GERD

What is it?

Note: US English - esophagus
         UK English - oesophagus.

Because of the different spelling, this disease is sometimes known as GORD the UK. This fact sheet uses both spellings.

GERD stands for gastroesophageal reflux disease. This is a condition caused by the weakening of the valve at the lower end of the gullet. This valve is called the lower oesophageal sphincter, or 'LES'. The 'LES' is designed to open to let food down into the stomach, and to close to keep it there. When the 'LES' is weak, food, drink and stomach acids surge upwards, or 'reflux', into the oesophagus.

Symptoms:
- Belching.
- Agitation around mealtimes.
- Stomach ache.
- Frequent vomiting
- Growth problems.
- Refusing to eat
- Hiccups.
- Gagging
- Choking.
- Frequent cough (particularly at night).
- Wheezing.
- Frequent colds.
- Rattling sound in chest.
- Regular sore throat in the morning.
- Sour taste in the mouth.

GERD can be behind other conditions

Doctors now know that GERD can be the hidden factor behind some chronic coughs, hoarseness and asthma-like symptoms. Sometimes sufferers may never have shown the most common symptoms of GERD, such as heartburn and belching.

Other symptoms which could be linked to GERD:

· Asthma.
GERD can aggravate asthma. Recent research has shown that most asthmatics suffer from acid reflux to some extent. It is possible GERD is making asthma worse if:

a) The asthma is noticeably worse after meals, lying down or doing exercise.
b) The asthma is mainly at night.
c) The asthma developed in adulthood. If GERD is found to be connected, treatment of it can cure asthma or decrease the need for asthma medications.

· Chest Pain.
Some sufferers experience chest pain which feels like angina or heart pain. If a doctor has ruled out the heart as the source of the pain, it is worth asking him/her to consider GERD as the potential cause.

· Ear / Nose / Throat Symptoms.
It is worth asking your doctor to consider GERD if standard treatments do not improve the following:

a) Chronic cough.
b) Sore throat.
c) Laryngitis with hoarseness
d) Frequent throat clearing.
e) Growths on the vocal chords.

What happens if GERD is left untreated?

· Barrett's Oesophagus.
Every time the stomach acids reflux, the oesophagus lining becomes inflamed. Regular inflammation can do serious damage to this lining, causing ulcers, bleeding and scar tissue. Eventually, the body tries to protect the oesophagus by replacing its normal lining with a tougher one, similar to the lining of the intestine. This stage of GERD is known as Barrett's Oesophagus.

Once it has developed, the risk of getting Oesophageal cancer is much greater. Because of this, it is important to have regular Endoscopy tests with biopsies (see section 4 for definitions) to make sure there are no cancerous cells.

· Peptic Stricture.
This is caused by scarring and severe acid damage to the lower oesophagus. Thick scar tissue forms in the oesophagus, making it thicker and tighter. Sufferers then develop dysphagia - this means difficulty swallowing and moving food down to the stomach. If solid food is swallowed, there is a danger of it getting stuck in the narrow oesophagus. Severe dysphagia makes it difficult to swallow liquids as well.

Peptic strictures often run less than 1cm along the oesophagus, but in advanced cases the whole length of the oesophagus can thicken and make the oesophagus shorter (see 'gastroplasty' below). Approximately 5-10% of GERD sufferers develop a peptic stricture. However if they have developed Barrett's Oesophagus (see above) the rate rises to 30%.

If the GERD sufferer has a peptic stricture then it has to be dilated - this means stretched or widened - before surgery or medical treatment for the GERD symptoms. This stretching is done in one of the following ways:

a) Axial dilator. These are known as 'balloon dilators'. They inflate inside the oesophagus and stretch the scar tissue.
b) Mercury filled bougie. This is a solid tube which stretches the oesophagus as the surgeon pushes it through.

These two methods are considered to be equally effective.

