Heartburn, Hiatal Hernia, and Gastroesophageal Reflux Disease (GERD)
On this page:
- What are the symptoms of GERD?
- GERD in Children
- What causes GERD?
- How is GERD treated?
- What if symptoms persist?
- What are the long-term complications of GERD?
- Points to Remember
- Hope Through Research
- For More Information
Gastroesophageal reflux disease, or GERD, occurs when the lower
esophageal sphincter (LES) does not close properly and stomach contents
leak back, or reflux, into the esophagus. The LES is a ring of muscle at
the bottom of the esophagus that acts like a valve between the esophagus
and stomach. The esophagus carries food from the mouth to the stomach.
When refluxed stomach acid touches the lining of the esophagus, it
causes a burning sensation in the chest or throat called heartburn. The
fluid may even be tasted in the back of the mouth, and this is called acid
indigestion. Occasional heartburn is common but does not necessarily mean
one has GERD. Heartburn that occurs more than twice a week may be
considered GERD, and it can eventually lead to more serious health
Anyone, including infants, children, and pregnant women, can have GERD.
What are the symptoms of GERD?
The main symptoms are persistent heartburn and acid regurgitation. Some
people have GERD without heartburn. Instead, they experience pain in the
chest, hoarseness in the morning, or trouble swallowing. You may feel like
you have food stuck in your throat or like you are choking or your throat
is tight. GERD can also cause a dry cough and bad breath.
GERD in Children
Studies* show that GERD is common and may be overlooked in infants and
children. It can cause repeated vomiting, coughing, and other respiratory
problems. Children's immature digestive systems are usually to blame, and
most infants grow out of GERD by the time they are 1 year old. Still, you
should talk to your child's doctor if the problem occurs regularly and
causes discomfort. Your doctor may recommend simple strategies for
avoiding reflux, like burping the infant several times during feeding or
keeping the infant in an upright position for 30 minutes after feeding. If
your child is older, the doctor may recommend avoiding
- sodas that contain caffeine
- chocolate and peppermint
- spicy foods like pizza
- acidic foods like oranges and tomatoes
- fried and fatty foods
Avoiding food 2 to 3 hours before bed may also help. The doctor may
recommend that the child sleep with head raised. If these changes do not
work, the doctor may prescribe medicine for your child. In rare cases, a
child may need surgery.
*Jung AD. Gastroesophageal reflux in infants and
children. American Family Physician. 2001;64(11):1853-1860.
What causes GERD?
No one knows why people get GERD. A hiatal hernia may contribute. A
hiatal hernia occurs when the upper part of the stomach is above the
diaphragm, the muscle wall that separates the stomach from the chest. The
diaphragm helps the LES keep acid from coming up into the esophagus. When
a hiatal hernia is present, it is easier for the acid to come up. In this
way, a hiatal hernia can cause reflux. A hiatal hernia can happen in
people of any age; many otherwise healthy people over 50 have a small one.
Other factors that may contribute to GERD include
- alcohol use
Also, certain foods can be associated with reflux events, including
- citrus fruits
- drinks with caffeine
- fatty and fried foods
- garlic and onions
- mint flavorings
- spicy foods
- tomato-based foods, like spaghetti sauce, chili, and pizza
How is GERD treated?
If you have had heartburn or any of the other symptoms for a while, you
should see your doctor. You may want to visit an internist, a doctor who
specializes in internal medicine, or a gastroenterologist, a doctor who
treats diseases of the stomach and intestines. Depending on how severe
your GERD is, treatment may involve one or more of the following lifestyle
changes and medications or surgery.
- If you smoke, stop.
- Do not drink alcohol.
- Lose weight if needed.
- Eat small meals.
- Wear loose-fitting clothes.
- Avoid lying down for 3 hours after a meal.
- Raise the head of your bed 6 to 8 inches by putting blocks of wood
under the bedposts-just using extra pillows will not help.
Your doctor may recommend over-the-counter antacids, which you can buy
without a prescription, or medications that stop acid production or help
the muscles that empty your stomach.
Antacids, such as Alka-Seltzer, Maalox, Mylanta, Pepto-Bismol,
Rolaids, and Riopan, are usually the first drugs recommended to relieve
heartburn and other mild GERD symptoms. Many brands on the market use
different combinations of three basic salts-magnesium, calcium, and
aluminum-with hydroxide or bicarbonate ions to neutralize the acid in
your stomach. Antacids, however, have side effects. Magnesium salt can
lead to diarrhea, and aluminum salts can cause constipation. Aluminum and
magnesium salts are often combined in a single product to balance these
Calcium carbonate antacids, such as Tums, Titralac, and Alka-2, can
also be a supplemental source of calcium. They can cause constipation as
Foaming agents, such as Gaviscon, work by covering your stomach
contents with foam to prevent reflux. These drugs may help those who have
no damage to the esophagus.
H2 blockers, such as cimetidine (Tagamet
HB), famotidine (Pepcid AC), nizatidine (Axid AR), and ranitidine (Zantac
75), impede acid production. They are available in prescription strength
and over the counter. These drugs provide short-term relief, but
over-the-counter H2 blockers should not be used
for more than a few weeks at a time. They are effective for about half of
those who have GERD symptoms. Many people benefit from taking H2
blockers at bedtime in combination with a proton pump inhibitor.
Proton pump inhibitors include omeprazole (Prilosec),
lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex),
and esomeprazole (Nexium), which are all available by prescription. Proton
pump inhibitors are more effective than H2
blockers and can relieve symptoms in almost everyone who has GERD.
Another group of drugs, prokinetics, helps strengthen the
sphincter and makes the stomach empty faster. This group includes
bethanechol (Urecholine) and metoclopramide (Reglan). Metoclopramide also
improves muscle action in the digestive tract, but these drugs have
frequent side effects that limit their usefulness.
