The passage of stomach contents into the esophagus, known as gastroesophageal reflux (GER), is associated with temporary loosening of the lower esophageal sphincter (as seen in Figure 1). This type of phenomenon is common in most healthy babies, and can occur multiple times per day in healthy children and adults alike. In adults who are healthy, gastroesophageal reflux (GER) takes place after eating and usually lasts less than three minutes, having little to no symptoms. Although much not known about GER symptoms and physiology in infants, regurgitation or spitting up appears daily in about half of babies. Gastroesophageal reflux disease (GERD) is characterized by symptoms or difficulties resulting from GER.

There are two classifications of symptoms or conditions linked to GERD: those that affect the esophagus and those that influence other areas of the body. Conditions affecting the esophagus can involve throwing up, failing to gain weight, discomfort in the abdomen/chest area, inflammation of the esophagus, and difficulty swallowing. Infantile symptoms of GERD that manifest outside of the esophagus are coughing, laryngitis, and wheezing.

What is GER?

GER occurs when the contents of the stomach go back up into the esophagus. A lot of folks may experience Gastroesophageal Reflux (GER) at times, but it can occur without producing any signs. In some situations, Gastroesophageal Reflux may be the cause of acid reflux or heartburn.

Does GER have another name?

Doctors also refer to GER as

acid indigestion
acid reflux
acid regurgitation
heartburn
reflux

How common is GER?

Having GER once in a while is common.

What is GERD?

Gastroesophageal reflux disease (GERD) is a serious, chronic condition where GER symptoms continue over a long period of time and can become troublesome or lead to further problems.

If you suspect you have GERD, it is recommended that you go and see your doctor.

How common is GERD?

It is believed that around one fifth of Americans suffer from GERD.1

Who is more likely to have GERD?

Anyone can develop GERD. You are more likely to have GERD if you

are overweight or have obesity
are a pregnant woman
take certain medicines
smoke or are regularly exposed to secondhand smoke

What are the complications of GERD?

Without medical attention, GERD has the potential to cause prolonged troubles, including esophagitis, the tightening of the esophagus, and Barrett’s esophagus, as well as issues affecting areas other than the esophagus.

Esophagitis

Esophagitis is inflammation in the esophagus. Esophagitis can be responsible for the development of ulcerations and hemorrhaging in the esophageal wall. Long-term inflammation of the esophagus boosts the risk of acquiring esophageal stricture and Barrett’s esophagus.

Esophageal stricture

A narrowing of the esophagus known as an esophageal stricture occurs when the esophagus is too narrow. Esophageal strictures can lead to problems with swallowing.

Barrett’s esophagus

Gastroesophageal reflux disease can sometimes result in Barrett’s esophagus, a condition where the tissue in the esophagus is replaced with tissue similar to the lining of the intestine. A small minority of persons with Barrett’s esophagus are at risk to acquire a form of cancer known as esophageal adenocarcinoma, according to the National Institutes of Health (NIH).

Complications outside the esophagus

In some cases, GERD sufferers develop issues in areas other than the esophagus, such as the mouth, throat, or lungs. These complications may include

asthma NIH external link
chronic cough NIH external link
hoarseness NIH external link
laryngitis—inflammation of your voice box that can cause you to lose your voice for a short time
wearing away of tooth enamel

Symptoms & Causes

What are the symptoms of GER and GERD?

GER and GERD frequently result in indications like

heartburn, a painful, burning feeling in the middle of your chest, behind your breastbone, rising from the lower tip of your breastbone toward your throat
regurgitation, or stomach contents coming back up through your esophagus and into your throat or mouth, which may cause you to taste food or stomach acid

Despite this, not everyone having GERD as an adult has the symptoms of heartburn or regurgitation. Other symptoms may include

chest pain
nausea
problems swallowing or pain while swallowing
symptoms of complications in the mouth, throat, or lungs, such as chronic cough or hoarseness

If you suspect that you may have GERD, it is recommended that you make an appointment with a doctor. If the symptoms of GERD are not improved with the use of non-prescription medication or modifications to your lifestyle, you should consider seeking medical treatment.

