Gastroesophageal reflux disease (GERD) is an often painful condition in which stomach acid rises up into the esophagus. How is it diagnosed and treated, and what complementary strategies may be helpful? Read on to find out.
What is GERD?
Gastroesophageal reflux disease (GERD) is a condition that causes stomach acid to rise up into the esophagus. This acid reflux can cause heartburn, bad breath, chest pain, nausea, breathing problems, and even erosion of the teeth [1, 2].
GERD occurs when the lower esophageal sphincter, the passage between the esophagus and the stomach, doesn’t close all the way. Risk factors for GERD include pregnancy, diabetes, and certain medications [3].
How is GERD Diagnosed?
First, a doctor will evaluate your symptoms to determine whether GERD is a possible cause. Heartburn is the major symptom associated with GERD, but vomiting, breathing problems, and tooth erosion can be signs of severe reflux [1, 2].
Doctors will often recommend lifestyle changes and medications to help control GERD without further testing. However, if symptoms persist, they will typically run further tests to determine whether your condition has a more complex underlying cause [4].
Endoscopy & Biopsy
Endoscopic procedures use a tiny camera and light to visually inspect diseased tissues. To check for peptic ulcers, endoscopy is typically performed by feeding the camera down the esophagus and into the stomach [4].
At this time, the doctor may use the endoscope to take a tiny tissue sample (a biopsy) for lab analysis [4].
Upper GI Series
This procedure uses a chalky liquid containing barium to coat the upper digestive tract and make it more visible to an X-ray. The patient typically fasts and stops drinking water before the procedure (your doctor will tell you how long you must be fasted) and drinks the barium liquid while sitting or standing in front of the X-ray machine [4].
Esophageal pH
There are a couple of ways to test the pH of the esophagus, which is the most reliable way to tell how much acid is washing up into the esophagus during normal activities (like eating or sleeping) [4].
In esophageal pH and impedance monitoring, a specialist will feed a catheter through the nose or mouth and into the esophagus. A monitor at the end of the tube will then measure the pH of the esophagus for the next 24 hours. The patient is typically asked to keep a diary of when, what, and how much they ate [4, 5].
In Bravo wireless esophageal pH monitoring, a specialist attaches a small capsule to the wall of the esophagus during an upper endoscopy. The capsule is wirelessly connected to a small receiver, which the patient will use to record GERD symptoms over the next 48 hours. The patient also typically keeps a meal diary, in which they also record when they start and stop eating and drinking for the day and when they lie down and get back up [4, 6, 5].
Esophageal Manometry
Esophageal manometry is a technique by which a doctor can measure muscle contractions in the esophagus. First, a specialist feeds a soft tube with a sensor down the esophagus; then, as the patient swallows, they pull the sensor back up, measuring muscle contractions all along the way [4].
The goal of esophageal manometry is often to check whether there are problems with the esophageal sphincter, the passage between the esophagus and the stomach. If this sphincter isn’t working well, the patient may be a candidate for surgery [4].
How is GERD Treated?
GERD is treated and managed with a variety of medical and complementary approaches. Your doctor is best positioned to evaluate your specific case and make the best recommendations for you; these may or may not include some or all of the approaches described in this section. Be sure to follow your doctor’s instructions carefully and never use any of the strategies listed here in place of what your doctor recommends or prescribes.
Dietary Interventions
Many doctors will recommend dietary changes that may help reduce the incidence and severity of acid reflux. These may include avoiding certain trigger foods and controlling the time of day at which you eat.
Trigger Foods to Avoid
Certain foods have been found to trigger or worsen GERD. These include:
- Fatty or greasy foods [7, 8]
- Spicy foods [7, 8]
- Alcoholic drinks [8]
- Peppermint: surprisingly, this folk remedy for digestive complaints has been linked to reflux. We recommend against using peppermint or peppermint oil if you have GERD [9, 10, 8].
