Are Too Many Babies Taking Antireflux Medications?

Spitting up is a common, albeit messy, part of being a baby. But some little ones have a harder time keeping their early diets down than others. So, infants these days are often prescribed medications to help keep their spit-ups — and the discomfort that can come with them — at bay. But now a new study is questioning whether many of the babies taking these drugs really need them.

Focusing on 44 infants with ongoing spitting up or vomiting problems, researchers used a test to measure the reflux (or regurgitation) of acid from the stomach into the esophagus. What they found: The vast majority of the babies couldn't technically be diagnosed with gastroesophageal reflux disease (GERD), a condition that's different from regular old reflux. Reflux is very common in infants, but it usually doesn't cause any health problems and stops before a baby's first birthday. Doctors diagnose GERD when a child's reflux is causing complications, like irritation of the esophagus due to refluxed stomach acid, poor weight gain, or breathing problems due to spit up spilling over into the child's lungs.

Although almost all of the 44 babies tested were on antireflux medications (42, in fact), only 8% of them could be considered to have GERD. And when the babies who didn't appear to have the condition after all were taken off the medications, the reflux symptoms in most of the babies improved or didn't get any worse.

So, why the large number of babies getting antireflux medications? The researchers say the high number of prescriptions could be because:

• Primary care doctors don't have a simple way to distinguish simple reflux from GERD, so they may prescribe the medication to see if it helps.
• Parents may become anxious and worried about their baby's ongoing problems and request a prescription. (The researchers note, though, that parents' reports of vomiting and spitting up are often highly exaggerated — often as much as five to six times more than the amount the baby is actually throwing up.)

Do You Really Need Acid Reflux Drugs?

If you, like millions of people, suffer from the pain and discomfort of acid reflux disease, your doctor may have suggested medications to help ease your symptoms. Acid reflux, also known as gastro-esophageal reflux disease or GERD, is a painful condition that occurs when stomach contents re-enter the esophagus, due to a weakness of the esophageal sphincter between the stomach and the esophagus. Stomach acids can be dangerous and cause damage to the throat and larynx if left untreated, so it is important to see a doctor to diagnose and treat your symptoms.

Often the use of an acid reflux drug can help to stop the pain and other symptoms almost immediately, bringing welcome relief. Some types of acid reflux drugs cause the production of less acid in the stomach, and some cause the acid to become less strong.

However, while there are many types of acid reflux drug that your doctor may prescribe, prescription medications can be expensive, and sometimes have unwanted side effects. And many people simply want to avoid ingesting chemical medications, preferring a more natural approach wherever possible. Luckily there are many alternatives to acid reflux drugs. Some simple changes in lifestyle may avoid the need for acid reflux drugs. These changes include a special diet to avoid aggravating the acid reflux disease.

One step to take if you wish to avoid taking acid reflux drugs is to eat smaller and more frequent meals. Eating large meals tends to cause the stomach to produce too much acid, while waiting too long between meals can also allow the acids to further irritate the already-sensitive esophageal tissues. You will often notice a bitter taste in the back of your throat in this case.

Eating different foods may also help. Avoid foods that are very spicy, or high in fat. You may also find it helpful to avoid or cut back on alcohol, caffeine, and smoking. Learn which foods are naturally acidic, such as tomatoes, and avoid them while treating your acid reflux disease.

Finally, lying down after meals can almost always make acid reflux symptoms worse. Avoid after-dinner naps, and do not eat directly before bedtime.

If you follow these simple changes, you may find that there is no need to take an acid reflux drug. However, if our symptoms do not improve, check back with your doctor, as acid reflux symptoms can be damaging in the long run.

Acid Reflux Relief Can Be Dangerous

Yes, even the very thing that’s supposed to bring you relief from the discomfort and pain of acid reflux symptoms can sometimes hurt you further. You should realize that taking strong prescription medications can have serious side effects, and are not usually made of natural ingredients but of chemicals that can have unexpected impact on the body. As well, they tend to only treat the symptoms, and not correct the problem that is causing the symptoms in the first place. While you may be glad of the temporary acid reflux relief, medications may not be a long-term solution.


The problem in acid reflux is that the body is failing to close off the esophagus from the stomach, so that foods you eat begin to mix with stomach acids as they should, but then sometimes begin to come back into the throat. Most medications taken for acid reflux relief just make the stomach produce less acid, so that it doesn’t hurt the esophagus as much. But you need the stomach acids to digest your foods properly. The natural balance of your digestive system is upset by this, and while you may get some temporary acid reflux relief, in the long run you can create more problems for yourself.

Antacids - Acid Reflux Relief or Not?

Antacids are named to indicate that they are used for acid reflux relief, but are they? They work by neutralizing stomach acids, but then your body ahs a hard time digesting some foods, and also in getting the proper nutrients and vitamins out of the foods you do digest. Antacids make it especially difficult for your body to absorb vitamin B and iron, which are very important for your health. It won’t do you much good to be free of acid reflux symptoms only to get sick from something else.

Antacids are best left for use for occasional heartburn. For permanent acid reflux relief, try changing your diet to include less acidic foods, do not eat large meals, avoid fast foods and any foods that are high in fat or sugar, and avoid very spicy foods. These changes may also help you lose weight, which is great because weight loss is also recommended as a step toward acid reflux relief. Cut down or avoid drinking alcohol and coffee, and stop smoking. These will bring you the acid reflux relief you are looking for

Acid Reflux Food Plans

Millions of people suffer from acid reflux, and while there are many medications that may help to treat the symptoms, most just offer relief from the pain. Antacids, meant for heartburn, can make the problem worse in the long run, as the stomach acids are needed to digest the foods you eat. Actually curing the underlying problem can be more difficult, but is not impossible. When suffering from acid reflux food that you eat will often make the problem worse. Learning which foods to avoid can be very helpful, so you may wish to develop a personal acid reflux food plan, as well as incorporating a few other simple lifestyle changes that may help you to feel better.


Your Acid Reflux Food Plan

The first step in your own acid reflux food should be to notice which of the foods you presently eat tend to make your symptoms worse. Commonly these will include spicy and high-fat foods, as well as foods high in acidity, such as tomatoes or other fruits and vegetables. Eating a lower-fat diet, avoiding very spicy choices, and choosing different vegetables will help quite a lot. Eating more whole grains is very helpful, and avoiding fast foods should be included in any acid reflux food plan.

