasionally during their lives, the diagnosis can often be difficult to make in patients who do not have heartburn symptoms. In this case, gastroesophageal reflux can be sometimes identified by a barium swallow (a test done in the radiology department where barium is swallowed while x-rays are taken). The best test for gastroesophageal reflux, however, is the 24-hour pH probe which measures stomach acid in the esophagus for 24 hours. This is performed by having a very thin wire passed through the nose and into the esophagus where it records the pH in the esophagus on a magnetic tape. Gastroesophageal reflux can also be indirectly diagnosed by upper endoscopy where the gastroenterologist can see esophagitis which is the damage done to the esophagus by the regurgitated acid.
There are both medical and nonmedical treatments for gastroesophageal reflux. For patients with moderate to severe GERD, nonmedical therapy should be used whether nor not patients are also receiving medical (drug) therapy.
Nonmedical therapy consists of minimizing the amount of stomach acid that refluxes into the esophagus. Because stomach acid tends to reflux more when you lay flat, it is useful to put a four to six inch support underneath the legs to the head of the bed so that the bed mattress and box springs remain at a very slight incline. This will allow gravity to help keep the stomach acid in the stomach and out of the esophagus. Additionally, you should avoid eating just before bedtime and ideally you should eat four hours or so before going to bed so that there is a minimal amount of food in the stomach when you lay down; this means eliminating midnight snacks. Certain foods can make the gastroesophageal reflux worse and these should be avoided or at least minimized, especially in the evening meals. These foods include citrus fruits, tomato based foods, fatty foods, caffeinated beverages, and alcohol.
There are several medications which can be effective for gastroesophageal reflux. For mild symptoms, the "H-2" blockers can minimize the heartburn symptoms. Additionally, over the counter antacids are often useful. For patients with more severe symptoms or symptoms which fail to resolve despite over the counter medications, "proton-pump" medications can be used. These include Prilosec and Prevacid. There are other medications which can cause the stomach to pass food and acid into the intestine more quickly therefore resulting in the stomach being empty more of the time. These include medications such as Reglan and Propulsid. Propulsid can have undesirable effects on the heart rhythm in some patients and in otherwise healthy patients taking certain medications so you should check with your physician about the relative merits versus risks of using Propulsid.
In the most difficult cases, surgery is often required where the connection between the esophagus and the stomach is "tightened up" using a fundoplication procedure. This is reserved for patients who fail medical therapy.
Physicians are only now beginning to appreciate the frequency of gastroesophageal reflux and the striking connection between GERD and lung diseases and lung symptoms. Fortunately, in nearly all patients, symptoms will improve with one or a combination of the above treatments. It is important not to give up on therapy too early as some symptoms of gastroesophageal reflux (such as vocal cord dysfunction and cough) can take several weeks before improvement is noted.
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