- Chocolate [8]
- Coffee [8]
Intermittent Fasting
Intermittent fasting is a broad term encompassing any diet in which a person doesn’t eat during specific times of the day or week. In the case of GERD, the most effective form of intermittent fasting is not eating for 2-3 hours before going to bed. However, it is unclear whether the fast itself has any effect, or whether simply staying upright for a long time after eating (and thereby using gravity to prevent anything from washing back up into the esophagus) is the key [11].
Calcium & Magnesium Balance
Some research has suggested that the ratio of calcium and magnesium in people’s diet could affect how likely they are to develop GERD. In a case-control study of esophageal diseases, researchers found that people who consumed more calcium relative to less magnesium were more likely to have GERD [12].
No studies have yet examined whether increasing dietary magnesium has any effect on existing cases of GERD. However, magnesium is an essential nutrient with many benefits, and nutritionists generally recommend eating plenty of magnesium-rich foods like leafy greens, nuts, whole grains, and seafood [13, 14].
As always, talk to your doctor before making sweeping changes to your diet.
Lifestyle Interventions
If you have GERD, your doctor will likely recommend lifestyle changes you can make to help reduce your risk of reflux and prevent a worsening of your condition. These may include some or all of the strategies discussed here; however, the appropriate strategies will depend heavily on your specific situation. Be sure to follow your doctor’s recommendations carefully.
Weight Loss
Obesity is considered a significant risk factor for the development of GERD. Your doctor may recommend weight loss and light exercise programs to help you improve your metabolic health [11].
Note, however, that strenuous exercise may trigger reflux in people with GERD; light or short sessions of physical activity do not appear to have a direct effect on reflux, but exercise is one of the best ways to improve metabolic health [15, 16, 17].
Smoking Cessation
People who smoke are considerably more likely to develop GERD than those who don’t, and quitting is considered an important step to controlling reflux. Even if you don’t smoke, it’s important to avoid secondhand smoke, which has the same detrimental effects as smoking itself [11].
If you have difficulty quitting, your doctor can help you find and develop strategies to help fight nicotine cravings.
Other Tips
Some other strategies you can try aim to use gravity and physical changes to help prevent reflux. First, wearing loose-fitting clothing, especially around the waistline, prevents undue pressure on your stomach. Tight-fitting clothing is believed to squeeze against the stomach and push acid up the esophagus [11].
Doctors also recommend staying upright for 2-3 hours after meals, keeping your torso as vertical as possible to make it more difficult for stomach acid to wash up into the esophagus. Finally, some people put blocks under two legs of their bed frames so that they are sleeping at a slight angle, with their heads higher up than their legs. This works with the same logic; that gravity makes it less likely for reflux to occur [11].
Supplements for GERD
The FDA has not approved any natural substances for medical use in GERD, and supplements generally lack solid clinical research. Speak with your doctor before using any of these substances, and never use them in place of something your doctor recommends or prescribes.
Insufficient Evidence For
The following substances have shown promise against GERD in limited, low-quality clinical studies; there is currently insufficient evidence to support their use in this context, and they should never replace what your doctor prescribes. Remember to talk to your doctor before starting any new supplement or making significant changes to your diet.
1) Melatonin
In a study of 36 GERD patients, melatonin supplementation was able to decrease GERD symptoms. Melatonin reduced esophageal pressure and prevented injury when used alone or in conjunction with omeprazole [18].
However, omeprazole, a drug that treats GERD, showed better results when administered alone than in combination with melatonin. So although melatonin may be able to treat GERD symptoms, it is not the best option to treat acid reflux [18].
2) Bitters
In one observational study, 50 patients with acid reflux were given an Ayurvedic syrup called Acidinol for 4 weeks. This multi-herbal formula with bitters such as neem (Azadirachta indica), relieved symptoms of heartburn, stomach pain, bloating, nausea, indigestion, and loss of appetite in over 75% of patients [19].
3) Amla
Amla, or Indian gooseberry, is a plant often used as part of Ayurvedic traditional medicine. Although all parts of the plant were used, the fruit was used the most and believed to have the highest medicinal power. Limited studies support this traditional stance, as the fruit has been found to contain the most active compounds [20].
In a study of 68 patients, 4 weeks of supplementation with amla extract led to a significant reduction in the frequency and severity of heartburn. However, more clinical evidence is required [21].
