FitSugar

Tips For Beating Bad Breath

FitSugar — Mon, 16 Apr 2007 02:30:00 -0700

Nothing is worse than having bad breath. Unless you're talking to someone who has bad breath, because that can be pretty bad too! Unfortunately you can not really do anything about someone else's bad breath, but you can do something about your own. MSNBC gives us these five food ideas to help combat bad breath:

Chew on this. Move over parsley, there are some new halitosis-fighting herbs in town. “Coriander, spearmint, tarragon, eucalyptus, rosemary and cardamom are all good for fighting bad breath,” says Dr. Christine Gerbstadt, who has lectured on oral health. You can chew on fresh herbs or make tonics by steeping them in hot water (as a tea). These herbs make an excellent digestive as well-doubling the benefits of ending a meal this way.

There's four more ideas, so read more

Get some active culture. No, not a Broadway play, but yogurt. A recent study found that a serving of yogurt each day reduces the level of odor-causing hydrogen sulfide in the mouth. Apparently it also cuts back on bacteria in the mouth-plaque and gum disease were reduced in the study’s yogurt eaters as well. Plus, the American Dietetic Association (ADA) recommends getting enough vitamin D from yogurt, cheese and milk if you’re worried about halitosis because this vitamin creates an inhospitable environment for bacteria growth. Be sure to get the kind of yogurt with active cultures-not overly processed or sugar-added varieties.
Crunchy types. Apples, carrots, celery-basically any fiber-rich fruit or vegetable is your friend when it comes to fighting halitosis. “Inside your mouth, plaque build-up causes odors,” explains Cynthia Sass, ADA spokeswoman and registered dietician. “Eating foods that increase saliva production keep the mouth moist-and rinsed out. Also, many carbs and proteins can get stuck in your teeth-even healthy foods like whole grain cereal or chicken breast.” So follow a meal with a Granny Smith (feel the saliva kick in at the mention of it?) to cleanse the mouth.
Masking techniques. Sugarless gum shouldn’t replace brushing your teeth after a meal, but in a pinch it can freshen breath (masking odors) and is another way to increase saliva production to rinse away plaque and bacteria. Mints can mask as well, but only briefly-and go for sugarless. Sugar creates plaque, and no one wants a mint that makes breath worse.
High C’s. Eating berries, citrus fruits, melons and other vitamin C-rich foods create an inhospitable environment for bacteria growth. A diet rich in vitamin C is also is important for preventing gum disease and gingivitis-both major causes of halitosis. Get your C in foods, not supplements, which can cause gastrointestinal upset in some, according to Sass, and exacerbate bad breath.

Source

Tazo Tea for the Soul

FitSugar — Thu, 08 Mar 2007 02:00:00 -0800

Have you heard of Tazo Tea? They're a unique tea company offering delicious tea from all over the world. The name Tazo actually means "river of life," and "fresh." It's a great name considering that Tazo teas are invigorating, satisfying, and all around good for the soul.

You can get black tea in flavors like Vanilla, Earl Grey, Citron, Darjeeling, and they even make a decaffeinated Chai tea.
Tazo also makes delicious green teas. You can get Green Ginger, Lotus, and Zen teas that combines green tea with the taste of spearmint, lemongrass, and a hint of lemon zest. I love the one named Om, which is a combination of green and black teas.

Since I have a sweet tooth, I love their herbal infusion teas. Flavors such as Sweet Cinnamon Spice, Wild Sweet Orange, and Tazo Honeybush are wonderful on a cold day.

Fit's Tips: I always keep Tazo's Calm tea in the house when I need to relax with the soothing taste of chamomile. Tazo's Refresh is great for a tummy ache with its mix of peppermint and spearmint. In the summer time, I love to make iced tea out of Tazo's Passion tea. It's a light red tea with a delicate hint of hibiscus flowers.

How to Prevent Bad Breath

FitSugar — Mon, 17 Aug 2009 10:00:24 -0700

We've all been embarrassed by occasional bouts of bad breath after eating a roasted garlic pizza or a sandwich piled with onions. If you're dealing with bad breath all the time, though, it can be mortifying. So here are some tips to keep your mouth smelling fresh.

Quit cigarettes if you're a smoker.
Get your teeth checked out by your dentist. Cavities and gum disease can cause bad breath.
Brush and floss during the day, every time you eat. When food particles hang out in your mouth, bacteria collects and emits stinky hydrogen sulfur vapors. So keep a toothbrush, toothpaste, and floss in your purse at all times to use after coffee breaks, lunch, and snacks.
Drink more water. It'll help keep the bacteria in your mouth to a minimum.
Don't mask your bad breath with sugary mints. They'll freshen your breath briefly, but the sugar will only cause more stinky plaque to build up. If you can't brush, go for sugarless gum instead since chewing increases saliva production, which is your best weapon against bad breath.

What else can help prevent bad breath? To find out, read more.

If you suffer from allergies or sinus infections, postnasal drip in the back of your throat can cause bad breath. So get your symptoms under control with antibiotics or allergy meds.
Keep in mind, though, that certain medications such as decongestants or allergy pills can cause dry mouth, which can also lead to bad breath. When your mouth is dry, dead cells and bacteria accumulate on your gums, tongue, and teeth. When these cells decompose, they produce a foul smell. Water helps, but if your symptoms are really bothering you try switching medications.
Eat yogurt. Studies have found that one serving of yogurt each day reduces the level of odor-causing hydrogen sulfide in the mouth. Be sure to eat ones with active cultures.
Avoid certain foods such as garlic, onions, and alcohol. Once consumed, these foods get absorbed into your bloodstream, are carried to your lungs, and are given off in your breath.
To help prevent the buildup of plague, which can cause bad breath, eat crunchy fibrous foods such as apples, carrots, and celery.
Bacterium aren't a fan of foods such as citrus fruits, berries, and melon because they make the environment in your mouth too acidic, so get your fill of vitamin C. Another plus for consuming vitamin C is that it also helps prevent gum disease and gingivitis.
Chew herbs such as parsley, coriander, spearmint, tarragon, eucalyptus, rosemary, and cardamom. These all help fight bad breath.
Clean your tongue with a tongue scraper. Use it twice a day to remove bacteria and dead skin cells from your tongue.

Got Bad Breath? Try This

FitSugar — Tue, 14 Oct 2008 13:00:00 -0700

We've all been embarrassed by occasional bouts of bad breath, but it can be mortifying if you're dealing with it all the time. When it comes to preventing this odorous issue, I don't need to tell you to quit cigarettes if you're a smoker or to brush and floss regularly (since you already know that), so here are some other tips to keep your mouth smelling fresh.

Get your teeth checked out by your dentist. Cavities and gum disease can cause bad breath.
Brush and floss during the day, every time you eat. When food particles hang out in your mouth, bacteria collects and emits stinky hydrogen sulfur vapors. So keep a toothbrush, toothpaste, and floss in your purse at all times to use after coffee breaks, lunch, and snacks.
Don't mask your bad breath with sugary mints or gum. They'll freshen your breath briefly, but the sugar will only cause more smelly plaque to build up. If you can't brush, go for sugarless breath fresheners instead.
If you suffer from allergies or sinus infections, postnasal drip in the back of your throat can cause bad breath. So get your symptoms under control with antibiotics or allergies meds.
Just so you know though, certain medications such as decongestants or allergy pills can cause dry mouth, which can also lead to bad breath. When your mouth is dry, dead cells and bacteria accumulate on your gums, tongue, and teeth. When these cells decompose, they produce a foul smell. Water helps, but if your symptoms are really bothering you try switching medications.

What else can help prevent bad breath? To find out read more.

Eat yogurt. Studies have found that one serving of yogurt each day reduces the level of odor-causing hydrogen sulfide in the mouth. Be sure to eat ones with active cultures.
Avoid certain foods such as garlic, onions, and alcohol. Once consumed, these foods get absorbed into your bloodstream, are carried to your lungs, and are given off in your breath.
To help prevent the buildup of plague, which can cause bad breath, eat crunchy fibrous foods such as apples, carrots, and celery.
Bacterium aren't a fan of foods such as citrus fruits, berries, and melon because they make the environment in your mouth too acidic, so get your fill of vitamin C. Another plus for consuming vitamin C is that it also helps prevent gum disease and gingivitis.
Chew herbs such as parsley, coriander, spearmint, tarragon, eucalyptus, rosemary, and cardamom. These all help fight bad breath.
Clean your tongue with a tongue scraper. Use it twice a day to remove bacteria and dead skin cells from your tongue.

Source

Gastroesophageal reflux disease and heartburn

FitSugar — Wed, 08 Oct 2008 17:35:29 -0700

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

New Research

Obesity and GERD. Increased weight in women is linked to more frequent GERD symptoms, according to the Nurses' Health Study, which included 10,545 female participants. Overweight and obese women were two to three times more likely to have frequent symptoms than women of normal weight. GERD symptoms decreased nearly 40% in women whose body mass index (BMI) dropped by more than 3.5, compared to women whose BMI remained the same.
Proton-Pump Inhibitors and Bone Fracture. Long-term use of PPIs may increase the risk of hip fractures in older adults, according to a study in the Journal of the American Medical Association. People taking high doses of PPIs for more than a year were 2.6 times as likely to fracture a hip as those who were not taking the drug. The authors suggested that the stomach acids blocked by PPIs may be needed to absorb calcium, or the drugs may interfere with the body's natural process of breaking down and rebuilding bones.
PPIs and H2 Blockers in Children. Otherwise healthy children who take PPI inhibitors or H2 blockers may be at increased risk for intestinal and respiratory infections, according to a study of 186 children with GERD. The rate of gastroenteritis and community-acquired pneumonia significantly increased in children who were taking these medications when researchers compared the 4 months before and after enrollment in the study.

New Approval

Proton-Pump Inhibitor Approved for Adolescents. Esomeprazole (Nexium) delayed-release capsules have been approved for use in children ages 12 - 17 for the short-term treatment of GERD. Research shows that this medication reduces heartburn symptoms in adolescents.

Introduction

Gastroesophageal reflux disease (GERD) is a condition in which acids from the stomach move backward into the esophagus (an action called reflux). Reflux occurs if the muscular actions in the esophagus or other protective mechanisms fail.

Click the icon to see an animation about heartburn.

The hallmark symptoms of GERD are:

Heartburn: a burning sensation in the chest and throat.
Regurgitation: a sensation of acid backed up in the esophagus.

Although acid is a primary factor in damage caused by GERD, other products of the digestive tract, including pepsin and bile, can also be harmful.

Heartburn is a condition in which the acidic stomach contents back up into the esophagus, causing pain in the chest area. This reflux usually occurs because the sphincter muscle between the esophagus and stomach is weakened. Standing or sitting after a meal can help reduce the reflux that causes heartburn. Continuous irritation of the esophagus lining as in gastroesophageal reflux disease is a risk factor for the development of adenocarcinoma.

The esophagus, commonly called the food pipe, is a narrow muscular tube about nine-and-a-half inches long. It begins below the tongue and ends at the stomach. The esophagus is narrowest at the top and bottom; it also narrows slightly in the middle. The esophagus consists of three basic layers:

An outer layer of fibrous tissue.
A middle layer containing smoother muscle.
An inner membrane, which contains numerous tiny glands.

Click the icon to see an image of the esophagus.

When a person swallows food, the esophagus moves it into the stomach through the action of peristalsis, wave-like muscle contractions. In the stomach, the starch, fat, and protein in food are broken down by acid and various enzymes, notably hydrochloric acid and pepsin. The lining of the stomach has a thin layer of mucous that protects it from these fluids.

If acid and enzymes back up into the esophagus, however, its lining offers only a weak defense. The esophagus is protected using specific muscles and other factors.

The most important structure protecting the esophagus may be the lower esophageal sphincter (LES). The LES is a band of muscle around the bottom of the esophagus where it meets the stomach.

The LES opens after a person swallows to let food enter the stomach and then immediately closes to prevent regurgitation of the stomach contents, including gastric acid.
The LES maintains this pressure barrier until food is swallowed again.

Click the icon to see an image of the stomach.

If the pressure barrier is not sufficient to prevent regurgitation and acid backs-up (reflux), then peristaltic action of the esophagus serves as an additional defense mechanism and pushes the contents back down into the stomach.

Esophagitis. In most people, GERD symptoms are short-lived and occur infrequently. In about 20% of cases, however, the condition becomes chronic. When the acid causes irritation or inflammation, the condition is called esophagitis. If the damage becomes extensive and injures the esophagus, the disorder is known as erosive esophagitis.