Other items that are known to exacerbate acid reflux include alcohol and caffeine. Try cutting down on drinking alcoholic drinks and coffee, and you may find it makes a big difference. Stopping smoking will help as well; while this is not food, it still affects your health.The timing and frequency of your meals is also important. If you eat just three large meals a day it probably makes the symptoms worse. Try eating more meals per day, but smaller meals each time. Eating too large an amount at one sitting makes your stomach produce more acid, which is the last thing you want. Eating more frequently means your stomach won’t have to be totally empty for very long, which can sometimes also cause pain, because it means there is nothing to mix with the stomach acids and keep them from burning your throat.

These lifestyle changes that start with an acid reflux food plan can bring welcome relief from the pain and distress of acid reflux. Remember to check with your doctor before making any major changes to your diet.

Making Your Acid Reflux Recipes Healthy

It’s not enough to make a recipe that won’t worsen your acid reflux; you also need it to be nutritious, especially if you’re hoping to improve your general health. Goof foods to include in an acid reflux recipe include a lot of fruits and vegetables. Among fruits, apples and bananas are usually best, as they are not acidic. There are lot of vegetables to use, such as cabbage, green beans, carrots, broccoli, and peas. Potatoes, a favorite among many people, are also good, but should be baked, roasted, or added to soups, not fried as that adds too much fat. Lean meats will not hurt, and while egg yolks tend to be avoided in a good acid reflux recipe, egg whites or egg substitutes are okay. And finally us low-fat or fat-free dairy products and whole grains. You will notice that many of these foods are similar to a diet intended for weight loss – this is true, and coincidentally losing weight is also helpful in reducing the symptoms of acid reflux.

Acid Reflux Recipe #1: Vegetable Broth



A good acid reflux recipe is a basic vegetable broth, which is a good basis for soup stock to be used in other recipes, as well as being delicious on its own. Commercial vegetable broths often contain a lot of ingredients that you want to avoid. Chop two cups each of celery leaves and beet tops, carrots, and potato peelings (the red-skinned kind is best.) Next add three chopped cups of celery, one small diced onion, a grated or sliced zucchini or squash, and maybe a bit of parsley. Cover with boiling water and simmer for half an hour. You can eat it as it is as a soup, or strain to use as clear stock. This recipe is rich in minerals and gentle on your digestive system, as well as delicious.

Acid Reflux Recipe #2: Lentils and Rice



Rinse one pound of organic lentils and boil with eight cups of water. To this you will add one diced onion, three cloves of garlic, which you can chop or put through a garlic press, two chopped or grated carrots, and two stalks of celery sliced thinly. Next you should add a bay leaf and some thyme to taste. With a lid on the pot, simmer until the lentils are tender; this should take about twenty minutes or so. Stir a few times while it simmers, and add more liquid if it is needed as the lentils absorb the water. When it is done, remember to remove the bay leaf.
Separately, prepare some brown rice – the package will have directions, but the usual ratio is a little over twice as much water as rice, i.e. two and a quarter cups of water to one cup of rice. When both the rice and lentils are done, serve by plating some rice and spooning lentils over top. Add salt and pepper to taste. You may wish to garnish with fresh parsley.

Acid Reflux Diet

* First of all, try to eat small, frequent meals instead of three big meals a day. Small amounts of food each time would exert less workload on the stomach and therefore requires less acid secretion for digestion. Make sure to include foods that are high in complex carbohydrates in each meal. These foods, such as rice, breads and pasta, are able to tie up excess stomach acid and are often easy on the stomach.
* Avoid high-fat meals such as those from the fast food chains. High fat foods will remain in the stomach longer, thus causing the need for more stomach acid in order to digest them.
* But remember, don't overeat! Eating too much of any foods will stimulate the stomach to secret more acids for digestion.
* Avoid or limit alcohol
* Maintain upright position during and at least 45 minutes after eating
* Try elevating the head of bed six to eight inches when lying down.

Don't think that beverages just quickly flow through your stomach without affecting acid production. Surprisingly, a lot of beverages stimulate acid secretion such as beer, wine and pop. The worst of all is beer. It could double your stomach acid within an hour.

Acid Reflux Diet

Many people take over-the-counter antacids for a quick ease of acid reflux, but for most people, a proper diet is the best solution for overcoming acid reflux.
Acid Reflux Diet Myth

* Myth 1: Drink milk

A lot of people try drinking milk to ease acid reflux before sleep. But often, milk ends up causing acid reflux during sleep. To understand the whole situation, we have to realize that the problem roots from eating too much at dinner time. Eating a big meal at dinner causes excess stomach acid production. Drinking milk could be a quick fix to the acid reflux problem. Unfortunately, milk has a rebound action and would eventually encourage secretion of more stomach acid, which causes the acid reflux. To solve the problem, try adjusting your diet by eating a small meal at dinner and have a small snack such as crackers before sleep.

* Myth 2: Avoid coffee, citrus fruits and Spicy food

We have been told for years that coffee, acidic fruit as well as spicy foods can aggravate acid reflux. Therefore, we should avoid these in our daily diet in order to reduce acid reflux. A recent study published in the Archives of Internal Medicine in May 2006 showed that none of these myths hold true. Researchers from the Stanford University found that the only two behavioral changes can reduce symptoms of acid reflux - eating less and elevate your head while sleeping.

Signs of Acid Reflux

Millions of people suffer from acid reflux or gastro-esophageal reflux disease (GERD) but not everyone knows all of the signs of acid reflux, as there are several. The most common one, which almost everyone knows about, is the extreme heartburn that happens after you eat, especially if you eat too much rich food. While this is sometimes just regular heartburn, in a lot of cases if you experience this often, it may actually be a sign of acid reflux.

The commonly seen heartburn or chest pain is sometimes mistaken for an actual heart attack, because it can be so severe and is in the same general region of the body. If you have such serious pains, don’t be too certain it’s a sign of acid reflux: go and see a doctor to be sure. Many people each year mistake the symptoms of actual heart attacks with acid reflux, as well as the other way around. But mistaking a real heart attack for acid reflux can be quite deadly. Don’t worry about being embarrassed in the emergency room – it’s better to be safe than sorry. As well, even acid reflux can be quite dangerous if left untreated, so it’s important to see a doctor either way.

Signs of a heart attack may include pain in the arm, and feeling worse after exercise. Signs of acid reflux most often come following eating certain things (like spicy or very fatty foods) and tend to get worse when you lie down after eating. If you know you have signs of acid reflux and have been diagnosed by a doctor, you may feel more able to tell the difference between them.

There are other signs of acid reflux, beyond the commonly known heartburn, and most of these are not mistaken for heart attacks but overlooked entirely or not known to be associated with acid reflux. These may include a bad taste in the mouth, sore throat, a feeling that food is coming up the throat, and tooth damage even when you are taking good care of your oral hygiene. All of these are due to stomach acids entering the throat or even the mouth, where they can do a lot of damage. It is important to deal with acid reflux, because if it goes on too long it can lead to scarring of the esophagus, bleeding ulcers, and even cancer of the throat. Luckily there are many treatment options available.