4) Quince
Quince is a fruit related to apples and pears. It is often eaten as food, but it also has a history of traditional medicinal use. In a study of 80 GERD patients, symptoms decreased as much after taking a quince extract syrup as after taking a conventional medication (omeprazole) [22].
Medical Interventions
Pharmaceuticals/Medication
Depending on the severity of GERD and how long symptoms have persisted, your doctor may prescribe one or more medications. It is extremely important to follow your doctor’s prescriptions to the letter; never add, remove, or change the dose of a drug without your doctor’s instructions to do so.
Antacids
The most commonly recommended medications for GERD are antacids, which buffer the pH of the stomach and make it less acidic. Some of the most common of these are calcium carbonate and magnesium hydroxide; the most popular name brands include Maalox, Mylanta, Riopan, and Rolaids [23, 24, 11].
Many antacids are available over the counter at your local pharmacy. Talk to your doctor if you’re unsure about which ones could be right for you.
H2 blockers
H2 blockers target histamine receptors in the stomach. H2 receptors stimulate the production of stomach acid, so H2 blockers suppress acid production. This class of drugs includes cimetidine, famotidine, nizatidine, and ranitidine [11].
These medications provide temporary relief from heartburn and other GERD symptoms and may help damaged tissues heal [11].
PPIs
Proton pump inhibitors also suppress the production of stomach acid. They are generally considered more effective than H2 blockers, and they are often prescribed for long-term treatment of GERD. Some common PPIs include esomeprazole (Nexium), lansoprazole (Prevacid), and omeprazole (Prilosec, Zegerid) [11].
Prokinetics
Prokinetics are a class of drugs that help the stomach empty more quickly so there is less time for stomach acid to wash up into the esophagus after a meal. The two most often prescribed are bethanechol (Urecholine) and metoclopramide (Reglan). Both can have side effects including nausea, diarrhea, fatigue, depression, and abnormal movement. They can also have dangerous interactions with other drugs; doctors may be more cautious about prescribing them as a result [11].
Antibiotics
Erythromycin and other antibiotics may also help the stomach empty more quickly and with fewer side effects than prokinetics. However, using antibiotics in the absence of a bacterial infection runs the risk of encouraging drug resistance in certain bacterial strains and of throwing the gut microbiome out of balance. Doctors are increasingly cautious about unnecessary antibiotics in the 21st century [11, 25].
Surgery
Severe cases of GERD, especially those in which the esophageal sphincter fails to close all the way, may require surgical intervention. Two types of surgeries are typically considered for severe GERD: fundoplication and endoscopic repair (sewing or radiofrequency) [11].
Fundoplication is a technique in which a surgeon uses a laparoscope to fold up the upper part of the stomach to reinforce the bottom of the esophagus. This increases the pressure around the lower esophagus and reduces reflux. The patient then typically spends 1-3 days at the hospital; full at-home recovery takes 2-3 weeks [11].
Endoscopic techniques are typically used to tighten the sphincter muscle, either with small stitches (endoscopic sewing) or heat lesions (endoscopic radiofrequency) [11].
Dental Treatment
Up to 88% of people with GERD may have tooth erosion due to acid reflux. If you have dental erosion, you may need to go see a dentist for treatment. If erosion is very severe, some teeth may need to be pulled and replaced with dental implants [26, 27].
Takeaway
Gastroesophageal reflux disease, or GERD, is a condition characterized by stomach acid washing up into the esophagus, often causing heartburn and other symptoms. Untreated GERD can lead to tissue damage and dental erosion.
Doctors usually only need a symptom history to diagnose GERD, though endoscopy, an upper GI series, or pH monitoring may be used. Once diagnosed, patients with GERD are advised to modify their diets, avoid trigger foods, and try some lifestyle changes to help control symptoms. Doctors may also prescribe medications to reduce stomach acid pH. Surgery is rarely required.
GERD can often be controlled through lifestyle changes and medication. Some supplements under investigation for potential benefits in GERD include amla, quince, and melatonin, though the quality of evidence is low.
