Treating gastroesophageal reflux disease (GERD) is important. If left alone GERD can lead to serious complications, such as esophageal ulcers (nonhealing mucosal defects), esophageal strictures, Barrett’s esophagus (a disorder of the cells lining the esophageal mucosa, which may lead to cancer), and esophageal cancer.
1. Lifestyle measures
The treatment of GERD starts with lifestyle measures, which may eliminate symptoms in some people with mild reflux. Traditionally, doctors recommend avoiding large meals that can increase pressure in the stomach and promote reflux.
Acidic foods (tomato-based products and citrus fruits, for example) and spicy foods may irritate an inflamed esophagus. Peppermint, spearmint, chocolate, cinnamon, coffee, and tea may reduce the pressure in the lower esophageal sphincter and promote reflux. Carbonated beverages may worsen reflux by increasing pressure in the stomach.
Conflicting studies about the effects of these foods on GERD, however, have cast some doubt on the subject. In 2013 the American College of Gastroenterology released updated clinical guide- lines for treating GERD based on an extensive analysis of medical research. The guidelines highlight three key lifestyle modifications as a first step:
• Lose weight if you are overweight or have recently gained weight.
• Elevate the head of your bed 6 to 8 inches at night with blocks or a foam wedge (not pillows, which can cause an unnatural bend in the body and increase pressure to the stomach) if you suffer from nighttime GERD.
• Avoid high-fat meals within two to three hours of bedtime.
Because of insufficient scientific evidence showing benefit, the guidelines don’t recommend dietary restrictions, although for some patients with specific reflux triggers, dietary changes may be helpful.
If lifestyle modifications don’t eliminate your symptoms, your doctor will recommend medication to neutralize or decrease acid production in the stomach. The guidelines recommend antacids, histamine H2-receptor antagonists (also known as H2 blockers), and proton pump inhibitors. Sometimes a single medication will work, but if it doesn’t control your symptoms, you may need to take a second medication.
• Antacids. Over-the-counter antacids containing aluminum oxide, magnesium carbonate, and sodium bicarbonate (for example, Gaviscon, Gelusil, Maalox, Mylanta) rapidly neutralize stomach acid and are taken after meals when you experience heartburn. These medications provide fast relief, but their effect is short lived.
• H2 blockers. Over-the-counter or prescription H2 blockers, such as cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR), and ranitidine (Zantac 75), have a longer effect on gastric acid than antacids. They usually need to be taken twice a day. A combination antacid/H2 blocker, Pepcid Complete, also appears to be more effective at relieving symptoms than H2 blockers or antacids alone.
• Proton pump inhibitors. These prescription drugs, which include esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec, Zegerid), pantoprazole (Protonix), rabeprazole (AcipHex), dexlansoprazole (Dexilant), and an omeprazole/sodium bicarbonate combination (Zegerid), are the most potent suppressors of gastric acid secretion. They have a long-lasting effect and need to be taken only once a day. Prilosec and Prevacid 24HR are available over the counter.
Besides providing the most effective heartburn relief, PPIs are best at healing erosive esophagitis—inflammation of the esophagus—caused by GERD, the guidelines say. Keep in mind, however, that there are concerns over long-term suppression of gastric acid using proton pump inhibitors, particularly that it could lead to bone fractures and infection.
In fact, the Food and Drug Administration now requires PPI labels to include a warning about a possible increased risk of hip, wrist and spine fractures.
In addition, the effects of H2 blockers and proton pump inhibitors can be enhanced by taking a promotility agent, such as metoclopramide (Reglan, Metozolv ODT). This type of medication increases acid clearance from the esophagus, raises the pressure of the lower esophageal sphincter, and speeds emptying of the stomach.
Lifestyle measures and medications are so effective at controlling reflux symptoms that few people need to undergo surgery. When surgery is required, the most common procedure is Nissen fundoplication. It involves lifting a portion of the stomach and tightening it around the gastroesophageal junction to increase pressure in the lower esophageal sphincter and prevent reflux.
The procedure is typically performed using a laparoscope, an instrument that can be inserted through small incisions in the abdomen. Five small incisions are made in the abdomen, and the surgeon inserts a tiny camera and specialized instruments through the incisions to perform the procedure.
Nissen fundoplication is performed in a hospital. You will receive general anesthesia and need to stay in the hospital for one to three days; you can return to work in two to three weeks.
Serious complications are rare but can include an adverse reaction to the anesthesia, blood loss, infection, and injury to the esophagus, stomach, or spleen. More common complications are difficulty swallowing, stomach bloating, belching, and vomiting. These problems usually improve within one to three months.
Surgery reduces reflux symptoms in most people, but it doesn’t always eliminate them. One study found that about 80 percent of people who underwent Nissen fundoplication still require medication on a regular basis to control their symptoms three years after surgery.
As an alternative to surgery, several methods for treating GERD endoscopically have been developed. These procedures are performed during an upper endoscopy on an outpatient basis and do not require incisions, general anesthesia, or a hospital stay like surgery does. However, these procedures are relatively new, and their long-term effectiveness is not yet fully known.