Sore Throats

If you have ever experienced acid reflux, you know that the symptoms can be very

uncomfortable. When the esophageal sphincter at the bottom of the esophagus is not

functioning properly, the stomach acids entering the esophagus from the stomach cause a

burning of the esophageal sphincter, and can also lead to irritation and pain of the rest

of the esophagus as well. The top of the esophagus is commonly known as the throat, which

is why acid reflux and sore throats often go hand in hand.

Some people do not realize they are suffering from acid reflux and sore throats seem like

they might just be a symptom of a cold or the flu, and so they drink tea to soothe their

throats, and perhaps take painkillers. Leaving acid reflux untreated can damage your

esophagus if it becomes more acute, however, causing scarring to the throat or even

bleeding ulcers in the stomach and digestive system. How can you tell if your sore throat

is caused by acid reflux? It may be worsened by lying down, and probably feels more

irritated after eating a meal, which is when acid reflux usually asserts itself. If you

think you are experiencing acid reflux and sore throats, see your doctor. There are several

solutions he or she may suggest.

Chest Pain

Almost every acid reflux sufferer experiences severe chest pains. It is so common to experience chest pain due to acid reflux that sometimes when people are actually having a heart attack they think it’s just acid reflux again and therefore don’t go to the hospital or get proper medical care.

Chest Pain or None in Acid Reflux – What’s the Difference?

In acid reflux sufferers who have chest pains, there doesn’t seem to be a difference in levels of acid, nor in the levels of aggravation of acid reflux when compared to acid reflux sufferers who don’t have chest pain. Right now it’s a mystery to doctors as to why some people experience acid reflux and chest pain while some only have the acid reflux. But dealing with the acid reflux is the same either way.

Acid reflux and chest pain can be dangerous if it’s not treated right, as well as being terrible uncomfortable. When acid leaves the stomach, is gathers in the esophagus or alimentary canal. The acid has to be neutralized, or eventually it will damage the esophagus and you’ll get bleeding ulcers – painful! So doctors are cautious to check the acid levels in the stomach and esophagus both before the treatment and during it, to make sure no damage is being done.

Dealing with Acid Reflux and Chest Pain Quickly and Easily

As soon as you are diagnosed with acid reflux and chest pain, you can get treatment that will relieve your symptoms and make you feel much better right away. Whether you are choosing traditional medications, or alternative treatments like herbal medicine, you’ll find the best first step is to stop smoking or drinking alcohol. It’s also important to eat small meals and snacks, more than three times a day. This will ensure that your stomach is never empty – an empty stomach will tend to produce more acid later when you do get to eat – and more acid is the last thing the acid reflux and chest pain sufferer wants! Try carrying small snacks with you at all times, because you never know when you might find yourself in a long meeting or heavy traffic.

In combination with your prescribed medications, if you eat smaller, more frequent meals, and stop drinking and smoking, you’ll find your acid reflux and chest pain much easier to manage.

Surgery for Acid Reflux Disease or GERD

There are many medications today to help relieve Acid Reflux, perscription and over the counter. For people with chronic acid reflux disease, these medications are sometimes just not enough and surgery may be their best chance for relief. The surgery can be done laparoscopically, but many patients don't want such a drastic procedure performed. Fortunately, a new less invasive outpatient surgery is available for acid reflux sufferers called the Plicator procedure.

Acid Reflux happens when the stomach contents refluxes back up into the esophagus because of a weak valve connecting the esophagus to the stomach. Surgery can correct this problem by tightening the valve to prevent the backup from the stomach to the esophagus. Until now, this procedure has been performed laparoscopically, which means a tiny camera/scope is inserted through a small incision which transmits images to a video monitor for the surgeon to see in order to perform surgery. General anesthesia is required for this type of surgery. Many patients are uncomfortable with such an invasive procedure.


The new less invasive surgery involves an instrument called the Plicator. This device enters the body by a tube down the throat. The surgeon uses it to grab, fold to tighten, and suture the stomach tissue without any incisions. This outpatient procedure requires the patient to be under conscious sedation instead of general anesthesia, and takes less than 30 minutes. Recovery time is a day or so, and patients can then stop taking antacid medication. The success rate of the Plicator procedure is now about 80% but it may need to be performed again after a few years to retighten the valve.

How To Prevent Nighttime Heartburn

Nearly eight in ten heartburn sufferers experience symptoms at night. If staying up all night isn't the option you are prepared to take for handling your nighttime heartburn, the following suggestions should help you.


1. Eat your big meal at lunch instead of at dinnertime.
2. Eat at least two to three hours before lying down. Eliminate late-night snacking.
3. Avoid foods that are known to lead to heartburn.
4. Sleep with your head and shoulder on an incline.

Tips:

1. It is beneficial to eat 4 or 5 smaller meals instead of 3 larger ones. This will also reduce the gastric pressure. Also, certain foods increase acid production and gastric pressure or they loosen the lower sphincter muscle. You will also want to avoid foods that can irritate the lining of the esophagus, such as spicy foods, coffee, citrus fruit and juices. This is especially true if you eat any of these foods at dinnertime because they can increase your chances of having nighttime heartburn.

2. The position you sleep in is important. Lying down flat presses the stomach's contents against the LES. With the head higher than the stomach, gravity helps reduce this pressure, and keeps stomach contents where they belong--in the stomach. You can elevate your head in a couple of ways. You can place bricks, blocks or anything that's sturdy securely under the legs at the head of your bed. You can also use a wedge-shaped pillow to elevate your head.

3. Just as loose fitting clothing is important during the day, heartburn sufferers need to make sure their bed clothes are also loose. Clothing that fits tightly around the abdomen will squeeze the stomach, forcing food up against the LES, and cause food to reflux into the esophagus. Clothing that can cause problems include tight-fitting belts and slenderizing undergarments.

4. Take an antacid before going to bed. Antacids will work very quickly on heartburn you may be experiencing before you go to bed. It can also be used for those heartburn episodes that wake you up during the night if the heartburn comes back. For longer relief a H2 blocker can be taken, as they usually work up to 12 hours, but may take a couple of hours to start working. One option is to combine the two. The antacid will provide quick relief you'll need until the H2 blocker starts working.

5. If you continue to experience frequent heartburn symptoms at night, see your health care provider. He or she will be able to diagnose whether you are suffering from just occasional heartburn, or something more serious, such as gastroesophageal reflux disease, an ulcer, or a hiatal hernia. You will be able to discuss with your health care provider different treatment options, including medications such as proton pump inhibitors.