After dilation
After dilation of a peptic stricture, patients are usually prescribed life-long proton pump inhibitor medication (see 'medication' section 5). This medication has proved to be the best for preventing the return of peptic strictures. It also reduces the uncomfortable symptoms of GERD. After the first dilation of a peptic stricture, a third of patients need to have the procedure again in less than twelve months. If the patient needs dilation again and again, then GERD surgery or a non-surgical procedure (see 'surgery' section 5) will be considered.

Gastroplasty
Many people who suffer repeated peptic strictures have a shortened oesophagus. If this is the case, the oesophagus must be lengthened back to a normal size before the patient can have further GERD treatment. This lengthening procedure is called Collis Gastroplasty.

· Hiatal hernia
Between the abdomen and the chest is a muscle which divides them, called the diaphragm. There is a natural opening - a hiatus - in the diaphragm, but sometimes it is too large. This can be as a result of strain, which has caused the opening to split, or a problem a baby is born with. When there is a split - known as a hernia - the stomach can bulge up through it into the chest. This is called a hiatal hernia. Over half of GERD sufferers also have a hiatal hernia. They vary in size and severity. Some doctors think a hiatal hernia itself weakens the LES and is eventually one of the causes of GERD.

Repairing a hiatal hernia
There are two main different techniques for repairing a hernia. A surgeon can either stitch the hernia up using surgical thread, which can cause problems if it is sewn too tightly, or patch it, using a special mesh patch. Healthy tissue will grow through and attach itself to the mesh patch after surgery. The patch method is an outpatient procedure, which requires only a local anaesthetic. The patch itself is inserted through an incision 4-5cm wide. The patient should be well enough to go home in 1-2hours. Normal activities can be resumed within 3 days. In general, the stitching method is done as open-surgery and requires a general anaesthetic. This means the doctor makes a large incision and a hospital stay will be necessary to recover from the operation. This technique can be performed less invasively, however, using a laporoscope. (see definitions in 'surgery', section 5)

· Oesophageal cancer
This is a relatively rare condition. Chronic, untreated GERD suffered over a period of many years has been linked to the development of Oesophageal cancer. However, this cancer is always curable if it is found early.

Diagnosis of GERD

The following are tests used by doctors to diagnose GERD:

· Chest X-ray

· Upper GI (gastrointestinal) series
These are X- rays of the organs of the upper part of the digestive system. The patient is asked to swallow a safe radioactive liquid - called barium - which shows up on a scan. The doctor makes X-ray films of the way this liquid moves. The patient may be asked to move into different positions on the x-ray table. These X-rays show the doctor the shape and condition of the oesophagus and also how good it is at moving liquid down to the stomach. These tests may also include being asked to swallow a 13mm capsule, also coated in barium, which shows how the oesophagus deals with solid material. If there is a hiatal hernia (see section 3), these tests will show the doctor how big it is.

· Endoscopy.
This is an internal examination of the intestines. This is done by passing a small, flexible tube with a light and a camera at the end, (an endoscope) down the throat and into the intestines. The camera projects an image onto a screen, which the doctor can examine. The test is usually done with sedatives.

· Oesophageal Manometric Studies.
In these tests, a small, flexible tube is passed through the nose into the oesophagus and stomach. The tube measures the pressure in the oesophagus and the strength of the 'LES.' It also measures the amount of acid which is refluxed over a period of 24 hours. This set of tests may also include the GI series - see above for a description.

All of these tests are used to see if a patient needs surgery and, if so, which kind of surgery would be best.

Conventional Treatments for GERD Medication:

Drug treatment can target GERD in various ways. The following is a list of prescription drugs available in the UK and the USA:

· H2 Blockers.
These work by reducing the amount of acid in the stomach. They work best on people with mild - moderate symptoms.
They include Famotidine (Pepcid AC), Cimetidine (Targamet HB) and Ranitidine (Zantac 73).

· Proton Pump Inhibitors.
These work by controlling the pump mechanism in the stomach's acid-making cells. They regulate the stomach's acid production.
They include Omeprazole, Lansoprazole, and Rabeprozole.