Non-Erosive Esophageal Reflux Disease. Symptoms of gastroesophageal reflux disease can occur without any signs of inflammation or injury to the esophagus. This condition is also referred to as non-erosive esophageal reflux disease (NERD). NERD rarely progresses to full-blown GERD. Patients with NERD have no signs of inflammation or erosion in the esophagus, but they experience certain symptoms of GERD, such as burning sensations behind the breastbone for at least 3 months. Researchers suggest that nerves lying near the surface of the lining become exposed to acid that has penetrated the layers. The nerves then trigger prolonged and painful symptoms in response.

Barrett's Esophagus. A small percentage of patients with GERD may eventually develop Barrett's esophagus, a serious complication of GERD that results in precancerous changes in the tissue lining the esophagus.

Eosinophilic Esophagitis. This is a distinct disorder characterized by difficult or painful swallowing. It can occur along with GERD. The lining of the esophagus develops furrows and rings. This condition can be treated with swallowed fluticasone propionate, the active ingredient in some asthma medications.

Causes

Anyone who eats a large amount of acidic foods can have mild and temporary heartburn. This is especially true when lifting, bending over, or taking a nap after eating a large meal high in fatty, acidic foods. Persistent GERD, however, may be due to various conditions, including abnormal biologic or structural factors.

The band of muscle tissue called the LES is responsible for closing and opening the lower end of the esophagus and is essential for maintaining a pressure barrier against contents from the stomach. It is a complex area of smooth muscles and various hormones. If it weakens and loses tone, the LES cannot close up completely after food empties into the stomach. In such cases, acid from the stomach backs up into the esophagus. Dietary substances, drugs, and nervous system factors can weaken the LES and impair its function.

A study showed that more than half of GERD patients had abnormal nerve or muscle function in the stomach. These abnormalities cause impaired motility, which is the inability of muscles to act spontaneously. The stomach muscles do not contract normally, which causes delays in stomach emptying, increasing the risk for acid back-up.

Some studies suggest that most people with atypical GERD symptoms (such as hoarseness, chronic cough, or the feeling of having a lump in the throat) may have specific abnormalities in the esophagus. (In one study, such abnormalities appeared in 73% of patients who had atypical symptoms.)

Motility Abnormalities. Problems in spontaneous muscle action (peristalsis) in the esophagus commonly occur in GERD, although it is not clear if such occurrences are a cause or result of long-term effects of GERD.

Adult-Ringed Esophagus. This condition is characterized by an esophagus with multiple rings and persistent trouble with swallowing (including getting food stuck in the esophagus). It occurs mostly in men.

The hiatus is a small hole in the diaphragm through which the esophagus passes into the stomach. It normally fits very snugly, but it may weaken and enlarge. When this happens, part of the stomach muscles may protrude into it, producing a condition called hiatal hernia. It is very common, occurring in over half of people over 60 years old, and is rarely serious. Until recent years, it was believed that most cases of persistent heartburn were caused by a hiatal hernia. Hiatal hernia may impair LES muscle function. Studies have failed to confirm evidence, however, that it is a common cause of GERD, although its presence may increase GERD symptoms in patients with both conditions.

A hiatal hernia occurs when part of the stomach protrudes up into the chest through the sheet of muscle called the diaphragm. This may result from a weakening of the surrounding tissues and may be aggravated by obesity or smoking.

Studies indicate that 31 - 43% of reflux may be hereditary. An inherited risk exists in many cases of GERD, possibly because of inherited muscular or structural problems in the stomach or esophagus. Genetic factors may play an especially strong role in susceptibility to Barrett's esophagus, a precancerous condition caused by very severe GERD.

At least half of people with asthma also have GERD. Some experts speculate that the coughing and sneezing accompanying asthmatic attacks cause changes in pressure in the chest that can trigger reflux. Certain asthma drugs that dilate the airways may relax the LES and contribute to GERD. On the other hand, GERD has been associated with a number of other upper respiratory problems and may be a cause of asthma, rather than a result.

Crohn's disease is a chronic ailment that causes inflammation and injury in the colon and other parts of the gastrointestinal tract, including the esophagus. Other disorders that may affect areas that can contribute to GERD include diabetes, any gastrointestinal disorder, peptic ulcers, lymphomas, and cancer.

Click the icon to see an image of inflammatory bowel disease.

Helicobacter Pylori, also called H. pylori, is a bacterium found in the mucous membranes and is now known to be a major cause of peptic ulcers. Antibiotics used to eradicate H. pylori are now accepted treatment for curing ulcers. Of some concern, however, are studies indicating that H. Pylori may actually protect against GERD by reducing stomach acid. Furthermore, curing ulcers by eliminating the bacteria might actually trigger GERD in some people. Studies are mixed, however, on whether patients with cured H. Pylori infections are at risk for GERD. An analysis of 8 studies reported no higher risk for GERD after antibiotic treatments, nor was GERD any worse in patients who already had it. Seven of the 8 studies, however, were conducted only 2 months after antibiotic treatment. Longer follow-up studies are needed to determine long-term consequences, if any.

In any case, the bacteria should be eradicated in infected patients with existing GERD who are taking ongoing acid suppressing agents. There is some evidence that the combination of H. pylori and chronic acid suppression in these patients can lead to atrophic gastritis, a precancerous condition in the stomach.

In some cases, the esophagus appears normal, but GERD symptoms are present. This may indicate an over-reaction of the immune system to irritants that are introduced into the esophagus. In such cases, the immune system reacts with an exaggerated (or hyper-reactive) response, triggering the release of certain factors that end up causing inflammation and possibly injury. (This event is similar to the asthmatic response in the airways.)

NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs), common causes of peptic ulcers, may also cause GERD and increase severity in people who already have GERD. In a 3-year study of 25,000 people, NSAID users were twice as likely to have GERD symptoms as non-users. Symptoms did not become evident until after about 6 months of regular use. There are dozens of NSAIDs, including over-the-counter aspirin, ibuprofen (Motrin, Advil, Nuprin), and naproxen (Aleve), as well as prescription anti-inflammatory medicines. A person with GERD who takes the occasional aspirin or other NSAID will not necessarily experience adverse effects. This is especially true if there are no risk factors or indications of ulcers. Acetaminophen (Tylenol), which is NOT an NSAID, is a good alternative for those who want to relieve mild pain. It does not, however, relieve inflammation.

Other Drugs. Many other drugs can cause GERD, including but not limited to the following: calcium channel blockers (used to treat high blood pressure and angina), anticholinergics (used in drugs that treat urinary tract disorders, allergies, and glaucoma), beta adrenergic agonists (used for asthma and obstructive lung diseases), dopamine (used in Parkinson's disease), bisphosphonates (used to treat osteoporosis), sedatives, antibiotics, potassium, or iron pills.

Weakened peristaltic movement in the esophagus may contribute to GERD. If the mucous membrane is impaired, even a normal amount of acid can harm the esophagus. Pressure on the abdomen caused by obesity and also wearing tight clothing can contribute to acid backing up into the esophagus.

Click the icon to see an image of peristalsis.

Risk Factors

GERD occurs monthly in about half of American adults. People of all ages are susceptible to GERD. Elderly people with GERD tend to have a more serious condition than younger people.

Eating Pattern. Anyone who eats a heavy meal and subsequently lies on the back or bends over from the waist is at risk for an attack of heartburn. Anyone who snacks at bedtime is at high risk for heartburn.

Pregnancy. Pregnant women are particularly vulnerable to heartburn in their third trimester as the growing uterus puts increasing pressure on the stomach. Heartburn in such cases is often resistant to dietary interventions and even antacids.

Obesity. A number of studies suggest that obesity contributes to GERD and may increase the risk for erosive esophagitis in GERD patients. The Nurses' Health Study found that being overweight or obese significantly increased GERD symptoms in women. The higher a woman's body mass index (BMI), the study found, the more frequent were her symptoms. Women who lost weight in the study saw a decrease in their symptoms. Research suggests that the prevalence of GERD symptoms among obese patients has been underreported. Other researchers have reported that increased BMI is associated with a higher risk for cancer of the esophagus (esophageal adenocarcinoma).

Respiratory Diseases. People with asthma are at very high risk for GERD. One study indicated that patients with chronic obstructive pulmonary diseases (e.g., emphysema or chronic bronchitis) were more likely to have GERD.

Chronic obstructive pulmonary disease (COPD) refers to chronic lung disorders that result in blocked air flow in the lungs. The two main COPD disorders are emphysema and chronic bronchitis, the most common causes of respiratory failure. Emphysema occurs when the walls between the lung's air sacs become weakened and the sacs get enlarged and filled with too much air. Damage from COPD is usually permanent and irreversible.

Smoking. Increasing evidence indicates that smoking raises the risk for GERD. Studies suggest that smoking reduces LES muscle function, increases acid secretion, impairs muscle reflexes in the throat, and damages protective mucous membranes. Smoking reduces salivation, which helps neutralize acid. Whether it is the smoke, nicotine, or both that triggers GERD is unknown. Some people who use nicotine patches to quit smoking, for example, experience heartburn, but it is not clear if it's the nicotine or stress that produces acid back-up.

Alcohol Use. Alcohol has mixed effects on GERD. It relaxes the LES muscles and, in high amounts, may irritate the mucous membrane of the esophagus. All alcoholic beverages increase stomach acid levels. A combination of heavy alcohol use and smoking increases the risk for esophageal cancer. (Small amounts of alcohol, however, may actually protect the mucosal layer.)

In general, overweight Caucasian males over 40 are at highest risk for complications, notably Barrett's esophagus. Others at high risk for severe symptoms, inflammation, or both include:

People who use nonsteroidal anti-inflammatory drugs (NSAIDs). Studies suggest that certain NSAID users are at higher risk for GERD, including older adults, women, alcohol and tobacco users, and patients with asthma, hiatal hernia, or obesity. One study reported that NSAIDs put people at risk for ulcers but not for erosive esophagitis or strictures. Interestingly, NSAIDs are being studied for protection against Barrett's esophagus.
People with hiatal hernia

GERD is very common in children of all ages, but it is usually mild. Heartburn has been reported in 1.8% of 3-year-olds and in 5.2% of young people 10 - 17 years old. Children with the following conditions are at higher risk for severe GERD:

Neurologic impairments
Food allergies
Scoliosis
Cyclic vomiting
Cystic fibrosis
Problems in the lungs, ear, nose, or throat
Any medical condition affecting the digestive tract

Symptoms in Children. A physician should examine any child who has the following symptoms as soon as possible, because they may indicate complications such as anemia, failure to gain weight, or respiratory problems. Symptoms of severe GERD in infants and small children may include:

Chronic coughing
Frequent infections
Wheezing
Gasping or frequent cessation in breathing while asleep (called sleep apnea). However, one study found no association between GERD and apneas in premature infants.
Frequent vomiting in infants. About half of all infants up to 3 months old regurgitate milk at least once a day. Some simply spit up; others vomit large amounts after feedings. Vomiting in infants and older children is rarely a sign of GERD. In infants it usually resolves by age one. Severe vomiting -- particularly if it is bilious (green colored) -- always requires a doctor's visit, since it could be a symptom of severe obstruction.
Having to burp babies very frequently during and after feeding.

Babies and children may experience these symptoms without having GERD. An Australian study suggested that many infants who have normal irritability may be treated inappropriately for reflux disorders.

Feeding Problems. Feeding problems may be more severe than previously thought in children with GERD. In one study, children who had GERD and problems swallowing tended to refuse food and were late in eating solids. They also cried more and reacted more negatively in general than non-GERD babies. Such behaviors negatively affected the mothers as well. These findings were supported in an earlier study which reported that children at 1 year who had GERD in infancy were no longer spitting up, but still tended to have negative dining experiences ("too slow," "upsetting"). However, these children were at no greater risk for respiratory illnesses than other 1-year-old children.

Associations with Asthma and Infections in the Upper Airways. In addition to asthma, GERD is associated with other upper airway problems, including ear infections and sinusitis. Some experts argue that the association with common childhood infections and asthma is unfounded, since GERD is normal in most children.

Dental Erosion. GERD can cause irreversible loss of tooth enamel. Based on a 2002 study, some experts suggest checking for GERD in children with dental erosions. In the study, no child without GERD experienced loss of tooth enamel.

Rare Complications in Infants. Although GERD is very common, the following complications are very rare and only occur in certain cases:

Failure to thrive
Feeding problems and severe vomiting may cause anemia
Acid back-up may be inhaled into the airways and cause pneumonia

The infant's life may be in danger if acid reflux causes spasms in the larynx severe enough to block the airways. In fact, some experts believe this action may contribute to sudden infant death syndrome (SIDS). More research is needed to determine whether this association is valid.

Managing GERD in Infancy. Here are some hints 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. 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. In one study, infants with gastroesophageal reflux who spent prolonged periods of time in infant seats, including car seats, had more reflux than those who spent waking time on their stomachs. If the physician recommends that babies with GERD sleep on their stomachs, parents should be sure that their 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.
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.