Nighttime Heartburn May Be Dangerous

Why is heartburn more dangerous at night? There are several reasons this may be the case, and why heartburn sufferers should take precautions.

When symptoms of Gastroesophageal Reflux Disease (GERD) occur at night, they can be more damaging than those same symptoms during the day. If you are a GERD sufferer, you know how your symptoms can cause problems, such as the pain and the irritation. When you sleep at night, your body is less prepared to deal with these symptoms, and less able to prevent possible lasting damage. While we know from experience that acid reflux at night can disrupt our sleep, we also need to understand the other potentially harmful factors that can make nighttime heartburn more likely to cause damage.

These factors include:

* Sleeping in a supine position.
Laying flat in bed allows stomach acid to flow more easily into the esophagus, and stay there more longer periods of time then when a person is in an upright position.Even elevating the head and shoulders 6 to 8 inches will help keep stomach acid where it belongs, in the stomach.

* We can't drink or swallow every time an acid reflux episode occurs when sleeping.
When GERD sufferers are awake and there's an episode of acid reflux, they often will rinse their mouth or swallow some liquid. Even swallowing saliva helps. When asleep, once the refluxed acid is in the esophagus or throat, the sufferer isn't always aware of it, and thus doesn't take steps to rinse the acid away.

* There's an increased risk of choking on refluxed stomach contents.
If refluxed acid is in the throat and mouth, a GERD sufferer can inhale this into their lungs. Once in the lungs, it can cause a GERD sufferer to cough and choke on this aspirated material. The acid can also cause the same damage to the lungs as it can cause when refluxed into the esophagus.


Anyone who is troubled with nighttime GERD symptoms should talk to their doctor. There are medications that can help control the acid reflux. The doctor can also discuss preventive measures a GERD sufferers can use to help prevent damage that can occur with nighttime reflux.

Acid Reflux Wedge Pillows

Acid Reflux happens when the liquid contents of your stomach reflux up into the esophagus. Many people suffer from nighttime acid reflux because when you lay down, the contents in your stomach is more likely to flow right into the esophagus since gravity is no longer helping to keep it down. If the liquid, which contains acid, stays long enough in the esophagus, it can cause damage to the lining of the esophagus. The contents of the stomach may even cause damage to the vocal cords or cause tooth decay. It can also irritate the throat which can cause coughing and sleepless nights.

There are many treatments to help with acid reflux disease, such as lifestyle changes, over the counter medications, or even surgery for severe cases. The acid reflux wedge pillow is one way to help prevent acid reflux from happening at night while you are sleeping. Sleeping at an incline 6 to 8 inches up on a acid reflux wedge pillow positions your body in a way that makes it difficult for the contents of your stomach to flow up into your esophagus. Gravity helps keep it down just as if you were standing up.

Infants and children with acid reflux can also benefit from an acid reflux wedge pillow. Since there are many concerns about SIDS, it is now recommended that children sleep either on their side or back. Children that sleep on their back are just as likely to suffer from acid reflux as adults. Some acid reflux wedge pillows especially made for infants and children have a harness like feature to keep them in place on the pillow. Some acid reflux wedge pillows are available for children with side barriers giving you the option to lay your child on his or her side.


A wedge pillow for acid reflux offers great relief for those who suffer from acid reflux disease. Using the acid reflux wedge pillow and other treatments together can help you to get that great night sleep you have been looking for.

Acid Reflux Disease in Infants & Babies

Acid reflux in infants is very common. At least half of all infants are born with some degree of reflux simply from immaturity of the the lower esophageal sphincter (LES). The LES is a valve at the bottom of the esophagus which opens to let food and liquids into your stomach and then closes again so it doesn't come back out. Acid reflux happens when this valve does not close properly, causing stomach contents to reflux back into the esophagus.

Control Acid Reflux To Prevent Esophageal Cancer

Esophageal Cancer

Increase in obesity linked to rising numbers of esophageal cancer cases.

For most of his adult life, 49-year-old Jim Bonell suffered from acid reflux, but he never considered the condition dangerous. That is, until he was diagnosed with esophageal cancer.

What Bonell didn't know was that his chronic acid reflux left him with a condition called Barrett's esophagus, which puts people at high risk for esophageal cancer. Barrett's is a condition in which the cells lining the lower esophagus change because of repeated exposure to stomach acid. Normally, the tissue lining the esophagus is similar to the lining in your mouth (squamous mucosa), but with Barrett's, the body replaces the normal esophageal lining with one similar to that found in the intestines.

"There were no symptoms that I had esophageal cancer," says Bonell. "Prior to being diagnosed, my acid reflux was really bad and getting worse. I was a Tums-eater. I'd eat a whole bunch of them."

Esophageal cancer rates are on the rise, and the increase may be due to an increase in obesity, says Mark B. Orringer, M.D. professor and head of thoracic surgery at the University of Michigan Health System. Obesity often causes a hiatus hernia and associated acid reflux.

Esophageal cancer has always carried a terrible prognosis. But thanks to an increasing awareness that heartburn may have serious implications along with earlier detection, improved staging tests and better treatment many patients like Bonell are winning the battle with this initially "silent" cancer.

Bonell has benefited from some of the surgical advances developed and refined at the U-M Health System. Traditionally, patients who needed to have their esophagus removed–either for esophageal cancer or Barrett's esophagus – underwent highly invasive surgery that involved opening the chest and abdomen.

But Orringer and his colleagues developed a procedure, called transhiatal esophagectomy, in which the esophagus is removed through incisions in the abdomen and the neck, without the need to open the chest.

Once the esophagus is removed, the stomach is freed up from attachments holding it in the belly and it is pulled up through the chest. The stomach is then connected to the remaining esophagus in the neck.

The risk of infection is significantly lowered with this procedure because if any leak at the connection in the neck occurs, the resulting infection drains externally rather than in the chest, says Orringer. Further, by avoiding the traditional chest incision, pneumonia after this operation is much less common.

"In a recent study of more than 2,000 patients who have undergone a transhiatal esophagectomy at the University of Michigan, the hospital mortality rate in the last 1,000 patients was 1 percent; that's one death in 100 operations," he notes. "When I began as a faculty member in 1973, the mortality for esophagectomy was as high as 20 percent at many institutions."

This development in surgical treatment is important given the dramatic rise in cancer cases that doctors believe stems from obesity and acid reflux. Twenty years ago, the most common type of esophageal cancer was squamous cancer, which arises from the squamous mucosa that lines the normal esophagus.

