Best Treatments for GERD

What is GERD (Gastroesophageal Reflux Disease)?

GERD is a chronic condition that causes stomach contents, including stomach acid, to flow back into the esophagus. This reflux happens when the lower esophageal sphincter (LES), a muscular ring that acts as a valve between the esophagus and stomach, weakens or relaxes at the wrong times. Different factors can contribute to GERD, including obesity, pregnancy, hiatal hernia, certain medications, dietary factors, smoking, and celiac disease [1][2][3].

Common symptoms of GERD are heartburn, regurgitation, difficulty swallowing, chronic cough, hoarseness, nausea, vomiting, and a higher concentration of pepsin in saliva. Tests that can diagnose GERD include an endoscopy, pH monitoring, barium swallow, mucosal impedance testing (assessing esophageal mucosal integrity and function), and manometry [1][2][3].

If left untreated, GERD can lead to complications such as esophagitis, Barrett's esophagus (a precancerous condition), esophageal stricture, aspiration pneumonia, and laryngopharyngeal reflux disease [1][2][3].

It is estimated that GERD affects approximately 10-20% of the population in Western countries, and is more common in North America and Europe compared to Asia [11][12]. Risk factors for developing GERD include older age, obesity, pregnancy, smoking, alcohol consumption, and certain medications (e.g., nonsteroidal anti-inflammatory drugs, calcium channel blockers, and antidepressants) [13].

Common Symptoms of GERD

The most common symptoms of GERD include [4][5]:

• Heartburn is a burning sensation in the chest, often radiating towards the throat or back. It is typically worse after meals and when lying down or bending over. About 60% of individuals with GERD get heartburn.
• Regurgitation is the involuntary return of stomach contents into the mouth or throat. It can happen during or after meals and may have a sour or bitter taste, and may cause a feeling of a lump in the throat or difficulty swallowing.
• Dysphagia is difficulty swallowing because of the irritation and inflammation of the esophagus caused by stomach acid reflux.
• Nausea, vomiting, and bloating: The reflux of stomach contents can stimulate the gag reflex, leading to nausea and vomiting. The swelling of the stomach can cause bloating.
• Belching is caused by the reflux of stomach contents and the distension of the stomach.
• Chronic cough and hoarseness: can be caused by the irritation of the larynx and upper airway.

Other less common symptoms of GERD may include chest pain, wheezing, dental erosion, and sleep problems [16]. The frequency and severity of symptoms can look different in everyone. Some people may experience only mild or infrequent symptoms, while others may have severe and frequent symptoms

.

Less common symptoms of GERD, such as chronic cough, asthma, laryngitis, and dental erosion, can be harder to treat. It is a good idea to speak to a specialist who can give you guidance in this case.

Lifestyle Changes for Managing GERD

Lifestyle changes are often the first and most important ways to manage GERD.

Key lifestyle changes include [4][5]:

• Dietary changes: Avoid trigger foods (e.g., fatty/fried foods, citrus fruits, tomatoes, caffeine, alcohol), eat smaller, more frequent meals, stay upright after meals, follow a low-carbohydrate diet, reduce sugar intake, and increase dietary fiber intake.
• Weight management: Maintaining a healthy weight through a balanced diet and regular exercise can improve symptoms and reduce the risk of complications. Excess weight, particularly around the abdomen, can raise abdominal pressure and contribute to GERD.
• Smoking cessation: Quitting smoking can improve GERD symptoms and reduce the risk of complications, as smoking weakens the lower esophageal sphincter (LES).
• Alcohol moderation: Limiting or avoiding alcohol can help, as alcohol can relax the LES and increase stomach acid production.
• Elevated head of bed: Sleeping with the head of the bed elevated (by around 6 inches) can help prevent reflux during the night and improve your sleep.
• Stress management: Doing stress-reducing activities, such as meditation, yoga, or deep breathing exercises, may help symptoms. Stress and anxiety can make symptoms worse by increasing stomach acid production and triggering muscle tension.
• Avoiding tight clothing: Wearing loose, comfortable clothing may help reduce GERD symptoms. Tight-fitting clothing around the abdomen can increase abdominal pressure and contribute to reflux.

In addition to these lifestyle changes, it can also help to avoid late-night meals (eating at least 3 hours before bedtime), to chew gum (which can increase saliva production and help neutralize stomach acid), and to maintain good posture (sitting upright and avoiding slouching) [18].

Medication Options for GERD Treatment

Medication is often needed to manage GERD symptoms and prevent complications. The main classes of medications used for GERD treatment include [4][6][7]:

• Proton pump inhibitors (PPIs): This is the most commonly prescribed class of medications for GERD. PPIs block the production of stomach acid, reducing the severity of reflux symptoms and allowing the esophageal lining to heal. Some examples are omeprazole (Prilosec), esomeprazole (Nexium), lansoprazole (Prevacid), pantoprazole (Protonix), and rabeprazole (Aciphex).
• Histamine-2 receptor antagonists (H2RAs): H2RAs block the action of histamine, a substance that stimulates the production of stomach acid. Examples include ranitidine (Zantac), famotidine (Pepcid), and cimetidine (Tagamet). H2RAs are generally less effective than PPIs but may be used for mild to moderate GERD or in combination with PPIs for more severe cases.
• Antacids: Antacids neutralize stomach acid and provide rapid but short-term relief of symptoms. They are often used as a supplement to PPI or H2RA medication or for the occasional relief of mild GERD symptoms. Examples include calcium carbonate (Tums, Rolaids), aluminum hydroxide/magnesium hydroxide (Maalox, Mylanta), and sodium bicarbonate (Alka-Seltzer).
• Potassium-competitive acid blockers (P-CABs): A new class of medications that work by blocking the potassium-competitive binding site on the proton pump, leading to more potent and durable acid suppression compared to PPIs.