· Prokinetic Drugs.
These are usually used along with one of the other drug treatments mentioned here. Some of the drugs in this family work by strengthening the tone of the 'LES', others help the stomach to empty quickly which allows less time for reflux to occur.
These include Metoclopramide and Bethanechol.

· Musocral Protectors.
These coat and protect the inflamed oesophagus and have a soothing effect.
They include Sucralfate (Clarafate).

Further reading/contacts - drugs for GERD
- http://www.rxlist.com
- http://www.drugdigest.org
- http://www.medicinenet.com
- http://www.mca.gov.uk 
Each of these sites contain information about how different drugs work and where they are available.

Surgery
Surgery can be an option if other treatments fail, or if any complications (see section 3) have developed. Some patients may choose surgery over prolonged medical therapy.

· Nissen Fundoplication.
This is the most common form of surgery for GERD. It involves the construction of a new 'valve' to replace the weakened 'LES'. This is done by wrapping the upper part of the stomach around the lower end of the oesophagus. This wrap supports the 'LES' and helps it to open and shut when it is supposed to. The operation can be done as open surgery - this means the surgeon cuts a large opening for his instruments across the abdomen - or as described below.

The alternative to open surgery is sometimes known as keyhole surgery. Nissen fundoplication was first performed in this way in 1991. Instead of the surgeon making a large incision, he/she makes small ones - usually 5-6 of them, of 5-10mm each - in the abdominal area. The area to be operated on is inflated with air to make room for the surgical tools. A laporoscope, a thin stick with a camera at the end of it, is fed through one of the incisions. The camera projects an enlarged image onto a screen, which the surgeon can look at. The surgical tools are also inserted through the small incisions in the abdomen and the surgeon watches his work on the screen.

The recovery time is good, with patients likely to be out of hospital within 2-3 days. For about two weeks after the operation, because swelling around the stitches temporarily narrows the oesophagus, patients should eat foods that are easy to swallow so nothing gets stuck.

Problems which can occur with nissen fundoplication

These figures are from operations performed by surgeons at the Mayo Clinic, Jacksonville, USA. They were all performed using the keyhole surgery technique and were carried out between 1991 - 1997.

· Perforation
25 out of 2,543 patients had their stomach or oesophagus punctured accidentally during the operation. This meant the surgeons decided to do open surgery instead.

· Bleeding
28 of the 2,543 needed a blood transfusion because of serious bleeding during the operation. The surgeons decided to do open surgery on 20 of them.

· Pneumothorax
This is when air and blood get trapped in the space around the lungs. 49 of the 2,453 patients suffered this problem. 5 patients in total were then given open surgery.

· Splenectomy
This is the removal of the spleen, which is a vital organ for fighting infections. Patients without a spleen are likely to be prone to certain bacterial infections. Only 2 of the 2,453 needed to have their spleens taken out as a result of the operation.

Non-surgical techniques
Even though these operations are performed by a qualified surgeon, in a hospital, they are not classified as 'surgical'. This is because they do not involve cutting the patient open in any way.

· The Bard.
This is a new technique only released by the USA Food and Drug Association (The FDA) in March 2000. The method is designed for adults, but it has been performed on teenagers and older children. An anaesthetic spray is used in the throat to stop the gagging/swallowing reflex. This means a flexible tube with a camera at the end of it - an endoscope - can be inserted through the mouth. The endoscope allows the surgeon to view the operation on a screen. At the bottom of the endoscope there is also a needle and surgical thread (suture). The surgeon makes stitches with the thread, sewing pleats between the 'LES' and the top of the stomach. This makes the 'LES' tighter and stiffer - and therefore stronger at preventing reflux. Normal activities can be resumed the next day.

· The Stretta Procedure.
An endoscope (a tube with a camera at the end of it) is inserted through the mouth. The camera shows the surgeon the exact position of the 'LES' on the screen. He or she then inserts another tube down to the level of the 'LES'. At the end of the second tube are tiny needles. These needles are electrodes, which send out powerful radio-frequency waves at the 'LES', causing heat and heat damage. The heat-damaged 'LES' heals by scarring over. This makes it thicker and stiffer and therefore better at preventing reflux. Again, normal activities can be resumed the next day.