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, they should not be given to children without physician supervision.

Milder medications, such as antacids, are used first.
H2 blockers may be tried next. They are available over the counter and include famotidine (Pepcid AC), cimetidine (Tagamet HB), ranitidine (Zantac 75), and nizatidine (Axid AR). The FDA has issued a warning on Pepcid AC for adults with kidney problems.
Proton-pump inhibitors (PPIs), such as omeprazole (Prilosec) and lansoprazole (Prevacid), are even more powerful agents that suppress the production of stomach acid. Delayed-release esomeprazole (Nexium) capsules have been approved for use in children ages 12 - 17 for the short-term treatment of GERD. One study found that esomeprazole (Nexium) in either a 20 or 40 mg dose once a day significantly reduced heartburn symptoms in adolescents. PPIs appear to be safe and effective even for children as young as 1 year old who fail the less intensive therapies. However, a 2006 study found that otherwise healthy children who were treated with H2 blockers and PPIs had an increased risk of developing respiratory and intestinal infections.

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 proton-pump inhibitor drugs, some children may be able to avoid surgery. Surgical fundoplication can be performed laparoscopically through small incisions. In one study, of 238 children from 5 months to 16 years of age who underwent laparoscopic fundoplication, all but 9 were symptom free at least 5 years after the surgery. A 2006 study found that children who underwent antireflux surgery before age 4 were less likely to be hospitalized again, or to have reflux-related events such as pneumonia and esophagitis after the surgery.

Symptoms

Heartburn. Heartburn is the primary symptom of GERD. It is a burning sensation that radiates up from the stomach to the chest and throat. Heartburn is most likely to occur in connection with the following activities:

After a heavy meal
Bending over
Lifting
Lying down, particularly on the back

According to one study, nearly three-quarters of patients with frequent GERD symptoms experience them at night. Patients with nighttime GERD also tend to experience more severe pain than those whose symptoms occur at other times. One study found that patients with nighttime pain reported levels of severity that were similar to those reported in angina and heart failure.

The severity of heartburn does not necessarily indicate actual injury in the esophagus. For example, Barrett's esophagus, which causes precancerous changes in the esophagus, may trigger few symptoms, especially in elderly people. On the other hand, people can suffer severe heartburn without the presence of damage to the esophagus.

Dyspepsia. Up to half of GERD patients have dyspepsia, a syndrome consisting of the following:

Pain and discomfort in the upper abdomen
Fullness in the stomach
Nausea after eating

People can have dyspepsia without having GERD.

Regurgitation. Regurgitation is the feeling of acid backing up in the throat. Sometimes acid regurgitates as far as the mouth and can be experienced as a "wet burp." Uncommonly, it may come out forcefully as vomit.

Many patients with GERD do not experience heartburn or regurgitation. Elderly patients with GERD often have less typical symptoms than do younger people. Instead symptoms may appear in other locations.

Chest Sensations or Pain. Patients may have the sensation that food is trapped behind the breastbone. Chest pain is a common symptom of GERD. It is very important to differentiate it from chest pain caused by heart conditions, such as angina and heart attack.

Symptoms in the Throat. Less commonly, GERD may produce symptoms that occur in the throat:

Acid laryngitis. A condition that includes hoarseness, dry cough, the sensation of having a lump in the throat, and the need to repeatedly clear the throat.
Trouble swallowing (dysphagia). In severe cases, patients may even choke or food may become trapped in the esophagus, causing severe chest pain. This may indicate a temporary spasm that narrows the tube, or it could also be an indication of serious esophageal damage or abnormalities.
Chronic sore throat
Persistent hiccups

Coughing and Respiratory Symptoms. Asthmatic symptoms, such as coughing and wheezing, may occur. In fact, in one study, GERD alone accounted for 41.1% of cases of chronic cough in nonsmoking patients. The incidence was even higher when GERD and asthma were combined.

Chronic Nausea and Vomiting. Nausea that persists for weeks or even months and is not attributable to a common cause of stomach upset may be a symptom of acid reflux. In rare cases, vomiting can occur as often as once a day. All other causes of chronic nausea and vomiting should be ruled out, including ulcers, stomach cancer, obstruction, and pancreas or gallbladder disorders.

Complications

Nearly everyone has an attack of heartburn at some point in their lives. In the vast majority of cases the condition is temporary and mild, causing only transient discomfort. If patients develop persistent gastroesophageal reflux disease with frequent relapses, however, and it remains untreated, serious complications may develop over time. They can include the following:

Erosive esophagitis (severe inflammation in the esophagus)
Severe narrowing (stricture) of the esophagus
Barrett's esophagus
Problems in other areas, including the teeth, throat, and airways leading to the lungs

Older people are at higher risk for complications from persistent GERD. The following conditions also put individuals at risk for recurrent and serious GERD:

The esophagus is very inflamed.
Initial symptoms are severe.
Symptoms persist in spite of treatments that successfully heal the esophagus.
There are severe underlying muscular abnormalities.

Erosive esophagitis develops in chronic GERD patients when acid causes enough irritation and inflammation to produce extensive injuries in the esophagus. Some studies have suggested that overweight Caucasian males with GERD are at highest risk for this condition. In anyone, however, the longer and more severe the GERD condition, the higher the risk for erosive esophagitis.

Bleeding. In one study, bleeding occurred in more than 8% of patients with erosive esophagitis (severe inflammation of the esophagus), which is associated with GERD. In very severe cases, the patient may detect dark-colored, tarry stools (indicating the presence of blood) or may vomit blood, particularly if ulcers have developed in the esophagus. This is a sign of severe damage and requires immediate attention.

Sometimes long-term bleeding can result in iron-deficiency anemia and may even require emergency transfusions. This condition can occur without heartburn or other warning symptoms, or even obvious blood in the stools.

Barrett's Esophagus (BE) and Esophageal Cancer. In some cases, BE develops as an advanced stage of erosive esophagitis. BE results in abnormal cellular changes in the esophagus that, in turn, put a patient at risk for esophageal cancer. There are many issues involved with BE, however, including its prevalence and true severity, that are unresolved.

Of note, GERD itself poses no significant risk for esophageal cancer. One study reported an annual incidence of 6.5 cancer cases per 10,000 people with regular GERD symptoms.

If the esophagus becomes severely injured over time, narrowed regions called strictures can develop, which may impair swallowing (dysphagia). Food may even become blocked in some cases. Stretching procedures or surgery may be required to restore normal swallowing. Paradoxically, strictures may actually prevent other GERD symptoms by helping to keep acid from traveling up the esophagus.

Asthma. Asthma and GERD often occur together. Studies report that reflux disorder coincides with 32 - 80% of asthma cases. Some theories for the causal connection between GERD and asthma are as follows:

Acid leaking from the lower esophagus in GERD stimulates the vagus nerves, which run through the gastrointestinal tract. These stimulated nerves trigger the nearby airways in the lung to constrict, which causes asthma symptoms.
Acid back-up that reaches the mouth may be inhaled into the airways (aspirated). Here, the acid triggers a reaction in the airways that causes asthma symptoms.

There is some evidence that asthma causes GERD. In contrast, some evidence suggests that GERD causes asthma. Some clinical trials report that treating GERD in patients who also have asthma reduces symptoms of both conditions. Not all such patients report improved asthma symptoms with GERD treatments, and these treatments do not appear to have much effect on actual lung function. One study suggested that this approach works in asthmatic individuals who tended to be overweight and to have severe GERD in the lower part of the esophagus.

Other Respiratory and Airway Conditions. Current studies indicate an association between GERD and various upper respiratory problems that occur in the sinuses, ear and nasal passages, and airways of the lung. People with GERD appear to have an above-average risk for chronic bronchitis, chronic sinusitis, emphysema, pulmonary fibrosis (lung scarring), and recurrent pneumonia. If a person inhales fluid from the esophagus (aspirates) into the lungs, serious pneumonia can occur. It is not yet known whether treatment of GERD would also reduce the risk for these respiratory conditions.

Dental erosion (the loss of the tooth's enamel coating) is a very common problem among GERD patients, including children. It results from the acid backing up into the mouth and eroding the enamel.

An estimated 20 - 60% of patients with GERD have atypical symptoms in the throat (hoarseness, sore throat) without any significant heartburn. A failure to diagnose and treat GERD may lead to persistent throat conditions such as chronic laryngitis, hoarseness, difficulty in speaking, sore throat, cough, constant throat clearing, and granulomas (soft, pink bumps) on the vocal cords.

GERD commonly occurs with obstructive sleep apnea, a condition in which breathing stops temporarily but repeatedly during sleep. It is not clear which condition is responsible for the other, but GERD is particularly severe when both conditions occur together. One study reported that spasms in the vocal cords caused by acid reflux may block the flow of air and cause sleep apnea in adults. On the other hand, other research suggests that the disordered breathing in sleep apnea alters pressure in the chest area and causes GERD. Both conditions may also have risk factors in common, such as sleeping on the back. Studies suggest that in such patients GERD can be markedly improved with a continuous positive airway pressure (CPAP) device, which opens the airways and is the standard treatment for severe sleep apnea.

Barrett's Esophagus

Barrett's esophagus (BE) is a serious condition in which changes occur in the cells that line the lower esophagus and cause the cells to become abnormal and precancerous. Barrett's esophagus is categorized as either long-segment or short-segment disease:

Long-segment BE occurs when abnormal cells affect 3 cm or more of the esophagus. This condition occurs in about 3 - 7% of GERD patients. It is associated with a more severe condition.
Short-segment BE affects less than 3 cm of the esophagus and is found in about 10 - 17% of GERD patients.

About 10% of patients with symptomatic GERD have BE. In some cases, BE develops as an advanced stage of erosive esophagitis. Some studies suggest that individuals at highest risk for BE are obese white males over the age of 50 with persistent GERD who drink alcohol. However, a number of studies have reported no relationship between alcohol use or being male and overweight with BE. Such studies have also reported no higher risk in smokers or relatives of BE patients. Only the persistence of symptoms suggested a higher risk. Nevertheless, not all patients with BE have either esophagitis or symptoms of GERD.

The true prevalence of BE, in fact, is not entirely clear, since studies suggest that significantly more than half of people with BE have no GERD symptoms at all. BE, then, is likely to be much more prevalent and probably less harmful than is currently believed. (BE that occurs without symptoms can only be identified in clinical trials or in autopsies, so it is difficult to determine the true extent.) Some evidence suggests that the presence of specific immune factors may be involved in determining the development of BE.

The rate of esophageal cancer has been rising steadily at about 2% a year in white men. The American Cancer Society estimates that there will be 15,560 new cases of esophageal cancer and 13,940 deaths from the disease in 2007. Esophageal cancer is also very difficult to cure. The 5-year survival rate for all stages of esophageal cancer is 17% in white patients, and 12% in African-American patients. Most cases of esophageal cancer start with BE, with less than half of the cases developing with any symptoms. Of note, only a minority of BE patients develop cancer. Some evidence suggests that acid reflux may contribute to the development of cancer in BE. Researchers have speculated that exposure to extra acid in people with Barrett's esophagus produces more of an enzyme called NOX5-S, which may put stress on cells, leading to DNA damage.

Evidence suggests that asymptomatic BE is quite common in the general population, and if true, BE would pose far less of a threat than is now believed. (GERD itself poses no significant risk for esophageal cancer. One study reported an annual incidence of 6.5 cancer cases per 10,000 people with regular GERD symptoms.)

Barrett's esophagus is diagnosed using endoscopy, a procedure that involves inserting a tube down the throat so that the physician can view the esophagus.

Monitoring High-Risk GERD Patients. Some experts recommend a one-time screening test for BE using endoscopy in high-risk patients (such as Caucasian overweight men) with chronic GERD.

Monitoring Patients with Barrett's Esophagus for Cancer. Periodic endoscopy is recommended for detecting early cancer in patients who have been diagnosed with Barrett's esophagus. In an important 2002 study, 5-year survival was 73% in BE patients whose cancer was detected with endoscopy screening and was 0% in patients who were not regularly screened.

To date, no treatments can reverse the cellular damage done after Barrett's esophagus has developed, although some procedures are showing promise.

Medications. Some evidence suggests that a combination of proton-pump inhibitors to suppress acid, coupled with anti-inflammatory COX-2 inhibitors, might be a promising approach.