But in the past 10 to 15 years, there has been a 350 percent increase in adenocarcinoma of the esophagus, a type of cancer that is related to the cellular changes in the esophagus that are the hallmark of Barrett's. It is now the most common form of esophageal cancer, occurring in 80 percent to 90 percent of patients. This increase in esophageal adenocarcinoma mirrors the rise of the obesity epidemic.

"There's no question that the incidence of esophageal cancer is increasing dramatically. We have an epidemic of obesity in this country," says Orringer. "I can't walk into a social setting where there are not some people who are quite overweight and complain of heartburn or acid indigestion. I think we should be very concerned."

Five tips for preventing Barrett's Esophagus and esophageal cancer

1. Work on losing weight. Obesity leads to hiatus hernia and reflux which are in turn responsible for the increasing rates of esophageal cancer. Talk to your family physician about developing a plan to lose weight by eating well and exercising regularly.

2. Don't lie down after eating. For those with acid reflux, the valve between the esophagus and the stomach doesn't function properly, allowing the contents of the stomach to back up into the esophagus. Lying down can make this problem worse, leading to late-night heartburn. Be sure to eat early to give your stomach time to empty before bedtime.

3. Sleep propped up. Lying down can exacerbate acid reflux. If you have reflux, consider arranging pillows so that your head and upper chest are elevated while you sleep. Stomach acid, like water, does not roll uphill.

4. Take an antacid. Neutralize stomach acid before it backs up into the esophagus with antacids.

5. Talk to your doctor. If you have a long history of severe heartburn or acid indigestion, talk to your doctor about Barrett's esophagus, which increases your risk of developing cancer. Even if your acid reflux symptoms are controlled, you still could be at risk. The only way to diagnose Barrett's is with an endoscopy and biopsy. Esophageal cancer can be cured, if it is diagnosed early.

Tips to Prevent Heartburn in Pregnancy

Heartburn in pregnancy is actually quite common. Follow these simple tips to help alleviate your symptoms...

During pregnancy, common everyday ailments tend to feel worse, especially during the first and third trimesters. Heartburn is no different. Heartburn is a common ailment, and during pregnancy it tends to surface even more. Most women experience heartburn in pregnancy at some point during their nine-month journey. However, some can be affected worse than others. Fret not -- there are things you can do to limit the severity of heartburn during your pregnancy.

During the third trimester the baby grows big enough to put pressure on your stomach. This causes the acid in the stomach to reflux. This can be easily avoided, however by avoiding binging and by eating small meals. This will keep acid reflux at bay. Instead of eating three large meals, try to eat five to six smaller meals spread throughout the day.

Your sleeping position can also cause acid to reflux. Sleep with your head and torso elevated to keep the food down in your stomach. Keep yourself comfortable by putting a pillow under your head and your back. Also, try to avoid going to bed within two hours of eating. Wait at least two hours before lying down to give your body some time to digest the food. As a general rule, go to bed two to three hours after you eat to mitigate heartburn in pregnancy.

Watching your posture can help prevent heartburn from occurring. Putting pressure on your stomach can cause heartburn in pregnancy. When you sit, do so in an upright position to keep the pressure off your stomach. When you stand or walk, keep your posture erect for the same reason.

A less common way to alleviate heartburn is to wear loose clothing. (Though you probably do this already.) This will also ease the pressure in your stomach. Wearing tight clothing puts unnecessary strain on your stomach and can encourage acid to come up into your espohagus, causing heartburn in pregnancy.

Perhaps the best way to avoid heartburn all together is to stay away from foods that are known to cause heartburn. For obvious reasons, alcohol should be avoided at all costs during pregnancy. Also on the restricted list are chocolate, citrus fruits, tomato-based foods, soft drinks, coffee and acidic juices.

Sipping water throughout your daily activities as opposed to chugging it occasionally can also help. Avoid fried food, food rich in fat and vinegar as well. Large quantities of water can actually increase heartburn in pregnancy. By eliminating these foods from your daily diet, you can alleviate the symptoms of heartburn in pregnancy.

For other tips on how to get rid of heartburn visit http://www.stopheartburntoday.com We'll help you find relief from your heartburn symptoms through medications for acid reflux and natural remedies as well.

Rules To Avoid Heartburn

There are some simple rules, some foods to avoid, and a sleeping position that are proven to limit, and even eliminate GERD and the GERD effect.

Rules to follow:

1. Do not eat later than 3 hours before plan to sleep. Generally, try to eat early in the evening, and always make the evening meal a light one.

2. Reduce your weight.

3. Stop smoking

4. Do not wear very tight clothing that could constrict the abdomen

5. Generally do not eat large meals, but smaller ones, and in the evening before reclining, do not eat any food on the restricted list.

6. Before sleeping, spend a few moments at a window and do some deep breathing, inhaling and exhaling deeply.

This will energize your nervous system and can assist in the prevention of GERD if the other measures are also followed.

Dietary Restrictions: The evening meal must not be large, or heavy, and completed no later than 3 hours before your intended sleep.

Acid Reflux Disease Diets

There are many different medications for the quick relief of acid reflux disease. However, an easy and effective long term solution can be as simple as following an acid reflux diet.

The first thing to do is eat smaller meals more frequently throughout the day. If you do this, your stomach will produce less acid for the smaller amount of food, therefore less acid will be available to enter the esophagus. The type of foods to avoid with acid reflux are foods that are low in fat, all vegetables(not fried), non citrus fruits, decaffinated beverages, and non spicy foods. Foods that would aggrevate or cause reflux and should be avoided are high fat foods(especially fast food), alcohol, chocolate, foods containing caffeine, peppermint and spearmint, Onions, and tomato products.

Prescribed acid reflux medications

Your doctor may perscribe a stronger medication to help a more serious acid reflux condition if over the counter medications don't help.

One type of medication, called a proton pump inhibitor, stops the production of an enzyme that produces stomach acid. This medication is more effective in stopping acid from being produced than the over the counter Histamine-2 receptor blockers.

Doctors also prescribe promotility agents. This medication strengthens the lower esophageal sphincter to help the food in the stomach empty faster

Over the counter Acid Reflux Medications

Antacids are a very effective way to help relieve acid reflux symptoms. If you take them 1 hour after meals they neutralize the acid in your stomach making it less likely for acid to reflux into the esophagus.

Histamine-2 receptor blockers are also available over the counter. This medication prevents acid production. These must be taken at least 1 hour before meals since they can only prevent acid from being produced, not eliminate it if it already exists.

Lifestyle Changes

Eating and then lying down right after can make it easier for the acid in your stomach to be available to reflux into the esophagus. If you eat and then lie down, the body is producing acid to digest the food so there is plenty available when fluids are refluxing into the esophagus. It's best if your stomach is empty when lying down. But, if the stomach is full, it would be helpful if you elevate the head of your bed 6 inches so gravity can help keep the acid down.