It is advisable to go to a doctor if any signs appear that may be connected to issues resulting from GERD as well as other serious health problems.

chest pain
loss of appetite
persistent vomiting
problems swallowing or pain while swallowing
signs of bleeding in the digestive tract, such as
- vomit that contains blood or looks like coffee grounds
- stool that contains blood or looks black and tarry
unexplained weight loss

What causes GER and GERD?

The majority of the time, your lower esophageal sphincter and diaphragm help keep gastric reflux (GER) from occurring, which happens when stomach contents travel up your esophagus. However, many people have GER once in a while.

Gastroesophageal Reflux Disease could arise if the lower esophageal muscle relaxes when it normally should not. Possible causes of GERD resulting from changes to the lower esophageal sphincter may include

being overweight or having obesity
being pregnant
smoking or inhaling secondhand smoke

Certain drugs may trigger GERD or exacerbate existing GERD symptoms. Examples include

benzodiazepines, sedatives that make you calmer or sleepy
calcium channel blockers, which are used to treat high blood pressure NIH external link
certain asthma NIH external link medicines
nonsteroidal anti-inflammatory drugs (NSAIDs)
tricyclic antidepressants NIH external link

Having a hiatal hernia raises the likelihood of experiencing GERD or intensifying existing GERD symptoms. A hiatal hernia is a medical issue in which part of the stomach is allowed to slip into the ribcage due to a large opening in the diaphragm.

Diagnosis

How do doctors diagnose GER & GERD?

Most of the time, medical professionals can identify gastroesophageal reflux (GER) and gastroesophageal reflux disease (GERD) by considering the patient’s reported ailments and past health history. If your symptoms point to you experiencing Gastroesophageal Reflux Disease, your doctor may opt to treat you via medicines and changes to your lifestyle as opposed to running tests.

Your doctor may recommend medical tests if

your symptoms suggest you might have a complication of GERD
your symptoms suggest that you might have another health problem that causes symptoms similar to those of GERD
your symptoms don’t improve after treatment with medicines and lifestyle changes

Your physician could potentially send you to a gastroenterologist so that they can identify and treat GERD.

What tests do doctors use to diagnose GERD?

Your physician may require one or several tests to determine GERD and monitor for any GERD complications or additional health conditions.

Upper gastrointestinal (GI) endoscopy

A doctor performs an upper GI endoscopy by using an endoscope, a flexible tube equipped with a camera. This procedure allows the doctor to observe the lining of the top part of the GI tract, including the esophagus, stomach, and duodenum. A doctor may take samples of tissue from the inside of your esophagus during an upper gastrointestinal endoscopy by inserting a tool through the endoscope. A pathologist will examine the tissue under a microscope. Medical professionals may request a upper gastrointestinal endoscopy to examine any issues with GERD or any other disorders that could be causing your symptoms aside from GERD.

Esophageal pH monitoring

The most precise method of determining the amount of stomach acid in the esophagus is to use esophageal pH monitoring. Two types of esophageal pH monitoring are

catheter monitoring, in which a health care professional passes one end of a catheter—a thin, flexible tube—through your nose and into your esophagus to measure acid and nonacid reflux
capsule monitoring, in which a health care professional uses an endoscope to place a small, wireless capsule on the lining of your esophagus to measure acid reflux

For esophageal pH monitoring, you will be hooked up to a gadget that perceives data from the catheter or capsule and logs details about your nutrition, rest, and indicators. The health practitioner will utilize this data to analyze the link between acid reflux in your esophagus and your lifestyle such as your diet, sleep, and signs. Medical professionals can utilize this test to confirm the identification of GERD or ascertain whether GERD treatments are effective.

CURRENT MANAGEMENT

Nonpharmacologic Management

Managing GERD in babies could involve a combination of modifications in the way they are feed and situated. A mother’s diet may need to be adjusted since a sensitivity to milk protein can cause the same type of symptoms usually seen in infants with GERD. It is suggested that mothers of breastfed infants try not eating milk and egg for two to four weeks to see if it helps. Formula containing proteins or single amino acids that have undergone extensive hydrolyzation may be an appropriate choice for infants who are being fed via formula. Another way to manage feeding is to make it more concentrated by either gradually blending in dry rice cereal, about one tablespoon for every ounce of formula, or changing to pre-thickened formulas for full-term non-allergic babies.