Proton-Pump Inhibitors. Some experts recommend very aggressive treatments to reduce acid reflux using high-dose proton-pump inhibitors. The standard agent has been omeprazole (Prilosec). Newer oral PPIs include lansoprazole (Prevacid), esomeprazole (Nexium), and rabeprazole (Aciphex). Even when drugs relieve symptoms completely, the condition usually recurs within months after the drugs are discontinued. In chronic cases, drugs may need to be taken throughout a patient's life. These agents provide no protection against Barrett's esophagus. Still, there is some evidence that acid reflux may contribute to the development of cancer in BE, although it is not yet known if acid blockers have any protective effects against cancer in these patients.
COX-2 (cyclooxygenase-2) inhibitors reduce inflammation and pain, as do well-known agents such as aspirin and ibuprofen, but COX-2 inhibitors may pose less of a risk for peptic ulcers and bleeding. Some early evidence suggests they may be protective against cancerous changes in patients with Barrett's esophagus. However, Vioxx and Bextra have been withdrawn from the market due to their association with an increased risk of heart attack. Celebrex remains available, but must be used with caution, especially by patients with cardiovascular risk factors. Also, research is mixed on the benefits of NSAIDs for esophageal cancer. Some studies have found that they may decrease the risk of developing or dying from esophageal cancer. However, a 2007 study indicated that a small dose of Celebrex did not prevent the progression of cancer in Barrett's esophagus patients.

Peptic ulcers may lead to emergency situations. Severe abdominal pain with or without evidence of bleeding may indicate a perforation of the ulcer through the stomach or duodenum. Vomiting of a substance that resembles coffee grounds, or the presence of black tarry stools, may indicate serious bleeding.

Procedures to Remove the Mucous Lining. Various techniques or devices have been developed to remove (ablate) the mucous lining of the esophagus. The intention is to remove early cancerous or precancerous tissue and allow regrowth of new and hopefully healthy tissue in the esophagus. Such techniques include photodynamic therapy (PDT) or laser, electrical, or heat probes.

Studies on the use of these ablation techniques combined with aggressive use of proton-pump inhibitors or surgical treatments are very encouraging. Some of these techniques may eventually even offer potential cures. At this time, they can be very effective in removing harmful tissue, although the benefits do not last in all patients. In one study, an average of 5.6 years after anti-GERD surgery and laser treatment, only a third of patients showed no evidence of renewed precancerous cell growth. These procedures also have complications, such as possible problems swallowing, that patients should discuss with their physician.

Esophagectomy. Esophagectomy is the surgical removal of all or part of the esophagus. Patients with Barrett's esophagus, who are otherwise healthy, are candidates for this procedure if endoscopy shows developing cancer. After esophageal removal, in total or in part, a new conduit for foods and fluids must be established to replace the absent esophagus. Alternatives include the stomach, colon, and part of the small intestine called the jejunum. The stomach is the optimal choice.

Diagnosis

If a patient suffers from chronic heartburn, chances are good the patient also has GERD. (Occasional heartburn does not necessarily indicate the presence of GERD.) The following is the general diagnostic approach:

A physician can usually make an easy diagnosis of GERD if the patient finds relief from persistent heartburn and acid regurgitation after taking antacids for short periods.
If the diagnosis is uncertain but the physician still suspects GERD, a drug trial using a proton-pump inhibitor medication, such as omeprazole (Prilosec) identifies 80 - 90% of people with the conditions. This class of medication blocks stomach acid secretion.

Laboratory or more invasive tests, including endoscopy, may be required if the diagnosis is still uncertain, if atypical symptoms are present, if Barrett's esophagus is suspected, or if complications, such as signs of bleeding or difficulty in swallowing, are present. Some of these tests are described below.

A barium swallow radiograph (x-ray) is useful for identifying structural abnormalities and erosive esophagitis (severe inflammation). When taking this test, the patient drinks a solution containing barium, then x-rays are taken. This test can show stricture, active ulcer craters, hiatal hernia, erosion, or other abnormalities. The test cannot reveal mild irritation.

Upper endoscopy, also called esophagogastroduodenoscopy or panendoscopy, is more accurate than a barium-swallow radiograph. It is also more invasive and expensive. It is widely used in GERD, including for identifying and grading severe esophagitis, for periodic monitoring of patients with Barrett's esophagus or for screening people at high risk, or when other complications are suspected. It is also now employed as part of various surgical techniques.

Endoscopy to Diagnose GERD. Endoscopy may be performed either in a hospital or in a doctor's office:

First, the patient should eat nothing for at least 6 hours before the procedure.
The doctor administers a local anesthetic using an oral spray and an intravenous sedative to suppress the gag reflex and to relax the patient.
Next, the physician places an endoscope (a thin flexible plastic tube containing a tiny camera) into the patient's mouth and down the esophagus. The procedure does not interfere with breathing. It may be slightly uncomfortable for some patients; others are able to sleep through it.
Once the endoscope is in place, the tiny camera allows the physician to see the surface of the esophagus and to search for abnormalities, including hiatal hernia and damage to the mucous lining.
The physician performs a biopsy (the removal and microscopic examination of small tissue sections). The biopsy may detect tissue injury indicative of GERD. It may also be used to detect cancer or other conditions, such as yeast (Candida albicans) or viral infections (e.g., herpes simplex and cytomegalovirus). Such infections are more likely to occur in people with impaired immune systems.
Complications from the procedure are uncommon. If they occur, complications are almost always mild and typically include minor bleeding from the biopsy site or irritation where medications were injected.

If a patient has moderate-to-severe GERD symptoms and the procedure reveals injury in the esophagus, usually no further tests are needed to confirm a diagnosis. The test is not foolproof, however. A visual view misses about half of esophageal abnormalities.

Capsule Endoscopy. Capsule endoscopy was first approved for use in 2001. A new version of this pill-sized camera, renamed PillCam, was approved by the FDA in 2004. PillCam reduces the imaging time previously required by the original capsule endoscopy technique. The PillCam capsule contains tiny video cameras on both ends. After the patient swallows the capsule, a series of 2600 color pictures are transmitted to a recording device where they can be downloaded and interpreted by a doctor. A newer version of the PillCam takes 14 frames per second as opposed to the 4 frames per second of the original device. The newer PillCam is superior in visualizing the entire esophagus and in identifying GERD. The entire procedure takes 20 minutes. The capsule is naturally passed through the digestive system within 24 hours. Capsule endoscopy may provide a more attractive and less invasive alternative for patients than traditional endoscopy. However, while capsule endoscopy is useful as a screening device for diagnosing esophageal conditions such as GERD and Barrett's esophagus, traditional endoscopy is still required for gathering tissue samples or removing polyps.

The (ambulatory) pH monitor examination may be employed to determine acid back-up. It is useful when endoscopy has not detected damage to the mucous lining in the esophagus, but GERD symptoms are present. pH monitoring may be used when patients have not found relief from medicine or surgery. The traditional trans-nasal catheter diagnostic procedure involved inserting a tubular probe through the nose and down to the esophagus. The tube was left in place for 24 hours. This test was irritating to the throat, and uncomfortable and awkward for most patients.

A new method, known as the Bravo pH test, uses a small capsule-sized data transmitter that is temporarily attached to the wall of the esophagus during endoscopy. The capsule records pH levels and transmits these data to a pager-sized receiver worn by the patient. Patients can continue their usual diet and activity schedule during the 24 - 48-hour monitoring period. After a few days, the capsule detaches from the esophagus, passes through the digestive tract, and is eliminated through a bowel movement.

Manometry is a technique that measures muscular pressure. It employs a tube containing various openings, which is placed through the esophagus. As the muscular action of the esophagus exerts pressure on the tube in various locations, a computer connected to the tube measures it. It is useful for the following situations:

To determine if a GERD patient would benefit from surgery by measuring pressure exerted by the lower esophageal sphincter muscles (LES).
To detect impaired stomach motility (an inability of the muscles to contract normally), which cannot be surgically corrected with standard procedures.
To determine if impaired peristalsis or other motor abnormalities are causing chest pain in people with GERD who have these symptoms.

Blood and Stool Tests. Stool tests may show traces of blood that are not visible. Blood tests for anemia should be performed if bleeding is suspected.

Bernstein Test. For patients with chest pain in which the diagnosis is uncertain, a procedure called the Bernstein test may be useful, although it is rarely used. A tube is inserted through the patient's nasal passage. Then solutions of hydrochloric acid and saline are administered separately into the esophagus. If the acid infusion causes symptoms and the saline solution does not, then a diagnosis of GERD is established.

Because many illnesses share similar symptoms, careful analysis and consideration of the patient's history is key to an accurate diagnosis. The following are only a few of the conditions that could accompany or resemble GERD.

Dyspepsia. The most common disorder confused with GERD is dyspepsia, which is defined as pain or discomfort in the upper abdomen without heartburn. Specific symptoms may include a feeling of fullness (particularly early in the meal), bloating, and nausea. Dyspepsia can be a symptom of GERD, but does not always occur with GERD. The drug metoclopramide (Reglan) helps stomach emptying and may be helpful for this condition.

Angina and Chest Pain. About 600,000 people come to emergency rooms each year with chest pains. More than 100,000 of these people are believed to actually have GERD. Chest pain from both GERD and from severe angina can occur after a heavy meal. In general, a heart problem is probably not responsible for the pain if it is worse at night and does not occur after exercise. It should be noted that the two conditions often coexist. In fact, there is some theory that in patients with coronary artery disease, acid reflux may actually trigger angina. In such cases, experts believe that acid in the esophagus may activate nerves that temporarily impair blood flow to the heart.

Asthma. Because asthma and GERD commonly occur together, physicians must be sure that each disorder is diagnosed accurately.

Other Diseases. Many gastrointestinal diseases (e.g., inflammatory bowel disease, ulcers, intestinal cancers) can cause GERD, but they are often easily identified, since they have other symptoms and affect other areas of the intestinal tract.

Treatment

Acid suppression continues to be the mainstay for treating GERD. The aim of drug therapy is to reduce the amount of acid present and improve any abnormalities in muscle function of the lower esophageal sphincter (LES), the esophagus, or the stomach.

Most cases of gastroesophageal reflux are mild and can be managed with lifestyle changes and over-the-counter medications and antacids.

Patients with moderate-to-severe symptoms that do not respond to lifestyle measures, or who are diagnosed at a late stage may be started on more or less potent agents depending on their complications at diagnosis. Experts argue, however, about the best way to initiate 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, usually omeprazole (Prilosec).
Step-down. A step-down approach first uses a more potent agent, most often a proton-pump inhibitor (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 recur, the drug is withdrawn. If symptoms recur, the patient is put on high-dose H2 blockers. In one study using this step-down approach, 58% of patients remained symptom-free after a year, with 27% not using any medications at all. Some physicians argue that the step-down approach should be used for most patients with moderate-to-severe GERD.

Recent guidelines indicate that PPIs should be the first drug treatment, and that these drugs should be given once a day for approximately 8 weeks. Even when symptoms are completely relieved by medication, they usually return within a few months after drug treatment has stopped. Long-term maintenance may be necessary.

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. In some cases, bile, not acid, may be responsible for symptoms, so that 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 indicated under certain circumstances:

If lifestyle changes and drug treatments have failed
In patients with 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 since minimally invasive surgical procedures are becoming more widely available, and since only surgery improves regurgitation. Furthermore, persistent GERD appears to be much more serious than was previously believed, and the long-term safety of acid suppression using medication is still uncertain.

Nevertheless, anti-GERD procedures have many complications and high failure rates (ranging from 30% at 5 years to 63% at 10 years) and, 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 (e.g., gas, bloating, trouble swallowing), with most occurring more than a year after surgery. Finally, evidence -- notably an important 2002 Swedish study -- now strongly suggests that the procedure 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.

Prevention

People with heartburn should first try lifestyle and dietary changes. In one study, 44% of patients who experienced symptoms of gastroesophageal reflux disease (GERD) reported improvement after changing their diet. Some suggestions are the following:

Avoid or reduce consumption of foods and beverages that contain caffeine, chocolate, peppermint, spearmint, and alcohol. Both caffeinated and decaffeinated coffees increase acid secretion.
Avoid all carbonated drinks, because they increase the risk for GERD.
Although physicians often advise patients with GERD to cut down on fatty foods, many studies have found no evidence that a low-fat or high-fat meal makes any difference in symptom exacerbation. One small study, however, found that the frequency of GERD symptoms increased with a high-fat compared to a low-fat diet. Better studies are needed to confirm this. In any case, as a rule, it is always wise to avoid saturated fats (which are from animal products), and cut down on all fats if one is overweight.
Choose low-fat or skim dairy products, poultry, or fish. Increasing protein may help strengthen muscles in the muscle valve.
Consume whole-grain products rich in selenium, which may have some protective role against dangerous cell changes in Barrett's esophagus.
Eat a diet rich in fruits and vegetables, although it's best to avoid acidic vegetables and fruits (e.g., oranges, lemons, grapefruit, pineapple, tomatoes).