Don't eat large meals. An over full stomach needs more acid to digest, meaning more acid to reflux into the esophagus.

Avoid Fatty foods or spicy foods, Citrus fruits, Onions,Tomato products, Coffee, Caffeinated tea, Alcoholic beverages, Chocolate, mints or peppermints, and Pepper. These foods weaken the lower esophageal sphincter, causing acid reflux.

Stop smoking, this also weakens the lower esophageal sphincter causing acid reflux.

Stay fit and exercise regularly(but not on a full stomach) since overweight people are more likely to suffer from acid reflux than someone who is in shape.

ACID REFLUX TREATMENTS

Acid reflux can't be cured, but it can be treated for relief. There are many ways to relieve the discomfort of acid reflux without a doctors help. These treatments include certain lifestyle changes and over the counter medications. If these treatments don't work, then a doctor may prescribe a medication for acid reflux relief.

What is a reasonable approach to the management of GERD?

There are several ways to approach the evaluation and management of GERD. The approach depends primarily on the frequency and severity of symptoms, the adequacy of the response to treatment, and the presence of complications.

For infrequent heartburn, the most common symptom of GERD, life-style changes and an occasional antacid may be all that is necessary. If heartburn is frequent, daily non-prescription-strength (over-the-counter) H2 antagonists may be necessary. A foam barrier also can be used with the antacid or H2 antagonist.

If life-style changes and antacids, non-prescription H2 antagonists, and a foam barrier do not adequately relieve heartburn, it is time to see a physician for further evaluation and to consider prescription-strength drugs. The evaluation by the physician should include an assessment for possible complications of GERD based on the presence of such symptoms or findings as cough, asthma, hoarseness, sore throat, difficulty swallowing, unexplained lung infections, or anemia (due to bleeding from esophageal inflammation or ulceration). Clues to the presence of diseases that may mimic GERD, such as gastric or duodenal ulcers and esophageal motility disorders, should be sought.

If there are no symptoms or signs of complications and no suspicion of other diseases, a therapeutic trial of acid suppression with H2 antagonists often is used. If H2 antagonists are not adequately effective, a second trial, this time with the more potent PPIs, can be given. Sometimes, a trial of treatment begins with a PPI and skips the H2 antagonist. If treatment relieves the symptoms completely, no further evaluation may be necessary and the effective drug, the H2 antagonist or PPI, is continued. As discussed above, however, there are potential problems with this commonly used approach and some physicians would recommend a further evaluation for almost all patients they see.

If at the time of evaluation, there are symptoms or signs that suggest complicated GERD or a disease other than GERD, or if the relief of symptoms with H2 antagonists or PPIs is not satisfactory, a further evaluation by endoscopy (EGD) definitely should be done.

There are several possible results of endoscopy and each requires a different approach to treatment. If the esophagus is normal and no other diseases are found, the goal of treatment simply is to relieve symptoms. Therefore, prescription strength H2 antagonists or PPIs are appropriate. If damage to the esophagus (esophagitis or ulceration) is found, the goal of treatment is healing the damage. In this case, PPIs are preferred over H2 antagonists because they are more effective for healing.

If complications of GERD, such as stricture or Barrett's esophagus are found, treatment with PPIs also is more appropriate. However, the adequacy of the PPI treatment probably should be evaluated with a 24-hour ph study during treatment with the PPI. (With PPIs, although the amount of acid reflux may be reduced enough to control symptoms, it may still be abnormally high. Therefore, judging the adequacy of suppression of acid reflux by only the response of symptoms to treatment is not satisfactory.) Strictures may also need to be treated by endoscopic dilatation (widening) of the esophageal narrowing. With Barrett's esophagus, periodic endoscopic examination should be done to identify pre-malignant changes in the esophagus.

If symptoms of GERD do not respond to maximum doses of PPI, there are two options for management. The first is to perform 24-hour ph testing to determine whether the PPI is ineffective or if a disease other than GERD is likely to be present. If the PPI is ineffective, a higher dose of PPI may be tried. The second option is to go ahead without 24 hour ph testing and to increase the dose of PPI. Another alternative is to add another drug to the PPI that works in a way that is different from the PPI, for example, a pro-motility drug or a foam barrier. If necessary, all three types of drugs can be used. If there is not a satisfactory response to this maximal treatment, 24 hour ph testing should be done.

Who should consider surgery or, perhaps, endoscopic treatment for GERD? (As mentioned previously, the effectiveness of the recently developed endoscopic treatments remains to be determined.) Patients should consider surgery if they have regurgitation that cannot be controlled with drugs. This recommendation is particularly important if the regurgitation results in infections in the lungs or occurs at night when aspiration into the lungs is more likely. Patients also should consider surgery if they require large doses of PPI or multiple drugs to control their reflux. Still, it is debated whether or not a desire to be free of the need to take life-long drugs to prevent symptoms of GERD is by itself a satisfactory reason for having surgery.

Some physicians--primarily surgeons--recommend that all patients with Barrett's esophagus should have surgery. This recommendation is based on the belief that surgery is more effective than treatment with drugs in preventing both the reflux and the cancerous changes in the esophagus. There are no studies, however, demonstrating the superiority of surgery over drugs for the treatment of GERD and its complications. Moreover, the effectiveness of drug treatment can be monitored with 24 hour ph testing

Emptying of the stomach

Most reflux during the day occurs after meals. This reflux probably is due to transient LES relaxations that are caused by distention of the stomach with food. A minority of patients with GERD, about 20%, has been found to have stomachs that empty abnormally slowly after a meal. The slower emptying of the stomach prolongs the distention of the stomach with food after meals. Therefore, the slower emptying prolongs the period of time during which reflux is more likely to occur.

Esophageal contractions

As previously mentioned, swallows are important in eliminating acid in the esophagus. Swallowing causes a ring-like wave of contraction of the esophageal muscles, which narrows the lumen (inner cavity) of the esophagus. The contraction, referred to as peristalsis, begins in the upper esophagus and travels to the lower esophagus. It pushes food, saliva, and whatever else is in the esophagus into the stomach.

When the wave of contraction is defective, refluxed acid is not pushed back into the stomach. In patients with GERD, several abnormalities of contraction have been described. For example, waves of contraction may not begin after each swallow or the waves of contraction may die out before they reach the stomach. Also, the pressure generated by the contractions may be too weak to push the acid back into the stomach. Such abnormalities of contraction, which reduce the clearance of acid from the esophagus, are found frequently in patients with GERD. In fact, they are found most frequently in those patients with the most severe GERD. The effects of abnormal esophageal contractions would be expected to be worse at night when gravity is not helping to return refluxed acid to the stomach. Note that smoking also substantially reduces the clearance of acid from the esophagus. This effect continues for at least 6 hours after the last cigarette.