Babies who have GERD may find their symptoms relieved if they are kept upright or laid on their stomachs. Although the prone position may be alright if the baby is kept in sight and is conscious, this position carries a heightened chance of Sudden Infant Death Syndrome (SIDS). Children who are more than 1 year in age would be better off in the prone position as the hazard of SIDS hugely decreases in the higher age groups.

It is suggested that in older children and teens, they ought to stay away from substances that cause symptoms, like caffeine, chocolate, alcohol, spicy foods, fruit juices, tomato and citrus fruits, and peppermint. Studies have revealed that chewing sugar-free gum after a meal may help in reducing cases of acid reflux.

Pharmacologic Management

The two main types of medicines used to treat GERD are those that reduce the production of acid, and those that help keep food moving through your digestive system. The major sorts of acid suppressing agents are antacids, histamine 2-antagonists (H2RAs), and proton pump substances (PPIs).

Antacids work to decrease heartburn by neutralizing gastric acid in either the esophagus or stomach. This mechanism allows mucosal healing of the esophagus. Limited proof exists to demonstrate symptom relief in babies and kids. Be careful when thinking of using antacids to treat children. Research has established a connection between ingesting antacids containing aluminum and developing aluminum toxicity as well as difficulties in young people. Young people in the age range of 15-17 who have consumed calcium-based products have encountered milk-alkali syndrome, an illness composed of three symptoms: excessively high calcium in the blood, alkalosis, and kidney failure. The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition stated that long-term antacid use is usually not the best choice of therapy for kids dealing with GERD. Furthermore, the security and effectiveness of surface protective elements, including alginates or sucralfate, have not been thoroughly studied in children.

H2RAs reduce the amount of acid that is released in the stomach by blocking H 2 receptors found on cells in the stomach. Clinical trials that took place with children and compared the effects of cimetidine and nizatidine to a placebo have revealed that these medications are superior to a fake treatment in providing relief for esophageal problems and helping to heal the mucosa. Two, eighteen, and nineteen double-blind, placebo-controlled, pediatric trials involving the administration of famotidine or ranitidine showed no positive results with children; however, specialists feel that these treatments are as effective as cimetidine and nizatidine. Studies of the body’s ability to process medicine determined that the highest ranitidine level in the bloodstream is achieved 2.5 hours after taking a dose, and that it has a duration of 2 hours before leaving the body. The acidity in the stomach begins to go up shortly after taking an H2RA and persists for around 6 hours.

It is advisable to keep an eye on kids for the potential progression of tachyphylaxis within 6 weeks of the start of treatment, hence limiting the treatment’s long-term application. Aside from that, H2RAs have been linked to liver sickness, and more particularly cimetidine has been associated with an augmented danger of gynecomastia, which could be comparable to the impacts of other H2RAs. H2RA medications could lead to undesirable effects that resemble long-lasting signs of GERD. Angry outbursts, agitation, pounding head pains, or an excessive tendency to sleep could be results of this. Care must be taken when figuring out the underlying source of these symptoms so that the amount of H2RAs is not raised unnecessarily.

PPIs are the strongest medications which show a better performance than H2RAs. PPIs inhibit the H + , K + -ATPase in the gastric parietal cell canaliculus, thereby decreasing acid secretion. In comparison to H2RAs, PPIs can maintain gastric pH >4 and inhibit meal-induced acid secretion for a longer period of time. The effectiveness of proton pump inhibitors (PPIs) to reduce acid levels does not decrease even with long-term use. Proton-pump inhibitors are able to mend erosive esophagitis at a faster rate than histamine-2-receptor antagonists. It is essential to ensure proper timing of PPIs for maximum effectiveness for the patient. Pharmacists should advise and teach patients or caretakers to take proton pump inhibitors (PPIs) approximately 30 minutes before eating.

Generally, PPIs are safe, with few negative reactions, and are typically well tolerated. It has been indicated that approximately 14% of grownup children and adults taking PPIs have experienced headaches, diarrhea, constipation, and nausea. No evidence was found from clinical trials using a placebo that treatment with PPIs would reduce irritability in infants.

It has not been shown to be beneficial to use any drugs like metoclopramide in order to treat GERD in children. Surgery is an option only for those with GERD symptoms that will not go away, are not helped by medication, or who experience life-threatening issues due to GERD; this could include fundoplication or total esophagogastric dissociation.