Patients who have trouble swallowing should avoid tough meats, vegetables with skins, doughy bread, and pasta.

Nearly three-quarters of patients with frequent GERD symptoms have them at night. Patients with nighttime GERD also tend to experience severe pain. It is very important to take preventive measures before going to sleep. Some suggestions for preventing acid reflux at night are as follows:

After meals, take a walk or, at the very least, remain upright.
Avoid bedtime snacks. In general, avoid eating for at least 2 hours prior to bedtime.
When going to bed, try lying on the left side rather than on the right. The stomach is located higher than the esophagus when a person sleeps on the right side, which can put pressure on the lower esophageal sphincter (LES), increasing the risk for fluid back-up.
Sleep in a tilted position to help keep acid in the stomach at night. To do this, raise the bed at an angle using 4- to 6-inch blocks at the head of the bed and use a wedge-support to elevate the top half of the body. (Extra pillows that only raise the head actually increase the risk for reflux.)

A reflux board is prescribed for use in children who have gastroesophageal reflux. A board tilts the child upward while he is lying in bed to prevent the stomach contents from going back into the esophagus and mouth, and possibly into the lungs.

Quitting smoking is essential.
People who are overweight should try to reduce food intake and exercise to lose weight.
People with GERD should avoid tight clothing, particularly around the abdomen.
If possible, GERD patients should avoid nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Motrin, Advil), or naproxen (Aleve), among others. Tylenol (acetaminophen) is a good alternative pain reliever.

Although gum chewing is commonly believed to increase the risk for GERD symptoms, one study reported it might be helpful. Because saliva helps neutralize acid and contains a number of other factors that protect the esophagus, chewing gum 30 minutes after a meal has been found to help relieve heartburn and even protect against damage caused by GERD. Chewing on anything at all can help since it stimulates saliva production.

Medications

Antacids neutralize digestive acids and are the primary drugs for mild symptoms. They are best used alone for relief of occasional and unpredictable episodes of heartburn. They all work by neutralizing the acid in the stomach. They may also stimulate the defensive systems in the stomach by increasing bicarbonate and mucous secretion. Many antacids are available without a prescription and are the first drugs recommended to relieve heartburn and mild symptoms. Despite the many brands, they all rely on various combinations of three basic ingredients: magnesium, calcium, or aluminum.

Magnesium. Magnesium salts are available in the form of magnesium carbonate, magnesium trisilicate, and most commonly, magnesium hydroxide (Milk of Magnesia). The major side effect of magnesium salts is diarrhea. Magnesium salts offered in combination products with aluminum (Mylanta and Maalox) balance the side effects of diarrhea and constipation.

Calcium. Calcium carbonate (Tums, Titralac, and Alka-2) is a potent and rapid acting antacid that can cause constipation. These antacids are actually sources of calcium. There have been rare cases of hypercalcemia (elevated levels of calcium in the blood) in people taking calcium carbonate for long periods of time. This can lead to kidney failure and is very dangerous. None of the other antacids has this side effect.

Aluminum. Aluminum salts (Amphogel, Alternagel) are also available. The most common side effect of antacids containing aluminum salts is constipation. People who take large amounts of antacids that contain aluminum may also be at risk for calcium loss, which can lead to osteoporosis.

Osteoporosis is a condition characterized by progressive loss of bone density, thinning of bone tissue, and increased vulnerability to fractures. Osteoporosis may result from disease, dietary or hormonal deficiency, or advanced age. Regular exercise and vitamin and mineral supplements can reduce and even reverse loss of bone density.

It is generally believed that liquid antacids work faster and are more potent than tablets, although evidence suggests that they all work equally well. Antacids can interact with a number of drugs in the intestines by reducing their absorption. These drugs include tetracycline, ciprofloxacin (Cipro), propranolol (Inderal), captopril (Capoten), and H2 blockers. Interactions can be avoided by taking the drugs 1 hour before or 3 hours after taking the antacid. Long-term use of nearly any antacid increases the risk for kidney stones.

H2 blockers impede acid production by blocking or antagonizing the actions of histamine, a chemical found in the body that encourages acid secretion in the stomach. They are available over the counter and provide symptom relief in about half of GERD patients. It takes 30 - 90 minutes for them to work, but the benefits last for hours. The drugs are usually taken at bedtime. Some people may need to take them twice a day.

H2 blockers inhibit acid secretion for 6 - 24 hours and are very useful for people who need persistent acid suppression. They may also prevent heartburn episodes in people who are able to predict its occurrence. In some studies, H2 blockers improved asthmatic symptoms in people who have both conditions. A 2001 study suggested, however, that they rarely provide complete symptom relief for chronic heartburn and dyspepsia and they have done little to reduce office visits to physicians for GERD.

Brands. Four H2 blockers are currently available in the U.S.:

Famotidine (Pepcid AC). Famotidine (Pepcid AC, Pepcid Oral) is the most potent H2 blocker. The most common side effect of famotidine is headache, which occurs in 4.7% of people who take it. Famotidine is virtually free of drug interactions, but the FDA has issued a warning on its use in patients with kidney problems.
Cimetidine (Tagamet, Tagamet HB). Cimetidine (Tagamet) is the oldest H2 blocker. It has few side effects; approximately 1% of people taking it will experience mild temporary diarrhea, dizziness, rash, or headache. Cimetidine interacts with a number of commonly used medications, such as phenytoin, theophylline, and warfarin. Long-term use of excessive doses (more than 3 grams a day) may cause impotence or breast enlargement in men. These problems resolve after the drug is discontinued.
Ranitidine (Zantac, Zantac 75, Zantac Efferdose, Zantac injection, Zantac Syrup). Ranitidine (Zantac) interacts with very few drugs. In a recent study, ranitidine provided more pain relief and healed ulcers more quickly than cimetidine in people less than 60 years old, but there was no difference in older patients. A common side effect associated with ranitidine is headache, which occurs in about 3% of the people who take it.
Nizatidine Capsules (Axid AR, Axid Capsules, Nizatidine Capsules). Nizatidine (Axid) is nearly free of side effects and drug interactions. A controlled-release form is proving to help alleviate nighttime GERD symptoms.

Famotidine is excreted primarily by the kidney. This can pose a danger to people with kidney problems. Physicians are now being advised by the U.S. Food and Drug Administration (FDA) and Health Canada to reduce the dose and increase the time between doses in patients with kidney failure. Use of the drug in those with impaired kidney function can affect the central nervous system and may result in anxiety, depression, insomnia or drowsiness, and mental disturbances.

Drug Combinations.

Over-the-counter antacids and H2 blockers: This combination may be the best approach for many people who experience heartburn after eating. Both classes of drugs are effective in relieving GERD, but have different timing. Antacids work within a few minutes but are short-acting, while H2 blockers take longer but have long-lasting benefits. Pepcid AC combined with an antacid (calcium carbonate and magnesium) is now available as Pepcid Complete.
Proton-pump inhibitors and H2 blockers: Physicians sometimes recommend a nighttime dose of an H2 blocker for people who are taking proton-pump inhibitors twice a day. This is based on the belief that adding the H2 blocker will prevent a rise in acid reflux at night. An important 2002 study, however, reported no additional benefits from the nighttime H2 blocker. Some experts recommended an H2 blocker in patients who are on proton-pump inhibitors only to prevent breakthrough symptoms, such as before a heavy meal.

Long Term Complications. In most cases, these agents have good safety profiles and few side effects. H2 blockers can interact with other drugs, although some less so than others. In all cases, however, the physician should be made aware of any other drugs a patient is taking. More research is needed. Anyone with kidney problems should use famotidine only under the direction of a physician.

Concerns and Limitations. Some experts are concerned that the use of acid-blocking drugs in people with peptic ulcers may mask ulcer symptoms and increase the risk for serious complications.

These agents provide no protection against Barrett's esophagus. In fact, of concern are reports that long-term acid suppression with these drugs may cause cancerous changes in the stomach in patients who are infected with H. pylori. Research on this question is still ongoing.

Proton-pump inhibitors (PPIs) suppress the production of stomach acid and work by inhibiting the molecule in the stomach glands that is responsible for acid secretion, which is called the gastric acid pump. According to recent guidelines, initial drug treatment should be with PPIs once daily for about 8 weeks.

The standard agent has been omeprazole (Prilosec), which is now available over the counter without a prescription. Newer prescription oral PPIs include esomeprazole (Nexium), lansoprazole (Prevacid), rabeprazole (Aciphex), and pantoprazole (Protonix).

Studies report significant relief from PPIs in most patients with heartburn. PPIs are effective for healing erosive esophagitis and may also be helpful in patients with chronic laryngitis that is suspected to be caused by GERD. The newer agents provide quicker symptom relief compared to omeprazole. However, a comparison study suggested that, to date, esomeprazole (Nexium) is the only newer oral PPI to show any significant advantage over omeprazole (Prilosec). All PPIs are more effective than the H2 blockers.

In addition to relieving most common symptoms, including heartburn, proton-pump inhibitors also have the following advantages:

They are effective in relieving chest pain and laryngitis caused by GERD.
They may also reduce acid reflux that typically occurs during strenuous exercise.

Patients with impaired esophageal muscular action are still likely to experience acid breakthrough and reflux at night. Proton-pump inhibitors also may have little or no effect on regurgitation or asthmatic symptoms. Some experts believe, however, that they should be the first drugs of choice, even for patients with milder symptoms. At this time, these drugs are recommended for the following patients:

Those with moderate symptoms that do not respond to H2 blockers
Those with severe symptoms
Those who have respiratory complications
Those who have persistent nausea
Those who have esophageal injury

These agents have no affect against non-acid reflux, such as bile back-up.

Adverse Effects. Proton-pump inhibitors may pose the following concerns:

Side effects are uncommon but may include headache, diarrhea, constipation, nausea, and itching.
Proton-pump inhibitors should be avoided by pregnant women and nursing mothers, although recent studies suggest that they do not pose an increased risk of birth defects.
They may interact with certain drugs, such as anti-seizure agents (such as phenytoin), anti-anxiety drugs (such as diazepam), and blood thinners (such as warfarin).
Long-term use of high-dose PPIs may produce vitamin B12 deficiencies, but studies are needed to confirm whether there is any significant risk. High-dose PPIs used over the long-term also may increase the risk of hip fracture in older adults, according to one study.

There is some evidence that acid reflux may contribute to the higher risk of cancer in BE, but it is not yet confirmed whether acid-blockers have any protective effects against cancer in these patients. In fact, the long-term use of proton-pump inhibitors by people with H. pylori may, in theory at least, reduce acid secretion enough to cause atrophic gastritis (chronic inflammation of the stomach). This condition is a risk factor for stomach cancer. To compound concerns, long-term use of PPIs may mask symptoms of stomach cancer and so delay a diagnosis. To date, however, there have been no reports of an increased risk of stomach cancer with the long-term use of these drugs.

Sucralfate (Carafate) protects the mucous lining in the gastrointestinal tract. It seems to work by sticking to an ulcer crater and protecting it from damage due to stomach acid and pepsin. It may be helpful for maintenance therapy in people with mild-to-moderate GERD. Other than constipation, which occurs in 2.2% of patients, the drug has few side effects. Sucralfate interacts with a wide variety of drugs, however, including warfarin, phenytoin, and tetracycline.

Most drugs used for GERD have no effect on non-acid reflux, such as back-up of bile. Baclofen, known as a gamma-amino butyric acid agonist, is commonly used to reduce muscle spasms. Investigators are now showing that it can reduce both acid and non-acid reflux episodes (as much as 70% in one study) and increase LES pressure, an important factor for preventing back-up.

Surgery

The standard surgical treatment for GERD is fundoplication. The goal of this procedure is twofold:

To increase LES pressure and, therefore, prevent acid back-up (reflux)
To repair any present hiatal hernia

There are two primary approaches:

Open Nissen fundoplication (the more invasive technique)
Laparoscopic fundoplication

In general, the overall long-term benefits of these procedures are similar. Some studies report that more than 90% of patients are free of heartburn after the operation and satisfied with their choice, even after 5 years. Fundoplication relieves GERD-induced coughs and some other respiratory symptoms in up to 85% of patients. (Its effect on asthma associated with GERD, however, is unclear.) It may enhance stomach emptying and improve peristalsis in about half of patients. (It may actually cause abnormal peristalsis in about 14% of patients, although in such cases the problem does not appear to be very significant.)

Still, it has other significant limitations and postoperative problems. For example, the results of one 2003 survey suggested that 18% of surgical patients still required anti-GERD medications and 38% had new symptoms (e.g., gas, bloating, trouble swallowing), with most occurring more than a year after surgery. Other studies have reported similar results. Also, fundoplication does not cure GERD. Finally, evidence from a 2002 Swedish study strongly suggests that the procedure does not reduce the risk for esophageal cancer in high-risk patients, such as those with Barrett's esophagus.

