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Gastroesophageal Reflux Disease (GERD); Treatment.

Gastroesophageal reflux disease (GERD), although common, is often unrecognized and left untreated, self-treated or treated incorrectly. This is unfortunate because GERD usually responds well to appropriate management.

The treatment of GERD typically occurs in a stepwise approach. By working closely with their health care professional, finding the right course of action can lead to an improved quality of life for most sufferers. For mild cases, those with only infrequent symptoms, all that may be required are changes in your diet, avoiding certain activities and over-the-counter medications. For more persistent symptoms, such as daily heartburn or symptoms that occur at night, a prescription medication may be required. Only in some special cases is surgery considered an option.

The cornerstone for all treatments begins with lifestyle changes. The key to these changes requires understanding what triggers and activities are contributing to your symptoms.

If you are having symptoms of GERD, here are some of modifications you can make in your life to prevent acid reflux:

Implement dietary changes.

* Eat smaller portions at mealtimes and snacks. Smaller portions pass quicker into your small intestine than large ones, thus decreasing the chance of acid reflux. Large portions also distend the stomach and trigger relaxations of the lower esophageal sphincter.

* Lose weight if you are overweight. (Obesity may contribute to GERD because the extra weight increases the pressure on your stomach and the lower esophageal sphincter, allowing reflux to occur.)

* Avoid lying down after eating a meal or snack for at least two-to-three hours. Go for a walk after a meal; not only will this help prevent GERD symptoms, but it will also burn some extra calories.

* Avoid foods and drinks that trigger symptoms. Common food triggers include fatty or fried foods, such as fried chicken, cream sauces, mayonnaise or ice cream Other problem foods to avoid include mints, chocolate, alcohol, coffee, tea, sodas, citrus fruits and tomatoes. These foods relax the lower esophageal sphincter muscle allowing stomach contents to wash back up or they are acidic and irritate the lining of the esophagus.

Stop smoking.

* If you smoke or use tobacco products, stop using them. Smoking damages the digestive system and some studies indicate that smoking relaxes the lower esophageal sphincter. Smoking also reduces the amount of bicarbonate in saliva, thus reducing its ability to protect the esophagus from stomach acid. Some nicotine replacement therapies (nicotine patch, nicotine gum) can cause indigestion, stomach pain and vomiting. Discuss possible side effects of these products with your health care professional before using them.

Avoid certain body positions and clothing.

* Tight clothing around your abdomen, such as girdles, tight jeans and elastic waist bands, can increase pressure on your stomach and lower esophageal sphincter.

* Elevate the head of your bed by six to eight inches or sleep on a wedge pillow to aid gravity to clear the acid refluxate back into the stomach.

* Bending over after eating can cause symptoms of GERD. Bend at your knees if you have to pick something up and avoid exercises that require you to bend at your waist. Additionally, avoid exercising after a heavy meal.

Check medications.

* Certain medications may make symptoms worse. Some of these include theophylline, which is used to treat asthma and emphysema; hormones such as progesterone, which can be found in birth control pills and some medications used to treat the symptoms of menopause; certain medications for the nervous system; calcium channel blockers, alpha blockers and beta blockers, which are used to treat heart conditions and high blood pressure; and anticholinergic drugs, which can be present in medications used to treat Parkinson's and certain over-the-counter cold preparations. If you think a medication you are taking might be contributing to your symptoms check with your health care professional about possibly changing to an alternative.

Medications Used to Treat GERD

Treating GERD with medications also may be an option. For certain patients some drugs will work better than others will or some dosages may have to be adjusted. Many patients will have to take medication for the rest of their lives; others may only needed it for short periods of time. Finding the right medication(s) and dosing schedules may take time. If symptoms persist while taking medication or if they return after discontinuing them, consult your health care professional. If symptoms of GERD occur during pregnancy, consult with your obstetrician before taking any medications.

Here's an overview of the most common medications used in the treatment of GERD:

Over-the-counter antacids

These products often are successful when symptoms are mild and infrequent. They work by neutralizing the stomach acid. Antacids are typically fast acting and can be taken as needed. Because they also are short acting, they do not work at preventing heartburn and are less useful for frequent symptoms. Typical antacid medications include the following:

* Tums

* Maalox

* Gaviscon

* Mylanta

* Rolaids

Most antacids contain either calcium carbonate (Tums, Rolaids, Mylanta, Maalox) or magnesium hydroxide (Phillips Milk of Magnesia). Sodium bicarbonate (baking soda) also may be used to relieve indigestion.

Calcium carbonate is an excellent source of dietary calcium and thickens stool. Magnesium hydroxide loosens stool. So, a chronically constipated person may wish to choose a magnesium-based product, to not only protect her esophagus, but to help produce a bowel movement in six to eight hours. A person with frequent loose stools would optimally choose a calcium carbonate product to thicken the stool and help prevent osteoporosis.

Antacids can interfere with how well the body absorbs other medications. Check with your health care professional if you are on any medications before using antacids. Optimally, the antacid should be taken at least two to four hours after other medications to diminish the likelihood of poor absorption. Individuals with high blood pressure should avoid antacids with high amounts of sodium, such as Gaviscon. Individuals with kidney disease should discuss using antacids with their physicians before taking them. Common side effects of antacids include diarrhea, constipation, belching and flatulence.

