Acid Reflux (GERD) and the Esophagus
Acid suppression continues to be the mainstay for treating GERD that does not respond to lifestyle changes and treatment. The aim of drug therapy is to reduce the amount of acid and improve any abnormalities in muscle function of the lower esophageal sphincter, esophagus, or stomach.
Most cases of gastroesophageal reflux are mild and can be managed with lifestyle changes, over-the-counter medications, and antacids.
Patients with moderate-to-severe symptoms that do not respond to lifestyle changes, or who are diagnosed at a late stage may be started on medications of varying strength, depending on their complications at diagnosis. Experts argue, however, about the best way to start drug treatment for GERD in most of these patients. The two major treatment options are known as the step-up and step-down approaches:
- Step-up. With a step-up drug approach the patient first tries an H2 blocker drug, which is available over the counter. These drugs include famotidine (Pepcid AC), cimetidine (Tagamet HB), ranitidine (Zantac 75), and nizatidine (Axid AR). If the condition fails to improve, therapy is "stepped up" to the more powerful proton-pump inhibitors (PPI), usually omeprazole (Prilosec).
- Step-down. A step-down approach first uses a more potent drug, most often a PPI, such as omeprazole (Prilosec). When patients have been symptom-free for 2 months or longer, they are then "stepped down" to a half-dose. If symptoms do not come back, the drug is stopped. If symptoms return, the patient is put on high-dose H2 blockers. Some physicians argue that the step-down approach should be used for most patients with moderate-to-severe GERD.
If neither approach relieves symptoms, the physician should look for other conditions. Endoscopy and other tests might be used to confirm GERD and rule out other disorders, as well as evaluate when treatment is not working. In some cases, bile, not acid, may be responsible for symptoms, so acid-reducing or blocking agents would not be helpful. (Bile is a fluid that is present in the small intestine and gallbladder.)
Surgery may be needed in certain circumstances:
- If lifestyle changes and drug treatments have failed
- If patients cannot tolerate medication
- In patients who have other medical complications
- In younger people with chronic GERD, who face a lifetime of expense and inconvenience with maintenance drug treatment
Some physicians are recommending surgery as the treatment of choice for many more patients with chronic GERD, particularly because minimally invasive surgical procedures are becoming more widely available, and only surgery improves regurgitation. Furthermore, persistent GERD appears to be much more serious than was previously believed, and the long-term safety of using medication for acid suppression is still uncertain.
Nevertheless, anti-GERD procedures have many complications and high failure rates. As with medications, current surgical procedures cannot cure GERD. About 15% of patients still require anti-GERD medications after surgery. Furthermore, about 40% of surgical patients are at risk for new symptoms after surgery (such as gas, bloating, and trouble swallowing), with most side effects occurring more than a year after surgery. Finally, evidence now suggests that surgery does not reduce the risk for esophageal cancer in high-risk patients, such as those with Barrett's esophagus. New procedures may improve current results, but at this time patients should consider surgical options very carefully with both a surgeon and their primary doctor.
Treatments for Barrett's Esophagus
To date, no treatments can reverse the cellular damage after Barrett's esophagus has developed, although some procedures are showing promise.
Medications. If a patient is diagnosed with Barrett's esophagus, the doctor will prescribe PPIs to suppress acid. Using these medications may help slow the progression of abnormal changes in the esophagus.
Surgery. Surgical treatment of Barrett's esophagus may be considered when patients develop high-grade dysplasia of the cells lining the esophagus. Barrett's esophagus alone is not a reason to perform anti- reflux surgery, and is only recommended when other reasons for this surgery are present. See "Surgery" section.
Managing GERD in Infancy and Childhood
Here are some tips on managing GERD in infants:
- During and after feeding, infants should be positioned vertically and burped frequently.
- If a baby with GERD is fed formula, the mother should ask the doctor how to thicken it in order to prevent splashing up from the stomach.
- Parents of infants with GERD should discuss the baby's sleeping position with their pediatrician. The seated position should be avoided, if possible. Experts strongly recommend that all healthy infants sleep on their backs to help prevent sudden infant death syndrome (SIDS). For babies with GERD, however, lying on the back may obstruct the airways. If the physician recommends that the baby sleeps on his stomach, the parents should be sure that the infant's mattress is very firm, possibly tilted up at the head, and that there are no pillows. The baby's head should be turned so that the mouth and nose are completely unobstructed. Carefully watch children who are placed on their stomach.
- Because food allergies may trigger GERD in children, parents may want to discuss a dietary plan with their physician that starts the child on formulas using non-allergenic proteins, and then incrementally adds other foods until symptoms are triggered.
- Proton-pump inhibitors (PPIs), such as omeprazole (Prilosec) and lansoprazole (Prevacid), are drugs that suppress the production of stomach acid. The FDA has approved the proton-pump inhibitor (PPI) esomeprazole (Nexium) for the short-term treatment of GERD in children ages 1 - 11. In studies, treatment with Nexium once a day for eight weeks was safe and well tolerated in children. The most common side effects were headache, diarrhea, abdominal pain, nausea, gas, constipation, dry mouth, and sleepiness.
Managing GERD in Children. The same drugs used in adults may be tried in children with chronic GERD. While some drugs are available over the counter, do not give them to children without physician supervision.
- Changes in diet can include eliminating foods that are acidic or possibly associated with reflux, such as tomatoes, chocolate, mint, juices, and carbonated or caffeinated drinks.
- Obese children should try to lose weight.
- Milder medications, such as antacids, are used first. However, long-term use of these drugs is generally not recommended due to side effects such as diarrhea or constipation.
- PPIs may also be effective in children. A delayed-release capsule and liquid form of Nexium has been approved for the short-term (up to 8 weeks) treatment of GERD in children ages 1 - 11. Nexium capsules were previously approved for use in children ages 12 - 17, also for short-term GERD treatment. The PPI rabeprazole sodium (ACIPHEX) is approved for the short-term (up to 8 weeks) treatment of adolescents ages 12 and over. PPIs appear to be safe and effective even for children as young as 1 year old who fail the less intensive therapies. However, children treated with H2 blockers and PPIs may have an increased risk of developing respiratory and intestinal infections.
- H2 blockers are available over the counter and include famotidine (Pepcid AC), cimetidine (Tagamet HB), ranitidine (Zantac 75), and nizatidine (Axid AR). Note: The FDA has issued a warning on Pepcid AC for people with kidney problems Ã¢â‚¬â€œ see below in the Medications section.
Surgical fundoplication involves wrapping the upper curve of the stomach (fundus) around the esophagus. The goal of this surgical technique is to strengthen the LES. Until recently, surgery was the primary treatment for children with severe complications from GERD because older drug therapies had severe side effects, were ineffective, or had not been designed for children. However, with the introduction of PPIs, some children may be able to avoid surgery.
Surgical fundoplication can be performed laparoscopically through small incisions. Weakening of the LES over the long-term occurs with children as well as adults.