Candidates. Fundoplication is recommended for patients whose condition includes one or more of the following:

Esophagitis (inflamed esophagus)
Symptoms that persist or are recurrent in spite of anti-reflux drug treatment
Strictures
Failure to gain or maintain weight (children)

Fundoplication has little benefit for patients with impaired stomach motility (an inability of the muscles to move spontaneously).

The Open Nissen Fundoplication Procedure. Until recently, most fundoplication procedures for GERD have been the 360° Nissen fundoplication. This is called an open procedure because it requires wide surgical incisions.

With this procedure, the physician wraps the upper part of the stomach (fundus) completely around the esophagus to form a collar-like structure.
The collar places pressure on the LES and prevents stomach fluids from backing up into the esophagus.
Open fundoplication requires a 6- to 10-day hospital stay.

Click the icon to see an illustrated series detailing gastroesophageal reflux surgery.

Laparoscopic Fundoplication. The standard invasive fundoplication procedure has been replaced in many cases by a less invasive fundoplication procedure that uses laparoscopy. In the operation:

Tiny incisions are made in the abdomen.
Small instruments and a tiny camera are inserted into tubes, through which the surgeon can view the region.
The surgeon creates a collar using the fundus, although the area is smaller to work with.

When performed by experienced surgeons, the procedure shows results that are equal to those of standard open fundoplication, but with faster recovery time.

Overall, laparoscopic fundoplication appears to be safe and effective in people of all ages, even babies. Laparoscopy is more difficult to perform in certain patients, including those who are obese, who have a short esophagus, or who have a history of previous surgery in the upper abdominal area. It may also be less successful in relieving atypical symptoms of GERD, including cough, abnormal chest pain, and choking. In about 8% of laparoscopies, it is necessary to convert to open surgery during the procedure because of unforeseen complications.

Other Variations. There are now a number of variants of fundoplication procedures. Examples include the following:

Toupet fundoplication employs only a partial wrap, as does a Thal fundoplication. Partial fundoplication procedures may be more effective in patients with poor or no esophageal motility (spontaneous muscle contraction). Those with normal motility may do better with the full-circle wrap.
Others use a very short and "floppy" Nissen full wrap.

Many surgeons report that such limited fundoplications result in earlier feeding and discharge from the hospital and a lower incidence of complications (trouble swallowing, gas bloating, gagging) than the full Nissan fundoplication. A British study, however, reported no significant differences in swallowing problems.

Postoperative Problems and Complications after Fundoplication. Postoperative problems can include a delay in intestinal functioning causing bloating, gagging, and vomiting. These side effects usually resolve in a few weeks. A 2003 study suggested, however, that 38% of patients develop such symptoms, and most occur more than a year after the procedures. If symptoms persist or if they start weeks or months after surgery, particularly if vomiting is present, then surgical complications are likely. Complications include the following:

An excessively wrapped fundus. This is fairly common and can cause difficulty swallowing (dysphagia), as well as gagging, gas, bloating, or an inability to burp. (A follow-up procedure that dilates the esophagus using an inflated balloon may help correct dysphagia, although it cannot treat other symptoms.)
Bowel obstruction
Wound infection
Injury to nearby organs
Respiratory complications, such as a collapsed lung. These are uncommon, particularly with laparoscopic fundoplication.
Muscle spasms after swallowing food. This can cause intense pain, and patients may require a liquid diet, sometimes for weeks. This is a rare complication in most patients, but it can be very high in children with neurologic abnormalities. Such children are already at very high risk for GERD.

Reasons for Treatment Failure. Long-term failure rates after fundoplication are 30% after 5 years and 63% after 10 years. Hiatal herniation is the most common reason for surgical failure and the need for a repeat fundoplication. Other common reasons for reoperation include breakdown, slippage, and excessive tightness of the wrap. Surgeon experience can lessen complication risks. Some studies have reported that repeat operations after open procedures occur in 9 - 30% of cases and 13% after laparoscopy. (Repeat surgery usually has good results.)

A number of treatments that make use of endoscopy are being used or investigated for increasing LES pressure and preventing reflux, as well as for treating severe GERD and its complications.

Transoral Flexible Endoscopic Suturing. Transoral flexible endoscopic suturing (sometimes referred to as Bard's procedure) uses a tiny device at the end of the endoscope that acts like a miniature sewing machine. It places stitches in two locations near the LES, which are then tied to tighten the valve and increase pressure. There is no incision and no need for general anesthesia.

Radiofrequency. Radiofrequency energy generated from the tip of a needle (sometimes called the Stretta procedure) heats and destroys tissue in the problem spots in the LES. Either the resulting scar tissue strengthens the muscle, or the heat kills the nerves that caused the malfunction. Patients may experience some chest or stomach pain afterwards. Few serious side effects have been reported, although there have been reports of perforation, hemorrhage, and even death. A recent study reported that 81% of patients remained symptom-free for up to 3 years following the Stretta procedure.

Implants. In 2003, the FDA approved the Enteryx procedure as a treatment option for people who have persistent symptoms of GERD and who regularly take and respond to PPIs. In 2005, however, the manufacturer of Enteryx (Boston Scientific), voluntarily removed Enteryx from clinical use due to problems related to the difficult injection technique.

Techniques to Stop Bleeding. Endoscopic ablation treatment of bleeding involves using a probe passed through the endoscopic tube, which applies electricity or heat to coagulate blood and stop the bleeding.

Dilation Procedures. Strictures (abnormally narrowed regions) may need to be dilated (opened) with endoscopy. Dilation may be performed by inflating a balloon in the passageway. About 30% of patients who need this procedure require a series of dilation treatments over a long duration in order to fully open the passageway. Long-term use of proton-pump inhibitors may reduce the duration of treatments.

One study also suggested that dilation may help correct swallowing problems that can occur after fundoplication. In the study dilation improved dysphagia in 67% of the surgical patients who had experienced it.

A recent advance is the development of small-caliber upper endoscopy, which does not require sedation and can be performed in the physician's office.

Resources

http://digestive.niddk.nih.gov -- National Digestive Diseases Information Clearinghouse
www.gastro.org -- American Gastroenterological Association
www.acg.gi.org -- American College of Gastroenterology
www.asge.org -- American Society for Gastrointestinal Endoscopy
www.ssat.com -- Society for Surgery of the Alimentary Tract
www.naspgn.org -- North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition
www.reflux.org -- Pediatric/Adolescent Gastroesophageal Reflux Association
www.iffgd.org -- International Foundation for Functional Gastrointestinal Disorders

References

DeVault KR, Castell DO. Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. Am J Gastroenterol. 2005;100(1):190-200.

Deviere J, Costamagna G, Neuhause H, Voderholzer W, Louis H, Tringali A, et al. Nonresorbable copolymer implantation for gastroesophageal reflux disease: a randomized sham-controlled multicenter trial. Gastroenterology. 2005;128(3):532-540.

Esposito C, Montupet P, van Der Zee D, Settimi A, Paye-Jaouen A, Centonze A, Bax NK. Long-term outcome of laparoscopic Nissen, Toupet, and Thal antireflux procedures for neurologically normal children with gastroesophageal reflux disease. Surg Endosc. 2006 Jun;20(6):855-8. Epub 2006 May 12. Accessed June 2, 2006.

Gilger MA, Yeh C, Chiang J, Dietrich C, Brandt ML, El-Serag HB. Outcomes of surgical fundoplication in children. Clin Gastroenterol Hepatol. 2004;2(11):978-984.

Gold BD, Schelman JM, Sabesin SM, Vitat P. Updates on the management of upper gastrointestinal disorders in primary care setting:NSAID-related gastropathies and pediatric reflux disease. The Journal of Family Practice. March 2007;56(3):S1-S11.

Hirano I, Richter JE, and the Practice Parameters Committee of the American College of Gastroenterology. ACG practice guidelines: esophageal reflux testing. American Journal of Gastroenterology. 2007;102:668-685.

Kim CY, O'Rourke RW, Chang EY, Jobe BA. Unsedated small-caliber upper endoscopy: an emerging diagnostic and therapeutic technology. Surg Innov. 2006 Mar;13(1):31-9.

Koslowsky B, Jacob H, Eliakim R, Adler SN. PillCam ESO in esophageal studies: improved diagnostic yield of 14 frames per second (fps) compared with 4 fps. Endoscopy. 2006 Jan;38(1):27-30.

Remedios M, Campbell C, Jones DM, Kerlin P. Eosinophilic esophagitis in adults: clinical, endoscopic, histologic findings,and response to treatment with fluticasone propionate. Gastrointest Endosc. 2006 Jan;63(1):3-12.

Rudolph CD, Mazur LJ, Liptak GS, Baker RD, Boyle JT, Colletti RB, et al. Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr. 2001;32 Suppl 2: S1-S31.

Review Date:
5/22/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

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adam.com

Gastroesophageal reflux disease

FitSugar — Wed, 08 Oct 2008 17:35:25 -0700

Overview

Signs and Symptoms

Causes

Risk Factors

Diagnosis

Treatment

Other Considerations

Supporting Research

HEALTH GUIDE REFERENCE FROM A.D.A.M

Gastroesophageal reflux disease (GERD) is a condition in which contents of the stomach or small intestine repeatedly move back up into the esophagus (the tube connecting the throat to the stomach). This regurgitating action is called reflux. Reflux causes heartburn, and although most people have an attack of heartburn at some point in their lives, persistent reflux and severe heartburn may indicate GERD.

Signs and Symptoms

Heartburn -- a burning sensation under the sternum in the chest -- is the primary symptom of GERD. Heartburn often occurs after a meal and worsens at night, when you are lying flat. It is more likely to occur following a heavy meal, or if you bend, lift, or lie down just after eating.

Other symptoms of GERD include:

Regurgitation of food

Belching

Nausea and vomiting

Chronic cough, wheezing

Sore throat, hoarseness or change in voice, difficulty swallowing

Chest pain

GERD is common in infants and young children, but is generally mild. If an infant has the following symptoms, however, call a doctor as soon as possible:

Ongoing coughing

Wheezing, gasping

Severe vomiting

Frequent burping

Causes

Normally when a person swallows, the muscular walls of the esophagus move in waves to push the food down into the stomach. Right after the food enters the stomach, a band of muscle (the lower esophageal sphincter, or LES) closes off the esophagus. If the muscle fails to close tightly enough or weakens over time, the stomach contents can back up into the esophagus, causing heartburn and other symptoms of GERD.

Substances in the digestive juices from the stomach (such as acid, pepsin, and bile) can damage the inner lining of the esophagus, causing inflammation ulcers (open sores), and, possibly, precancerous changes to cells (called Barrett's esophagus).

Any of the following may compromise the LES:

Pregnancy

Obesity

Hiatal hernia (a condition in which a portion of the stomach protrudes through an opening in the diaphragm where the esophagus normally fits snuggly and passes into the stomach)

Recurrent or persistent vomiting

Nasogastric tubes (these are inserted through the nose and into the stomach for a variety of medical reasons)

Smoking cigarettes

Some medicines, including calcium channel blockers (a class of meds used for high blood pressure such as amlodipine, diltiazem, felodipine, nifedipine, nisoldipine, and verapamil), anticholinergic drugs (including benztropine, biperiden, dicyclomine, hyoscyamine, isopropamide, and scopolamine), iron pills, non-steroidal anti-inflammatory drugs (NSAIDs including aspirin and ibuprofen), potassium, dopamine (for Parkinson's disease), sedatives, bisphosphonates (alendronate and risedronate for osteoporosis), and beta blockers (such as atenolol, labetalol, metoprolol, nadolol, pindolol, and propranolol, for high blood pressure or heart disease)

Risk Factors

Heavy meals

Lying down or bending after a meal

Eating immediately prior to exercise

Prior esophageal surgery

Esophageal stricture (narrowing of the esophagus)

Cigarette smoking

Alcohol intake

Psychological stress

Children with the following conditions are at particular risk for GERD:

Neurologic impairment

Food allergies

Scoliosis

Frequent vomiting

Cystic fibrosis

Digestive disorders

Diagnosis

GERD is generally not difficult to diagnose. Your symptoms, what you eat and drink, medications you are taking, and your lifestyle are usually enough to make a clear diagnosis. If the diagnosis is unclear to your doctor, one or more tests may be performed:

Upper endoscopy, called esophageal gastroduodenoscopy (EGD), which involves the insertion of a tube down your throat into the esophagus to look for signs of reflux, inflammation, ulcers, or other changes in the esophagus.