Acid reducers

These drugs work by decreasing the amount of acid produced by the stomach, and are available in both prescription and over-the-counter (OTC) doses. Typically the prescription form is a larger dose and may benefit some patients who are not relieved by the over-the-counter preparation or find that their insurance provider helps with the cost of prescription medications but not OTC drugs. Combining an acid reducer and lifestyle changes often help people with more frequent GERD symptoms. Typical acid reducers include the following:

* Nizatidine (also known as Axid, Axid AR)

* Famotidine (also known as Pepcid, Pepcid AC)

* Cimetidine (also known as Tagamet, Tagamet HB)

* Ranitidine (also known as Zantac, Zantac GELdose)

Side effects of these drugs, although uncommon, include abdominal pain, constipation, diarrhea, nausea, confusion, drowsiness, headache, decreased sexual desire and ability and gynecomastia (enlarged breasts, especially in men). People with kidney or liver disease or weakened immunity should consult their health care professional before taking these drugs.

Proton pump inhibitors

These drugs are also acid reducers, but are much more powerful and a newer class of medications than other acid reducers listed above. Proton pump inhibitors (PPIs) are the most commonly prescribed class of medications for the treatment of heartburn and acid reflux disease. They work by blocking acid production in the cells lining the stomach. These prescription drugs can reduce the amount of acid in the stomach by as much as 95 percent. They do not work as quickly as antacids but they can prevent the symptoms of reflux for many hours.

These drugs are also used to treat esophageal inflammation (esophagitis) and esophageal erosions. PPIs have been intensely studied with over 300 published studies evaluating the use of PPIs for the treatment of GERD. It has been found that the majority of patients with esophagitis are healed after six to eight weeks using a proton pump inhibitor. Typical medications include the following:

* lansoprazole (also known as Prevacid)

* omeprazole (also known as Prilosec)

* rabeprazole (also known as AcipHex)

* pantoprazole (also known as Protonix)

* esomeprazole (also known as Nexium)

The most common side effects are abdominal pain, headache, diarrhea, dry mouth, lightheadedness, headache and rash. Mild side effects are most common in the first two weeks of use. If mild, the medication should be continued into week three. Most patients adjust to the medication quickly and the side effects disappear. If the side effects continue beyond week three, you should contact your health care professional to try another PPI. If no side effects occur in the first two weeks, and you develop diarrhea six months later, it is highly unlikely that the diarrhea is caused by the PPI. Usually, if a PPI is going to cause a side effect, it will do so in the first two weeks of use.

People with liver conditions should consult their physicians before starting these drugs.

Prilosec is now available as an over-the-counter treatment (OTC) for frequent heartburn.

In July 2003, the U.S. Food and Drug Administration (FDA) approved omeprazole (Prilosec) as an OTC drug product and this medication is now available in stores nationwide. Prilosec OTC is an appropriate medication to take if you experience "frequent" heartburn-heartburn that occurs two or more times a week.

According to the FDA, Prilosec OTC does not provide immediate relief of heartburn symptoms and, if you suffer only occasional heartburn (one or less occurrences of heartburn per week), another type of OTC medication, such as one of the antacids described above, is more appropriate for you to use.

Prilosec is still available by prescription. The prescription form of omeprazole is designed to treat those medical conditions that require a health care professional's supervision. These conditions include inflammation of the esophagus (esophagitis), and ulcers.

If, after taking Prilosec OTC according to the labeling instructions, your heartburn symptoms get worse or you feel that you need to take it for longer than 14 days, contact your health care professional to have your symptoms evaluated and to discuss your treatment options.

Prokinetic agents

These drugs work by tightening the lower esophageal sphincter, which helps prevent acid from washing back up into the esophagus. They also minimally increase the muscular contractions of the esophagus and the stomach and aid in emptying the stomach faster. A typical prokinetic agent is:

* Metoclopramide (also known as Reglan or Maxolon)

There can be significant side affects with these medications such as uncontrollable spasms of the head, neck or jaw, anxiety and frequent urination.

Sucralfate

This drug coats the lining of the esophagus and helps to protect the lining from the stomach acid. This may be used in pregnant patients, those who can not tolerate acid reducers, or it may be used in combination with other drugs. Typical medications include:

* Carafate

* Sulcrate

Very little of this drug is actually absorbed into the body. It is recommended that other medications be taken at least one hour prior to taking sucralfate as this drug may prohibit absorption of other drugs. If you are taking a blood thinning medication, such a Coumadin, you should use this medication with caution. Prolonged use may interfere with absorption of essential vitamins (K,A, D and E).

Surgery

Surgery is considered an alternative to medical therapy for GERD. The best candidates for surgery are young patients (i.e. requiring long-term treatment) with typical GERD symptoms (i.e. heartburn and regurgitation) who respond to medical therapy (i.e. patients seek alternatives to taking daily medications). Patients with atypical symptoms or symptoms "refractory to medical therapy" should be investigated, and surgery should only be considered if an association of symptoms with acid or non-acid reflux can be documented.

Fundoplication is the most common surgery used. This surgery reinforces the lower esophageal sphincter by wrapping the top of the stomach around the bottom of the esophagus. One advantage of surgery is that a hiatal hernia can be corrected at the same time. Surgery is not always successful, and many patients will still require some form of medication. There can also be significant complications with surgery including bleeding, infection, pain and even death. Other complications are the inability to belch/vomit and increased flatulence.

New techniques using endoscopy are being developed, but the safety and effectiveness of these alternatives are still being determined.

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Editorial Staff of the National Women's Health Resource Center 2002/12/01 2005/03/16 Gastroesophageal reflux disease (GERD) is the abnormal backflow of stomach acid up into the esophagus, the long, muscular tube that connects the back of the mouth to the stomach. Acid Laryngitis,acid regurgitation,Barrett's esophagus,Esophageal strictures,Esophagitis,Gastroesophageal reflux disease,GERD,Reflux dyspareunia
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Publication:NWHRC Health Center - Gastroesophageal Reflux Disease
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Date:Mar 16, 2005
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