Treatment options for GERD

Photo of a man holding his stomach in pain (toranico / iStockphoto / Thinkstock) Typical symptoms of GERD, such as heartburn and acid reflux, can sometimes be relieved by changing your diet. Effective medications are also available. Surgery may be considered in some cases.

If you often experience acid reflux, have severe heartburn, and it greatly affects your everyday life, you may have what is known as “gastro-esophageal reflux disease,” or GERD for short. In GERD, some of the stomach contents flow back into the food pipe because the entrance to the stomach doesn't close properly.

What can you do to relieve the symptoms?

There is a lack of good research on whether making changes in daily life can help relieve heartburn and acid reflux. But it can be worth trying to change certain habits. For instance, the symptoms might get better if you stop smoking or drink less alcohol.

If certain foods appear to make your symptoms worse, avoiding those foods could help. The problems are often caused by specific things, such as coffee, chocolate, very fatty or spicy foods, citrus fruits or fizzy drinks. It might take time and patience to find out which types of food you don't tolerate well. Sometimes people also find that food hardly has any effect on their symptoms.

People who are overweight are often advised to lose weight because the extra pounds can put a strain on the digestive system and push against the food pipe and stomach. This could affect the function of the sphincter muscle that closes off the lower, narrower end of the food pipe. Meals that have a lot of fat or calories in them, or large meals, can cause GERD symptoms too. But thin people who have low-fat diets can also have reflux and heartburn. So there is no guarantee that your symptoms will get better if you lose weight or change your diet.

Many people wake up several times a night because of pain and burning in their food pipe. Some then decide to stop eating late in the evening, or only lie down at least three hours after a meal. Others sleep with their upper body raised. Lying on your left side can also help because then the entrance to your stomach is higher than your stomach itself.

Which medications can help?

If your symptoms don't improve despite making changes to your lifestyle, medication is a further treatment option. Various medications are available, some of which can relieve the symptoms very effectively - but the effect only lasts for as long as you take it.

Proton pump inhibitors (PPIs)

Proton pump inhibitors (PPIs) reduce the production of acidic stomach juices by inhibiting a certain enzyme. They can relieve typical symptoms like heartburn. Studies have tested just how effective these medications are. It was found that:

  • 25 out of 100 people who took a dummy drug (placebo) hardly had heartburn any more after 2 to 8 weeks.
  • 70 out of 100 people who took a PPI hardly had heartburn any more after 2 to 8 weeks.

In other words, the medications led to a noticeable improvement in symptoms in 45 out of 100 people.

Research has shown that proton pump inhibitors usually relieve the symptoms or reduce food pipe inflammations better than other medications (called H2-receptor antagonists) do. But PPIs sometimes don't reduce the production of stomach acid enough at night. If this happens, people may have reflux symptoms at night despite taking medication. In Germany, PPIs are available over the counter at low doses and in small pack sizes. A prescription is needed for higher doses.

H2-receptor antagonists (H2RAs)

H2-receptor antagonists prevent large amounts of stomach juices from being made. They do this by blocking the action of the hormone histamine in the stomach. Studies have shown that these drugs can relieve the symptoms of reflux:

  • 41 out of 100 people who took a dummy drug (placebo) hardly had heartburn any more after 2 to 6 weeks.
  • 55 out of 100 people who took an H2-receptor antagonist hardly had heartburn any more after 2 to 6 weeks.

In other words, the medication relieved heartburn in 14 out of 100 people.

Other medications

Antacids used to be a commonly used treatment option in Germany. These drugs are meant to bind to stomach acid, neutralizing acidic stomach juices in the food pipe and stomach. But no good-quality studies have shown that antacids help in people who have GERD. The same is true for alginate-based products. Alginates have a gel-like consistency in the stomach. The idea is that they will act as a physical barrier that prevents stomach contents from backing up into the food pipe.

Prokinetics are also meant to help keep stomach contents from flowing back, by speeding up the emptying of your stomach. But it’s not clear whether these medications help to relieve heartburn or reflux, either.

Antacids, alginates or prokinetics might be an option if someone only has mild heartburn or can’t tolerate the medications mentioned above. In Germany and other countries, they are available in pharmacies without a prescription.

What side effects do the medications have?

Overall, about 2 out of 100 people who take proton pump inhibitors have side effects like diarrhea, nausea or vomiting, pain in the upper stomach area, difficulty swallowing or headaches. Sometimes these side effects can be avoided by switching to a different PPI or changing the dose.

The long-term use of PPIs can increase the risk of bone fractures, particularly if they are taken at high doses for more than a year. There is some debate as to whether these drugs might also make people more likely to develop a severe inflammation of the bowel, pneumonia or cardiovascular (heart and blood vessel) problems.

Fewer than 1 out of 100 people who take H2-receptor antagonists have side effects such as nausea or headaches.

When can surgery help?

Not everyone finds it easy to take medication every day for many years. And sometimes the medication doesn’t have the desired effect, or the symptoms are very bad. If that is the case, people might consider having surgery.

The aim of anti-reflux surgery (fundoplication) is to prevent stomach acid from flowing back into the food pipe. In this operation, the upper part of the stomach is wrapped around the lower end of the food pipe and fixed in place by sewing it to the diaphragm, stomach or food pipe. This strengthens the muscle at the lower end of the food pipe (the esophageal sphincter) in order to help prevent heartburn and reflux.

Nowadays this surgical procedure is usually done laparoscopically – also known as minimally invasive or keyhole surgery. This means the doctor inserts the surgical instruments into the abdomen (belly) through small cuts in the skin.

Fundoplication can be done in two ways, depending on whether a section of the stomach is wrapped all the way around the food pipe, or only part of the way around it. A complete fundoplication, where the stomach is wrapped all the way around the food pipe, is called Nissen fundoplication. In what is known as Toupet fundoplication, the stomach is only partially wrapped around the food pipe. This surgical technique is the method of choice if, for example, there is a problem with the movements of the food pipe (called a motility disorder). 

Illustration: Nissen fundoplication: The upper part of the stomach is wrapped around the lower end of the food pipe like a collar.

How effective is anti-reflux surgery?

There is not enough research to be able to say whether anti-reflux surgery relieves the symptoms more effectively than medication does. But some evidence suggests that people who have had the surgery feel less restricted by their heartburn and reflux than people who take medication do – at least within the first year after surgery. It’s not clear whether this advantage of surgery is sustained in the long term.

What are the disadvantages of anti-reflux surgery?

 

Every surgical procedure carries certain risks. Quite a lot of people have symptoms such as flatulence (“passing wind” or “farting”) and regurgitation after having anti-reflux surgery. But these symptoms could also be caused by the disease itself, and not by the surgery. Surgery causes swallowing problems in some people, or makes existing swallowing problems worse. Up to 23 out of 100 people in the studies had symptoms like these after fundoplication surgery.

Possible serious complications of surgery include severe bleeding, organ injury and infections. Up to 2 out of 100 people have severe bleeding, and the digestive tract is injured in about 1 out of 100 people.

Labels: Digestion and metabolism, Gastro-esophageal reflux disease, GERD, Heartburn, K21, K22, R63, Reflux disease