A barium swallow, which involves visualization of the esophagus through a series of x-rays following the swallowing of a substance called barium. This looks at the movement of the esophagus and whether any fluid comes back from the stomach into the esophagus.

Manometry measures the pressure of the sphincter muscle. If the pressure is low, this is consistent with GERD.

Treatment

The primary goals of treatment are to reduce the reflux (regurgitation), stop the harmful effect of the stomach's materials by reducing its acid content, improve the clearance of food through to the stomach, and protect the walls of the esophagus.

For mild cases, these goals can be accomplished by making lifestyle changes (such as avoiding certain foods) and by taking over-the-counter medication. Health care professionals may recommend herbs such as DGL-licorice (Glycyrrhiza glabra ) for their soothing properties. Prescription medicines may be recommended as needed.

For moderate-to-severe cases, prescription medication may be used more regularly, and the condition may be monitored more closely. If these measures fail, surgery may ultimately be required.

Lifestyle

Making changes to or avoiding certain habits can go a long way to relieving or preventing your symptoms of GERD.

The following are typical suggestions for people with GERD:

Avoid behavior that does not allow food to easily move down into and through the stomach. This includes bending, lying down, or participating in jarring exercises soon after a meal.

Don't eat heavy meals.

Avoid acidic foods and drinks. These include caffeinated beverages, decaffeinated coffee, and orange juice.

Avoid alcohol, chocolate, spearmint, and peppermint. These can relax the lower esophageal sphincter.

Avoid carbonated beverages.

Avoid eating fatty foods, including full-fat milk, which also may relax the lower esophageal sphincter tone. Take medication with plenty of water.

Lose weight if you are overweight.

Quit smoking.

Avoid medications that provoke symptoms. These include smooth-muscle relaxants, such as calcium channel blockers (including amlodipine, diltiazem, felodipine, nifedipine, nisoldipine, and verapamil, which are used for high blood pressure), anticholinergic drugs (including benztropine, biperiden, dicyclomine, hyoscyamine, isopropamide, and scopolamine), iron pills, non-steroidal anti-inflammatory drugs (NSAIDs including aspirin and ibuprofen), potassium, dopamine (for Parkinson's disease), sedatives, bisphosphonates (alendronate and risedronate for osteoporosis), and beta blockers (such as atenolol, labetalol, metoprolol, nadolol, pindolol, and propranolol, for high blood pressure or heart disease).

If you experience more frequent symptoms at night, you may be relieved by:

Raising the head of your bed about 6 inches.

Avoiding bedtime snacks.

Stress may worsen symptoms. Therefore, relaxation, such as yoga, tai chi, or meditation, is worth considering as part of your treatment plan.

Medications

The main aim of drug treatment is to control the acidity of the stomach. This can be achieved with either nonprescription or prescription drugs, depending on the severity and frequency of your reflux. Your doctor will determine which medicine is best for you.

There are several different types of medications used for GERD, and each works in a different way. Over-the-counter antacids neutralize the stomach acids. Histamine H2 blockers interfere with the production of acid, and proton pump inhibitors suppress molecules in the glands responsible for the release of acid. Avoid taking other medications within 3 hours of an antacid because antacids may limit the absorption of other drugs.

Antacids, available over the counter, may relieve heartburn or indigestion. Antacids include aluminum hydroxide (Amphojel, AlternaGEL), magnesium hydroxide (Phillips' Milk of Magnesia), aluminum hydroxide and magnesium hydroxide (Maalox, Mylanta), calcium carbonate (Rolaids, Titralac, Tums), and sodium bicarbonate (Alka-Seltzer). Antacids may block medications from being absorbed and thereby decrease the medicine's effectiveness. It is recommended to take antacids at least 1 hour before or 2 hours after taking medications. Ask your pharmacist or doctor for more information.

H2 blockers, such as cimetidine (Tagemet), ranitidine (Zantac), nizatidine (Axid), and famotidine (Pepcid), reduce gastric acid secretion.

Proton-pump inhibitors, including esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix), and rabeprazole (Aciphex), decrease gastric acid production.

Sucralfate (Carafate) makes a coating over the ulcer crater, protecting it from further damage.

Prokinetic agents, specifically metoclopramide (Reglan), promote movement of stomach acids along the gastrointestinal tract, rather than backing up into the esophagus.

Surgery and Other Procedures

For a small number of people, diet, medication, and lifestyle changes are not enough to relieve symptoms of GERD. In such cases, a surgical procedure called fundoplication may be performed to prevent reflux and repair a hiatal hernia (a condition that may cause GERD). As many as 90% of people who have had this operation report no longer having heartburn.

Nutrition and Dietary Supplements

Nutritional therapy is one of the first treatments recommended for GERD.

Doctors used to recommend eating bland foods with milk and only small amounts of food with each meal. Following these nutritional tips may help reduce symptoms:

Eat antioxidant foods, including fruits (such as blueberries, cherries, and tomatoes), and vegetables (such as squash and bell peppers).

Eat foods high in B-vitamins and calcium, such as almonds, beans, whole grains (if no allergy), dark leafy greens (such as spinach and kale), and sea vegetables.

Avoid refined foods, such as white breads, pastas, and especially sugar.

Eat fewer red meats and more lean meats, cold-water fish, tofu (soy, if no allergy) or beans for protein.

Use healthy oils, such as olive oil or vegetable oil.

Reduce or eliminate trans-fatty acids, found in commercially baked goods such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.

Avoid beverages that can irritate the lining of the stomach or increase acid production including coffee (with or without caffeine), alcohol, and carbonated beverages.

Drink 6 - 8 glasses of filtered water daily.

Exercise at least 30 minutes daily, 5 days a week.

Nutritional deficiencies may be addressed with the following supplements:

A multivitamin daily, containing the antioxidant vitamins A, C, E, the B-vitamins, and trace minerals, such as magnesium, calcium, zinc, and selenium.

Omega-3 fatty acids, such as fish oil, 1 - 2 capsules or 1 tablespoonful oil 2 - 3 times daily, to help decrease inflammation and improve immunity. Cold-water fish, such as salmon or halibut, are good sources, but supplementation is recommended.

Probiotic supplement (containing Lactobacillus acidophilus), 5 - 10 billion CFUs (colony forming units) a day, for maintenance of gastrointestinal and immune health. Some probiotic supplements may need to be refrigerated for best results. Your child may also take probiotic supplements. Consult with your health care provider before giving your child any dietary supplements.

Alpha-lipoic acid, 25 - 50 mg twice daily, for antioxidant support.

Melatonin, 2 - 6 mg at bedtime, for immune support and gastric protection.

Vitamin C, 500 - 1,000 mg one to three times daily, as an antioxidant and for immune support.

L-glutamine, 500 - 1,000 mg 3 times daily, for support of gastrointestinal health and immunity.

Grapefruit seed extract (Citrus paradisi), 100 mg capsule or 5 - 10 drops (in favorite beverage) 3 times daily when needed, for antibacterial, antifungal, and antiviral activity, and for immunity.

Resveratrol (from red wine), 50 - 200 mg daily, to help decrease inflammation and for antioxidant effects.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider to get your problem diagnosed before starting any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, you should make teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink 2 - 4 cups per day. You may use tinctures alone or in combination as noted.

Green tea (Camelia sinensis) standardized extract, 250 - 500 mg daily, for antioxidant, anti-inflammatory, and heart health effects. Use caffeine-free products. You may also prepare teas from the leaf of this herb.

Cat's claw (Uncaria tomentosa) standardized extract, 20 mg 3 times a day, for inflammation and antibacterial or antifungal activity.

Reishi mushroom (Ganoderma lucidum), 150 - 300 mg 2 - 3 times daily, for inflammation and for immunity. You may also take a tincture of this mushroom extract, 30 - 60 drops 2 - 3 times a day.

Olive leaf (Olea europaea) standardized extract, 250 - 500 mg 1 - 3 times daily, for antibacterial or antifungal activity and immunity. You may also prepare teas from the leaf of this herb.

DGL-licorice (Glycyrrhiza glabra) standardized extract, 250 - 500 mg 3 times daily, chewed either 1 hour before or 2 hours after meals. Glycyrrhizin is a chemical found in licorice that causes side effects and drug interactions. DGL is deglycyrrhizinated licorice, or licorice with the glycyrrhizin removed.

Mastic (Pistacia lentiscus) standardized extract, 1,000 - 2,000 mg daily in divided dosages, for activity against H. Pylori.

Tumeric (Curcuma longa) standardized extract, 300 mg 3 times a day, for pain and inflammation.

Homeopathy

Although few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider the following remedies for the treatment of GERD symptoms based on their knowledge and experience. Before prescribing a remedy, homeopaths take into account your constitutional type - your physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each individual.

Pulsatilla -- for heartburn, queasiness, a bad taste in the mouth brought on by eating rich foods and fats (especially ice cream); symptoms may include vomiting partly digested food. This remedy is most appropriate for an individual whose tongue is coated with a white or yellow substance.

Ipecacuahna -- for persistent and severe nausea, with or without vomiting and diarrhea, caused by an excess of rich or fatty foods.

Carbo vegetabilis -- for bloating and indigestion, especially with flatulence and fatigue.

Nux vomica -- for heartburn, nausea, retching without vomiting, and sour burps caused by overeating, alcohol use, or coffee drinking. This remedy is most appropriate for individuals who also feel irritable and sensitive to noise and light.

Other Considerations

Pregnancy

GERD is quite common during pregnancy, particularly in the third trimester.

Warnings and Precautions

Contact your health care provider if the medication recommended does not help or if you experience side effects, such as cramping or diarrhea.

Prognosis and Complications

The acidic contents of the stomach can damage the esophagus, causing narrowing, ulcers, erosion, and precancerous changes to cells known as Barrett's esophagus. GERD can also result in respiratory diseases, ear, nose, throat conditions, and tooth decay. Most people can effectively manage their symptoms with lifestyle modifications and medications.

Supporting Research

Austin GL, Thiny MT, Westman EC, Yancy WS Jr, Shaheen NJ.A very low-carbohydrate diet improves gastroesophageal reflux and its symptoms. Dig Dis Sci. 2006;51(:1307-12.

Berardi RR. Proton pump inhibition. An effective, safe approach to GERD management. Postgrad Med. 2001;Spec No:24-35.

Borrelli F, Izzo AA. The plant kingdom as a source of anti-ulcer remedies. [Review]. Phytother Res. 2000;14(:581-591.

Bujanda L. The effects of alcohol consumption upon the gastrointestinal tract. Am J Gastroenterol. 2000;95(12):3374-3382.

Burger O, Ofek I, Tabak M, Weiss EI, Sharon N, Neeman I. A high molecular mass constituent of cranberry juice inhibits helicobacter pylori adhesion to human gastric mucus. FEMS Immunol Med Microbiol. 2000 Dec;29(4):295-301.

Burger O, Weiss E, Sharon N, Tabak M, Neeman I, Ofek I. Inhibition of Helicobacter pylori adhesion to human gastric mucus by a high-molecular-weight constituent of cranberry juice. Crit Rev Food Sci Nutr. 2002;42(3 Suppl):279-284.

Cabrera C, Artacho R, Gimenez R. Beneficial effects of green tea--a review. J Am Coll Nutr. 2006;25(2):79-99.

Coron E, Hatlebakk JG, Galmiche JP.Medical therapy of gastroesophageal reflux disease. Curr Opin Gastroenterol. 2007;23(4):434-9.

Debreceni L, Denes L. Acupuncture treatment for duodenal ulcer. Acupunct Electrother Res. 1988;13(2-3):105-108.

Diehl DL. Acupuncture for gastrointestinal and hepatobiliary disorders. J Altern Complement Med. 1999;5(1):27-45.

El-Serag HB, Satia JA, Rabeneck L. Dietary intake and the risk of gastro-esophageal reflux disease: a cross sectional study in volunteers. Gut. 2005;54(1):11-7.

Fox M, Barr C, Nolan S, et al. The effects of dietary fat and calorie density on esophageal acid exposure and reflux symptoms. Clin Gastroenterol Hepatol. 2007;5(4):439-44.

Fox M, Barr C, Nolan S, Lomer M, Anggiansah A, Wong T. The effects of dietary fat and calorie density on esophageal acid exposure and reflux symptoms. Clin Gastroenterol Hepatol. 2007;5(4):439-44.

Gorbach SL. Probiotics in the third millennium. Dig Liver Dis. 2002;34(Suppl 2):S2-S7.

GrahamDY, Rakel RE, Fendrick AM, et al. Recognizing peptic ulcer disease: keys to clinical and laboratory diagnosis. Postgrad Med. 1999;105(3):113-133.