Hiatal hernia

Hiatal hernias contribute to reflux, although the way in which they contribute is not clear. A majority of patients with GERD have hiatal hernias, but many do not. Therefore, it is not necessary to have a hiatal hernia in order to have GERD. Moreover, many people have hiatal hernias but do not have GERD. It is not known for certain how or why hiatal hernias develop.

Normally, the LES is located at the same level where the esophagus passes from the chest through the diaphragm and into the abdomen. (The diaphragm is a muscular, horizontal partition that separates the chest from the abdomen.) When there is a hiatal hernia, a small part of the upper stomach that attaches to the esophagus pushes up through the diaphragm. As a result, a small part of the stomach and the LES come to lie in the chest, and the LES is no longer at the level of the diaphragm.

It appears that the diaphragm that surrounds the LES is important in preventing reflux. That is, in individuals without hiatal hernias, the diaphragm surrounding the esophagus is continuously contracted, but then relaxes with swallows, just like the LES. Note that the effects of the LES and diaphragm occur at the same location in patients without hiatal hernias. Therefore, the barrier to reflux is equal to the sum of the pressures generated by the LES and the diaphragm. When the LES moves into the chest with a hiatal hernia, the diaphragm and the LES continue to exert their pressures and barrier effect. However, they now do so at different locations. Consequently, the pressures are no longer additive. Instead, a single, high-pressure barrier to reflux is replaced by two barriers of lower pressure, and reflux thus occurs more easily. So, decreasing the pressure barrier is one way that an hiatal hernia can contribute to reflux.

There is a second way in which hiatal hernias might contribute to reflux. When a hiatal hernia is present, there is a hernial sac, which is a small pouch of stomach above the diaphragm. The sac is pinched off from the esophagus above by the LES and from the stomach below by the diaphragm. What's important about this situation is that the sac can trap acid that comes from the stomach. This trap keeps the acid close to the esophagus. As a result, it is easier for the acid to reflux when the LES relaxes with a swallow or a transient relaxation.

Finally, there is a third way in which hiatal hernias might contribute to reflux. The esophagus normally joins the stomach obliquely, which means not straight on or at a 90-degree angle. Due to this oblique angle of entry, a flap of tissue is formed between the stomach and esophagus. This flap of tissue is believed to act like a valve, shutting off the esophagus from the stomach and preventing reflux. When there is a hiatal hernia, the entry of the esophagus into the stomach is pulled up into the chest. Therefore, the valve-like flap is distorted or disappears and it no longer can help prevent reflux.

Lower esophageal sphincter

The action of the lower esophageal sphincter (LES) is perhaps the most important factor (mechanism) for preventing reflux. The esophagus is a muscular tube that extends from the lower throat to the stomach. The LES is a specialized ring of muscle that surrounds the lower-most end of the esophagus where it joins the stomach. The muscle that makes up the LES is active most of the time. This means that it is contracting and closing off the passage from the esophagus into the stomach. This closing of the passage prevents reflux. When food or saliva is swallowed, the LES relaxes for a few seconds to allow the food or saliva to pass from the esophagus into the stomach, and then it closes again.

Several different abnormalities of the LES have been found in patients with GERD. Two of them involve the function of the LES. The first is abnormally weak contraction of the LES, which reduces its ability to prevent reflux. The second is abnormal relaxations of the LES, called transient LES relaxations. They are abnormal in that they do not accompany swallows and they last for a long time, up to several minutes. These prolonged relaxations allow reflux to occur more easily. The transient LES relaxations occur in patients with GERD most commonly after meals when the stomach is distended with food. Transient LES relaxations also occur in individuals without GERD, but they are infrequent.

The most recently-described abnormality in patients with GERD is laxity of the LES. Specifically, similar distending pressures open the LES more in patients with GERD than in individuals without GERD. At least theoretically, this would allow easier opening of the LES and/or greater backward flow of acid into the esophagus when the LES is open.

What causes GERD?

The cause of GERD is complex. There probably are multiple causes, and different causes may be operative in different individuals or even in the same individual at various times. A small number of patients with GERD produce abnormally large amounts of acid, but this is uncommon and not a contributing factor in the vast majority of patients. The factors that contribute to causing GERD are the lower esophageal sphincter, hiatal hernias, esophageal contractions, and emptying of the stomach.

Acid perfusion test

The acid perfusion (Bernstein) test is used to determine if chest pain is caused by acid reflux. For the test, a thin tube is passed through one nostril, down the back of the throat, and into the middle of the esophagus. A dilute, acid solution and a physiologic (normal) salt solution are alternately poured (perfused) through the catheter and into the esophagus. The patient is unaware of which solution is being infused. If the perfusion with acid provokes the patient's usual pain and perfusion of the salt solution produces no pain, it is likely that the patient's pain is caused by acid reflux.

The acid perfusion test, however, is used only rarely. A better test for correlating pain and acid reflux is a 24-hour esophageal ph study during which patients note when they are having pain. It then can be determined from the ph recording if there was an episode of acid reflux at the time of the pain. This is the preferable way of deciding if acid reflux is causing a patient's pain.

Gastric emptying studies

Gastric emptying studies are studies that determine how well food empties from the stomach. As discussed above, about 20 % of patients with GERD have a slow emptying of the stomach that may be contributing to the reflux of acid. For gastric emptying studies, the patient eats a meal that is labeled with a radioactive substance. A sensor that is similar to a Geiger counter is placed over the stomach to measure how quickly the radioactive substance in the meal empties from the stomach.

Information from the emptying study can be useful for managing patients with GERD. For example, if a patient with GERD continues to have symptoms despite treatment with the usual medications, doctors might prescribe other medications that speed-up emptying of the stomach. Alternatively, in conjunction with GERD surgery, they might do a surgical procedure that promotes a more rapid emptying of the stomach. Nevertheless, it is still debated whether a finding of reduced gastric emptying should prompt changes in the surgical treatment of GERD.

Symptoms of nausea, vomiting, and regurgitation may be due either to abnormal gastric emptying or GERD. An evaluation of gastric emptying, therefore, may be useful in identifying patients whose symptoms are due to abnormal emptying rather than to GERD.

Esophageal motility testing

Esophageal motility testing determines how well the muscles of the esophagus are working. For motility testing, a thin tube (catheter) is passed through a nostril, down the back of the throat, and into the esophagus. On the part of the catheter that is inside the esophagus are sensors that sense pressure. When the muscle of the esophagus contracts, a pressure is generated within the esophagus that is detected by the sensors on the catheter. The end of the catheter that protrudes from the nostril is attached to a recorder that records the pressure. During the test, the pressure at rest and the relaxation of the lower esophageal sphincter are evaluated. The patient then swallows sips of water to evaluate the contractions of the esophagus.