At the moment, the surgery available in the UK is limited. Most hospitals do only fundoplication (see above) and tend to favour the older, open-surgery technique. Newer, non-surgical techniques tend to be performed only in America, but pressure from patients may lead to surgeons doing them more often in the UK. It is important to remember that the long-term results/problems with the newer techniques have not yet been documented.

GERD Complications and how they affect the surgical and non-surgical techniques in the section above.

· Barrett's oesophagus (see section 3)
If the GERD sufferer has developed this condition then biopsies will need to be taken before surgery. Biopsies are tiny samples, which are cut out and tested. The patient swallows an endoscope and the tool for cutting the samples is passed through it. These samples are taken out and tested to see how severely the cells have been affected by Barrett's Oesophagus.

· Peptic Stricture (see section 3)
Strictures need to be dilated (widened) before surgery can take place. This is done by stretching the narrowed part of the oesophagus - techniques are described in section 3. Biopsies (see paragraph above) will also need to be taken.

· Hiatal hernia(see section 3)
If the GERD sufferer has developed a hiatal hernia, this will need to be repaired before or alongside any other surgery / treatment needed. A hernia is repaired in several ways, explained in section 3.

Further reading / contacts for GERD surgery.

· http://www.lapsurgery.com
- a site which discusses surgical techniques and advances.

· http://www.sdheartburn.com
- a useful site which explains and illustrates surgical techniques.

American Society for Gastrointestinal Endoscopy (ASGE)
13 Elm Street
Manchester, MA
01944
Tel: (508) 526-8330
http://www.asge.org

The Society for Surgery of the Alimentary Tract (SSAT)
13 Elm Street
Manchester, MA
01944
Tel: (978) 526-8330
http://www.ssat.com

Society of American Gastrointestinal Endoscopic Surgeons (SAGES)
2716 Ocean Park Boulevard
Suite 3000
Santa Monica, CA
90405
Tel: (310) 314-2404
http://www.sages.org/

National Digestive Diseases Information Clearinghouse
2 Information Way
Bethesda, MD
20892-3570
Tel: (301) 654-3810
http://www.niddk.nih.gov/health/digest/nddic.htm

Alternative treatments for GERD.

Herbs
The following are all herbs that can be used to relieve GERD symptoms:

Meadowsweet
This can reduce acid production. You can make a drink by putting a teaspoon of meadowsweet into boiling water and letting it stand for five minutes.

Liquorice
This is anti-inflammatory. Chewable lozenges are best for GERD. Liquorice is not suitable long-term or for people with high blood pressure.

Slippery Elm
This protects irritated tissues and helps them to heal. As a powder it can be mixed with water.

Valerian
This helps poor digestion.

Wild Yam
Anti-inflammatory and gives relief to poor digestion caused by long-term stress.

St John's Wort
This helps with depression, but it is also a pain reliever.

Skullcap
This is calming and helps sleep.

Linden Flowers
Particularly good for treating painful gas or wind.

Homeopathy
Below is a list of the remedies usually prescribed by a homeopathic doctor for GERD symptoms. The doctor will also tell you what strength and dosage is needed.

Arsenicum album
This is for burning pain that feels better with warmth.

Carbo vegetalis
This is for bloating and indigestion that is worse when lying down. Also good for flatulence and fatigue.

Lycopodium
This is for heartburn.

Nux Vomica
This is for heartburn with cramping and constipation.