Han KS. The effect of an integrated stress management program on the psychologic and physiologic stress reactions of peptic ulcer in Korea . J Holist Nurs. 2002;20(1):61-80.

Jarosz M. Effects of high dose vitamin C treatment on Helicobacter pylori infection and total vitamin C concentration in gastric juice. Eur J Cancer Prev. 1999;7(60:449-454.

Junghard O, Wiklund IK. Effect of baseline symptom severity on patient-reported outcomes in gastroesophageal reflux disease. Eur J Gastroenterol Hepatol. 2007;19(7):555-60.

Kaltenbach T, Crockett S, Gerson LB. Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach. Arch Intern Med. 2006;166(9):965-71.

Kamolz T, Granderath FA, Bammer T, Pasiut M, Pointner R. Psychological intervention influences the outcome of laparoscopic antireflux surgery in patients with stress-related symptoms of gastroesophageal reflux disease. Scand J Gastroenterol. 2001;36(:800-805.

Kang JY, Yeoh KG, Chia HP, Lee HP, Chia YW, Guan R, Yap I. Chili -- protective factor against peptic ulcer? Dig Dis Sci. 1995;40(3):576-579.

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Klausz G, Tiszai A, Lenart Z, et al., Helicobacter pylori-induced immunological responses in patients with duodenal ulcer and in patients with cardiomyopathies. Acta Microbiol Immunol Hung. 2004;51(3):311-20.

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Marteau P, Boutron-Ruault MC. Nutritional advantages of probiotics and prebiotics. Br J Nutr. 2002;87(Suppl 2)):S153-S157.

Marteau PR. Probiotics in clinical conditions. Clin Rev Allergy Immunol. 2002;22(3):255-273.

Martin B. Prevention of gastrointestinal complications in the critically ill patient. AACN Adv CritCare. 2007;18(2):158-66.

McManus TJ. Helicobacter pylori: an emerging infectious disease. Nurs Pract. 2000;25(:42-46.

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Review Date:
8/23/2007
Reviewed By:
Ernest B. Hawkins, MS, BSPharm, RPh, Health Education Resources; and Steven D. Ehrlich, N.M.D., private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).

A.D.A.M. Copyright

The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997-2009 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.

adam.com

Heartburn

admin — Thu, 04 Sep 2008 19:05:35 -0700

Overview

Definition

Alternative Names

Common Causes

Home Care

Call your health care provider if

What to expect at your health care provider's office

References

Illustrations

Digestive system

Hiatal hernia - X-ray

Hiatal hernia

Gastroesophageal reflux disease

HEALTH GUIDE REFERENCE FROM A.D.A.M

Definition

Heartburn is a painful burning sensation in the esophagus, just below or behind the breastbone. The pain often rises in your chest and may radiate to your neck or throat.

Alternative Names

Pyrosis; Non-cardiac chest pain

Common Causes

Almost everyone has occasional heartburn. If you have frequent, ongoing heartburn, you may have gastroesophageal reflux disease (GERD).

Normally, when food or liquid enters your stomach, a band of muscle at the end of your esophagus (called the lower esophageal sphincter or LES) closes off the esophagus. If this muscle fails to close tightly enough, stomach contents can back up (reflux) into the esophagus. This partially digested material is usually acidic and can irritate the esophagus, causing heartburn and other symptoms.

Heartburn is more likely to occur if you have a hiatal hernia, which is when the top part of the stomach protrudes upward into the chest cavity. This weakens the LES and makes it easier for acid to reflux from the stomach into the esophagus.

Heartburn can be brought on or worsened by pregnancy and by many different medications.

Such drugs include:

Calcium channel blockers for high blood pressure

Progestin for abnormal menstrual bleeding or birth control

Anticholinergics (e.g., for sea sickness)

Certain bronchodilators for asthma

Tricyclic antidepressants

Dopamine for Parkinson's disease

Sedatives for insomnia or anxiety

Beta blockers for high blood pressure or heart disease

If you suspect that one of your medications may be causing heartburn, talk to your doctor. NEVER change or stop medication you take regularly without talking to your doctor.

Home Care

Pay attention to heartburn and treat it, especially if you feel symptoms often. Over time, ongoing reflux can damage the lining of your esophagus and cause serious problems. The good news is that making changes to certain habits can go a long way to preventing heartburn and other symptoms of GERD.

The following tips will help you avoid heartburn and other GERD symptoms. If these measures are not working, talk to your doctor.

First, avoid foods and beverages that can trigger reflux, such as:

Alcohol

Caffeine, carbonated beverages

Chocolate

Citrus fruits and juices

Tomatoes and tomato sauces

Spicy or fatty foods, full-fat dairy products

Peppermint and spearmint

Next, try changing your eating habits:

Eat smaller meals. A full stomach puts extra pressure on the lower esophageal sphincter (LES), increasing the chance that food will reflux.

Avoid eating or lying down within 2-3 hours of bedtime. Lying down with a full stomach results in stomach contents pressing harder against the LES.

Avoid bending over or exercising just after eating.

Make other lifestyle changes as needed:

Lose weight if you are overweight. Obesity increases abdominal pressure, which can push stomach contents up into the esophagus. In some cases, GERD symptoms disappear completely after an overweight person loses 10-15 pounds.

Stop smoking. Chemicals in cigarette smoke weaken the LES.

Sleep with your head raised about 6 inches. Sleeping with the head higher than the stomach reduces the likelihood that partially digested food will reflux into the esophagus. Place books, bricks, or blocks securely under the legs at the head of your bed. Or use a wedge-shaped pillow under your mattress. Sleeping on extra pillows does NOT work well for relieving heartburn.

Avoid tight-fitting belts or garments around the waist. They squeeze the stomach, and may force food to reflux.

Reduce stress. Try yoga, tai chi, or meditation.

If you still do not have full relief, try over-the-counter medications:

Antacids, like Maalox or Mylanta, work by neutralizing stomach acid.

H2 blockers, like Pepcid AC, Tagamet, and Zantac, reduce stomach acid production.

Proton pump inhibitors, like Prilosec OTC, stop nearly all stomach acid production.

Call your health care provider if

Call 911 if:

You vomit material that is bloody or black like coffee grounds.

Your stools are black (like tar) or maroon.

The burning sensation is accompanied by chest squeezing, crushing, or pressure. Sometimes a heart attack is mistaken for heartburn.

Call your doctor if:

The problem becomes frequent or doesn't go away with a few weeks of self-care.

You start losing weight unintentionally.

You have difficulty swallowing (food feels stuck as it goes down).

You have a persistent, unexplained cough or wheezing.

Your symptoms get worse with antacids or H2 blockers.

You think that one of your medications may be causing heartburn. DO NOT change or stop your medication on your own, without discussing with your doctor.

What to expect at your health care provider's office

Heartburn is usually easy to diagnose from the symptoms you describe to your doctor. Sometimes, heartburn can be confused with another stomach problem called dyspepsia. If the diagnosis is unclear, then you may be sent to a gastroenterologist for further testing.

First, your doctor will perform a physical examination and ask questions about your heartburn, such as:

When did it begin?

How long does each episode last?

Is this the first time you have had heartburn?

What do you usually eat at each meal? Before you feel heartburn, have you eaten a spicy or fatty meal?

Do you drink a lot of coffee, other caffeinated beverages, or alcohol? Do you smoke?

Do you wear clothing that is tight in the chest or abdomen?

Does the pain also appear in the chest, jaw, arm, or elsewhere?

What medications are you taking?

Are you vomiting blood or black material?

Do you have blood in your stools?

Do you have black, tarry stools?

Are there other symptoms accompanying your heartburn?

The following tests may be performed:

Upper GI series

Esophageal motility to measure the pressure of your LES

Upper endoscopy to look at the inside lining of your esophagus and stomach

If self care has not been successful, your doctor may consider prescribing you medications to reduce acid secretion. These are stronger than the medications available over the counter. Any sign of bleeding will require a more complicated treatment plan.

References

DeVault KR, Castell DO. Updated Guidelines for the Diagnosis and Treatment of Gastroesophageal Reflux Disease. Am J Gastroenterol. 2005;100:190-200.

Smith L. Updated ACG Guidelines for Diagnosis and Treatment of GERD. Am Fam Physician. 2005; 71(12): 2376-2382.

Fass R. Predictors of heartburn during sleep in a large prospective cohort study. Chest. 2005; 127(5): 1658-1666.

McCarthy D. Living with chronic heartburn: insights into its debilitating effects. Gastroenterol Clin North Am. 2003; 32(3 Suppl): S1-S9.

Review Date: 5/3/2007

Reviewed By: Jenifer K. Lehrer, MD, Department of Gastroenterology, Frankford-Torresdale Hospital, Jefferson Health System, Philadelphia, PA. Review provided by VeriMed Healthcare Network.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).

A.D.A.M. Copyright

The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997-2009 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.

adam.com

Source Doc: 1_003114

Heartburn prevention

admin — Thu, 04 Sep 2008 18:51:45 -0700

Overview

Information

References

Illustrations

Heartburn prevention

HEALTH GUIDE REFERENCE FROM A.D.A.M

Information

To prevent heartburn, avoid foods and beverages that may trigger your symptoms. These include alcohol, caffeine, carbonated beverages, chocolate, citrus fruits and juices, tomatoes, tomato sauces, spicy or fatty foods, full-fat dairy products, peppermint, and spearmint.

Also, try the following changes to your eating habits and lifestyle:

Don't smoke

Sleep with your head raised about 6 inches

Lose weight if you are overweight

Reduce stress

Avoid garments or belts that fit tightly around your waist

Drink plenty of fluids

Avoid bending over or exercising just after eating

DO NOT lie down with a full stomach. For example, avoid eating within 2-3 hours of bedtime

Eat smaller meals

See: Heartburn

References

Feldman M, Friedman LS, Sleisenger MH, eds. Sleisenger & Fordtran’s Gastrointestinal and Liver Disease. 7th ed. Philadelphia, Pa: WB Saunders; 2002.

Goldman L, Ausiello D. Cecil Textbook of Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007.

Review Date: 11/13/2007

Reviewed By: Christian Stone, M.D., Division of Gastroenterology, Washington University in St. Louis School of Medicine, St. Louis, MO. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).

A.D.A.M. Copyright

The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997-2009 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.

adam.com

Source Doc: 1_002101

Get Your Butt in Gear: Victoria's Secret Workout Pants

FitSugar — Tue, 10 Apr 2007 02:00:00 -0700

We all know Victoria's Secret makes some sexy lingerie, but they are now also making great yoga pants. I first learned about Victoria's Secret yoga line from team member CGW when she bookmarked a pair as a Fit Find. They have a ton of different styles and colors to choose from, and they're not at all over-priced.

Although they're labeled "yoga pants," they'd be great for any kind of exercise from walking, to jogging, to Pilates, to kick-boxing, to casual bike riding. Wear them to the gym, on a lazy Sunday, or to relax in at home - they'll add flexibility to your wardrobe. (ha - get it?)

I like the splash of color at the waistband of this Foldover Yoga Pant. They come in tons of color combinations like black/strawberry, fern green/spearmint, and midnight/seaside blue. Nowadays, everyone wears black pants, so it's nice to have something that's a little different and a little more colorful for spring.

Another great thing about these cotton/lycra pants is that not only do they come in sizes XS-XL, but you can also choose whether you want a 30", 32", or 34" inseam. You can get these adorable ultra-low rise pants For $29.

Interested in seeing some other styles? Then, read more

Victoria's Secret Yogawear line includes full length or cropped pants, shorts, capris, and loose fitting or straight leg pants. They also have regular waistbands, as well as the foldover ones above. Check out all the styles.

View 13 Photos ›

Would You Buy Weight Loss Lip Gloss?

FitSugar — Fri, 06 Apr 2007 08:45:00 -0700

There are so many weight loss products out there it is hard to decipher from those that work and those that don't. Some products, however, make it very easy to say, "Save your money."

Beautiful lips-skinny hips is the slogan for Joey New York LipFIT Lip Gloss ($15.00), which is a lip gloss that apparently curbs appetite. This is because it contains a blend of peppermint, grapefruit and spearmint fragrances and when applied to the lips, the fresh minty aroma has been 'proven' (uh-huh) to safely help inhibit appetite. The gloss also contains ingredients to firm and plump lips instantly; all while making you feel not hungry. I think a more appropriate slogan would be Beautiful lips-You'll Probably Still Want the Chips. Still interested? Buy it from SkinStore.com.

I know, I know... I am a skeptic at heart, but I am still curious, would you buy it?

Would You Buy Weight Loss Lip Gloss?
Yes! I'll try anything.

No! I've learned my lesson on products that seem too good to be true.

Depends. If it looks good on my lips, then it may be worth a shot.

Other. Tell us below!