Because drugs work in different ways, combinations of drugs may help
control symptoms. People who get heartburn after eating may take both
antacids and H2 blockers. The antacids work first
to neutralize the acid in the stomach, while the H2
blockers act on acid production. By the time the antacid stops working,
the H2 blocker will have stopped acid production.
Your doctor is the best source of information on how to use medications
What if symptoms persist?
If your heartburn does not improve with lifestyle changes or drugs, you
may need additional tests.
- A barium swallow radiograph uses x rays to help spot
abnormalities such as a hiatal hernia and severe inflammation of the
esophagus. With this test, you drink a solution and then x rays are
taken. Mild irritation will not appear on this test, although
narrowing of the esophagus-called stricture-ulcers, hiatal hernia,
and other problems will.
- Upper endoscopy is more accurate than a barium swallow
radiograph and may be performed in a hospital or a doctor's office.
The doctor will spray your throat to numb it and slide down a thin,
flexible plastic tube called an endoscope. A tiny camera in the
endoscope allows the doctor to see the surface of the esophagus and to
search for abnormalities. If you have had moderate to severe symptoms
and this procedure reveals injury to the esophagus, usually no other
tests are needed to confirm GERD.
The doctor may use tiny tweezers (forceps) in the endoscope to remove
a small piece of tissue for biopsy. A biopsy viewed under a microscope
can reveal damage caused by acid reflux and rule out other problems if
no infecting organisms or abnormal growths are found.
- In an ambulatory pH monitoring examination, the doctor puts a
tiny tube into the esophagus that will stay there for 24 hours. While
you go about your normal activities, it measures when and how much
acid comes up into your esophagus. This test is useful in people with
GERD symptoms but no esophageal damage. The procedure is also helpful
in detecting whether respiratory symptoms, including wheezing and
coughing, are triggered by reflux.
Surgery is an option when medicine and lifestyle changes do not work.
Surgery may also be a reasonable alternative to a lifetime of drugs and
Fundoplication, usually a specific variation called Nissen
fundoplication, is the standard surgical treatment for GERD. The upper
part of the stomach is wrapped around the LES to strengthen the sphincter
and prevent acid reflux and to repair a hiatal hernia.
This fundoplication procedure may be done using a laparoscope
and requires only tiny incisions in the abdomen. To perform the
fundoplication, surgeons use small instruments that hold a tiny camera.
Laparoscopic fundoplication has been used safely and effectively in people
of all ages, even babies. When performed by experienced surgeons, the
procedure is reported to be as good as standard fundoplication.
Furthermore, people can leave the hospital in 1 to 3 days and return to
work in 2 to 3 weeks.
In 2000, the U.S. Food and Drug Administration (FDA) approved two
endoscopic devices to treat chronic heartburn. The Bard EndoCinch system
puts stitches in the LES to create little pleats that help strengthen the
muscle. The Stretta system uses electrodes to create tiny cuts on the LES.
When the cuts heal, the scar tissue helps toughen the muscle. The
long-term effects of these two procedures are unknown.
Recently the FDA approved an implant that may help people with GERD who
wish to avoid surgery. Enteryx is a solution that becomes spongy and
reinforces the LES to keep stomach acid from flowing into the esophagus.
It is injected during endoscopy. The implant is approved for people who
have GERD and who require and respond to proton pump inhibitors. The
long-term effects of the implant are unknown.
What are the long-term complications of GERD?
Sometimes GERD can cause serious complications. Inflammation of the
esophagus from stomach acid causes bleeding or ulcers. In addition, scars
from tissue damage can narrow the esophagus and make swallowing difficult.
Some people develop Barrett's esophagus, where cells in the esophageal
lining take on an abnormal shape and color, which over time can lead to
Also, studies have shown that asthma, chronic cough, and pulmonary
fibrosis may be aggravated or even caused by GERD.
For information about Barrett's esophagus, please see the Barrett's
Esophagus fact sheet from the National Institute of Diabetes and
Digestive and Kidney Diseases.
Points to Remember
- Heartburn, also called acid indigestion, is the most common symptom
of GERD. Anyone experiencing heartburn twice a week or more may have
- You can have GERD without having heartburn. Your symptoms could be
excessive clearing of the throat, problems swallowing, the feeling
that food is stuck in your throat, burning in the mouth, or pain in
- In infants and children, GERD may cause repeated vomiting, coughing,
and other respiratory problems. Most babies grow out of GERD by their
- If you have been using antacids for more than 2 weeks, it is time to
see a doctor. Most doctors can treat GERD. Or you may want to visit an
internist-a doctor who specializes in internal medicine-or a
gastroenterologist-a doctor who treats diseases of the stomach and
- Doctors usually recommend lifestyle and dietary changes to relieve
heartburn. Many people with GERD also need medication. Surgery may be
Hope Through Research
No one knows why some people who have heartburn develop GERD. Several
factors may be involved, and research is under way on many levels. Risk
factors-what makes some people get GERD but not others-are being
explored, as is GERD's role in other conditions such as asthma and
The role of hiatal hernia in GERD continues to be debated and explored.
It is a complex topic because some people have a hiatal hernia without
having reflux, while others have reflux without having a hernia.
Much research is needed into the role of the bacterium Helicobacter
pylori. Our ability to eliminate H. pylori has been responsible
for reduced rates of peptic ulcer disease and some gastric cancers. At the
same time, GERD, Barrett's esophagus, and cancers of the esophagus have
increased. Researchers wonder whether having H. pylori helps
prevent GERD and other diseases. Future treatment will be greatly affected
by the results of this research.
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