The choice of medication and dosage depends on the severity of GERD symptoms, possible complications, and personal factors such as age, comorbidities, and potential drug interactions.

Long-term PPI is linked to possible negative side effects, such as an increased risk of bone fractures, Clostridium difficile infection, pneumonia, and vitamin B12 deficiency [21]. It is important to use the lowest effective dose of PPIs and to stop using them if they are no longer needed.

Surgical Interventions for Severe GERD

Surgery is recommended for people with severe GERD who have not responded well to lifestyle changes and medications, or who have developed complications such as Barrett's esophagus or esophageal strictures [25].The main surgical options include [8][9][10]:

• Fundoplication: Fundoplication involves wrapping the upper part of the stomach around the lower esophageal sphincter to strengthen the barrier and prevent reflux. Two main types are Nissen fundoplication and partial fundoplication.
• Magnetic sphincter augmentation (MSA): A relatively new and less invasive option, MSA involves implanting a flexible ring of magnetic beads around the lower esophageal sphincter to strengthen the barrier and prevent reflux.
• Esophageal lengthening procedures: In cases of hiatal hernia, where the lower esophageal sphincter is displaced below the diaphragm, esophageal lengthening procedures like Collis gastroplasty can create a new, longer esophagus. This is often combined with fundoplication.

Surgical treatments are effective in controlling GERD symptoms and reducing long-term complications. However, potential risks of surgery include difficulty swallowing, bloating, inability to vomit/belch, and gallstone formation.

Surgery is recommended for people with severe GERD who have not responded well to lifestyle changes and medications, or who have developed complications such as Barrett's esophagus or esophageal strictures [25].

Conclusion

GERD is a common condition that should be managed to prevent complications and improve quality of life. Treatment typically involves a combination of lifestyle modifications, medication, and in severe cases, surgical interventions.

Lifestyle changes, such as dietary modifications, weight management, smoking cessation, alcohol moderation, sleeping with the head of the bed elevated, stress management, and avoiding tight clothing, can help address the underlying causes and alleviate GERD symptoms.

Medication options, including proton pump inhibitors (PPIs), histamine-2 receptor antagonists (H2RAs), antacids, and potassium-competitive acid blockers (P-CABs), can provide symptom relief and prevent complications.

Citations:

1. Mayo Clinic, Gastroesophageal reflux disease (GERD)
2. National Institute of Diabetes and Digestive and Kidney Diseases, Symptoms & Causes of GER & GERD
3. American College of Gastroenterology, Diagnosis and Management of Gastroesophageal Reflux Disease
4. Katz, P. O., Gerson, L. B., & Vela, M. F. (2013). Guidelines for the diagnosis and management of gastroesophageal reflux disease. The American Journal of Gastroenterology, 108(3), 308-328. doi:10.1038/ajg.2012.444
5. Vakil, N., van Zanten, S. V., Kahrilas, P., Dent, J., & Jones, R. (2006). The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. The American Journal of Gastroenterology, 101(8), 1900-1920. doi:10.1111/j.1572-0241.2006.00630.x
6. Vandana Garg, Prashant Narang, Ritu Taneja. (2022). Antacids revisited: review on contemporary facts and relevance for self-management. Therapeutic Advances in Gastroenterology, 15, 17562848221139740. https://doi.org/10.1177/17562848221139740
7. Kevin Z Huang, H Christian Weber. (2022). Potassium-competitive acid blockers and acid-related disorders. Current Opinion in Gastroenterology, 38(4), 406-411. doi: 10.1097/MOG.0000000000000840
8. Stefanidis, D., Hope, W. W., Kohn, G. P., Reardon, P. R., Richardson, W. S., & Fanelli, R. D. (2010). Guidelines for surgical treatment of gastroesophageal reflux disease. Surgical endoscopy, 24(11), 2647-2669.
9. Ganz, R. A., Edmundowicz, S. A., Taiganides, P. A., Lipham, J. C., Smith, C. D., DeVault, K. R., ... & Schlack-Haerer, S. C. (2016). Long-term outcomes of patients receiving a magnetic sphincter augmentation device for gastroesophageal reflux. Clinical Gastroenterology and Hepatology, 14(5), 671-677.
10. Bremner, R. M., DeMeester, T. R., Bremner, C. G., & Mason, R. J. (1997). Surgical approaches to the treatment of gastroesophageal reflux disease. Gastroenterology Clinics of North America, 26(3), 595-618.
11. El-Serag, H. B., Sweet, S., Winchester, C. C., & Dent, J. (2014). Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut, 63(6), 871-880. doi:10.1136/gutjnl-2012-304269