Lifestyle Changes
There are various lifestyle triggers to GERD. There are also simple things which you can do to improve the symptoms. (For lifestyle changes suitable for babies with GERD, visit http://www.parenting.com)

· Things to avoid include:
- Foods which contribute to heartburn: chocolate, coffee, peppermint, high-fat or spicy foods, food containing tomatoes, alcohol, citrus fruit / juices.
- Tobacco. Smoking may increase stomach acid production and weaken the 'LES', which causes reflux.
- Being overweight. Obesity can aggravate GERD.
- Lying down after eating: It is advisable to wait at least two hours before lying down after eating, so the evening meal should be eaten two hours before going to bed.
- Tight clothing This can make digestion difficult

· Things which can help include:
- Raising the head while sleeping. Much of the damage done by GERD takes places at night. If the head is raised, the stomach acids cannot rise up the oesophagus so easily and so they have less chance to make it inflamed. One option is to sit the legs at the head end of the bed on a plank of wood, propped up by pieces of wood to about six inches off the floor. Obviously, it is important the structure is stable.
- Because GERD can be made more severe by food intolerance or allergies, it may be worth considering food allergy testing. (For more information on food allergies, fact sheets are available from the HSF on Candida and Gluten/Casein allergies.)

Further GERD Reading

American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)
8630 Fenton Street
Suite 412
Silver Spring, MD
20910-3805
Tel: (301) 587-6315
http://www.clinnutr.org

http://www.parenting.com
This site contains useful tips on lifestyle changes for babies with GERD.

http://www.allergy.co.uk
This is a site which describes the various food allergy tests available. It is recommended by the British Allergy Foundation.

British Homeopathic Association
15 Clerkenwell Close
London
EC1R 0AA
Tel: 020 7566 7800
http:// www.trusthomeopathy.org

Biolab
The Stonehouse
9 Weymouth Street
London W1N 3FF
Tel: 020 7636 5959 H
http://www.biolab.co.uk

York Nutritional Laboratory
Murton way
Osbaldwick
York
YO19 5US
Tel: 01904 777722
http://www.allergy.co.uk

Allergy Diagnostic Centre
Grays Farm production Village
Grays Farm Road
Orpington
Kent
BR5 3BD
Tel: 020 8308 1363
http://www.pathlynx.co.uk/adc

Allergy Diagnostic Laboratory
68 Milton Park Estate
Abingdon
Oxfordshire
OX14 4RX
Tel: 01235 862757

General addresses / sites

http://www.reflux.org
Paediatric / Adolescent Gastroesophageal Reflux Association (PAGER) Useful, general information on the net.

http://www.geocities.com/HotSprings/Villa/2193/
Calls itself 'The Gerd Word'. Good site offering information, support and chat with parents of children with GERD. There is a good message board for any GERD questions. Most info about doctors applies only to America.

The American Gastroenterological Association (AGA)
7910 Woodmont Avenue
7th Floor
Bethesda, MD
20814
Tel: 301-654-2055
http://www.gastro.org

The National Digestive Diseases Information Clearinghouse
2 Information Way
Bethesda, MD
20892-3570
http://www.niddk.nih.gov/health/digest/nddic.htm

American College of Gastroenterology
4900 B South 31st Street
Arlington, VA
22206
Tel: (703) 820-7400
http://www.acg.gi.org

American Gastroenterological Association (AGA)
National Office
7910 Woodmont Avenue
7th Floor
Bethesda, MD
20814
Tel: (301) 654-2055
http://www.gastro.org

General reading about GERD
- Fantle Shimberg Elaine. Coping With Chronic Heartburn : What You Need to Know About Acid Reflux and Gerd ISBN: 031226884X
- Gilbert Udall Kate Managing Acid Reflux: Complementary Treatments for Indigestion and Other Digestive Disorders. ISBN: 1580543316
- Minocha Anil. Adamec Christine. How to Stop Heartburn: Simple Ways to Heal Heartburn and Acid Reflux ISBN: 0471391395
- Panchecko Paulo. Living with Chronic Heartburn. ISBN: 1578261023
- Bell Richard. Rikkers Layton. Mulholland Michael.Digestive Tract Surgery ISBN: 0397513445
- Brostoff Jonathan. Gamlin Linda. Food Allergies and Food Intolerance : The Complete Guide to Their Identification and Treatment ISBN: 0892818751

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