Esophageal motility testing has two important uses in evaluating GERD. The first is in evaluating symptoms that do not respond to treatment for GERD. The abnormal function of the esophageal muscle sometimes causes symptoms that resemble the symptoms of GERD. Motility testing can identify these abnormalities and lead to a diagnosis of an esophageal motility disorder. The second use is evaluation prior to surgical or endoscopic treatment for GERD. In this situation, the purpose is to identify patients who also have motility disorders of the esophageal muscle. The reason for this is that in patients with motility disorders, some surgeons will modify the type of surgery they perform for GERD.

Esophageal acid testing

Esophageal acid testing is considered a "gold standard" for diagnosing GERD. As discussed above, the reflux of acid is common in the general population. However, patients with the symptoms or complications of GERD have reflux of more acid than individuals without the symptoms or complications of GERD. Moreover, normal individuals and patients with GERD can be distinguished fairly well from each other by the amount of time that the esophagus contains acid.

The amount of time that the esophagus contains acid is determined by a test called a 24-hour esophageal ph test. (Ph is a mathematical way of expressing the amount of acidity.) For this test, a small tube (catheter) is passed through the nose and positioned in the esophagus. On the tip of the catheter is a sensor that senses acid. The other end of the catheter exits from the nose, wraps back over the ear, and travels down to the waist, where it is attached to a recorder. Each time acid refluxes back into the esophagus from the stomach, it stimulates the sensor and the recorder records the episode of reflux. After a 20 to 24 hour period of time, the catheter is removed and the record of reflux from the recorder is analyzed.

There are problems with using ph testing for diagnosing GERD. Despite the fact that normal individuals and patients with GERD can be separated fairly well on the basis of ph studies, the separation is not perfect. Therefore, some patients with GERD will have normal amounts of acid reflux and some patients without GERD will have abnormal amounts of acid reflux. It requires something other than the ph test to confirm the presence of GERD, for example, typical symptoms, response to treatment, or the presence of complications of GERD.

Ph testing has uses in the management of GERD other than just diagnosing GERD. For example, the test can help determine why GERD symptoms do not respond to treatment. Perhaps 10 to 20 percent of patients will not have their symptoms substantially improved by treatment for GERD. This lack of response to treatment could be caused by ineffective treatment. This means that the medication is not adequately suppressing the production of acid by the stomach and thereby is not reducing acid reflux. Alternatively, the lack of response can be explained by a wrong diagnosis of GERD. In both of these situations, the ph test can be very useful. If testing reveals substantial reflux of acid while medication is continued, then the treatment is ineffective and will need to be changed. If testing reveals good acid suppression with minimal reflux of acid, the diagnosis of GERD is likely to be wrong and other causes for the symptoms need to be sought.

Ph testing also can be used to help evaluate whether reflux is the cause of symptoms (usually heartburn). To make this evaluation, while the 24-hour ph testing is being done, patients record each time they have symptoms. Then, when the test is being analyzed, it can be determined whether or not acid reflux occurred at the time of the symptoms. If reflux did occur at the same time as the symptoms, then reflux is likely to be the cause of the symptoms. If there was no reflux at the time of symptoms, then reflux is unlikely to be the cause of the symptoms.

Lastly, ph testing can be used to evaluate patients prior to endoscopic or surgical treatment for GERD. As discussed above, some 20 % of patients will have a decrease in their symptoms even though they don't have GERD (the placebo effect). Prior to endoscopic or surgical treatment, it is important to identify these patients because they are not likely to benefit from the treatments. The ph study can be used to identify these patients because they will have normal amounts of acid reflux.

A newer method for prolonged measurement (48 hours) of acid exposure in the esophagus utilizes a small, wireless capsule that is attached to the esophagus just above the LES. The capsule is passed to the lower esophagus by a tube inserted through either the mouth or the nose. After the capsule is attached to the esophagus, the tube is removed. The capsule measures the acid refluxing into the esophagus and transmits this information to a receiver that is worn at the waist. After the study, usually after 48 hours, the information from the receiver is downloaded into a computer and analyzed. The capsule falls off of the esophagus after 3-5 days and is passed in the stool. (The capsule is not reused.) The advantage of the capsule over standard ph testing is that there is no discomfort from a catheter that passes through the throat and nose. Moreover, with the capsule, patients look normal (they don't have a catheter protruding from their noses) and are more likely to go about their daily activities, for example, go to work, without feeling self-conscious. Capsule ph testing is expensive. Sometimes the capsule does not attach to the esophagus or falls off prematurely. For periods of time the receiver may not receive signals from the capsule, and some of the information about reflux of acid may be lost. Occasionally there is pain with swallowing after the capsule has been placed. Use of the capsule is an exciting use of new technology, but with its inherent problems and lack of widespread use and evaluation, it is not yet clear what its role should be.

Examination of the throat and larynx

When GERD affects the throat or larynx and causes symptoms of cough, hoarseness, or sore throat, patients often visit an ear, nose, and throat (ENT) specialist. The ENT specialist frequently finds signs of inflammation of the throat or larynx. Although diseases of the throat or larynx usually are the cause of the inflammation, sometimes GERD can be the cause. Accordingly, ENT specialists often try acid-suppressing treatment to confirm the diagnosis of GERD. This approach, however, has the same problems that, as discussed above, result from using the response to treatment to confirm GERD.

X-rays

Before the introduction of endoscopy, an x-ray of the esophagus (called an esophagram) was the only means of diagnosing GERD. Patients swallowed barium (contrast material), and x-rays of the barium-filled esophagus were then taken. The problem with the esophagram was that it was an insensitive test for diagnosing GERD. That is, it failed to find signs of GERD in many patients who had GERD because the patients had little or no damage to the lining of the esophagus. The x-rays were able to show only the infrequent complications of GERD, for example, ulcers and strictures. X-rays have been abandoned as a means of diagnosing GERD, although they still can be useful in addition to endoscopy in the evaluation of complications.

Endoscopy

Upper gastrointestinal endoscopy (also known as esophago-gastro-duodenoscopy or EGD) is a common way of diagnosing GERD. EGD is a procedure in which a tube containing an optical system for visualization is swallowed. As the tube progresses down the gastrointestinal tract, the lining of the esophagus, stomach, and duodenum can be examined.

The esophagus of most patients with symptoms of reflux looks normal. Therefore, in most patients, endoscopy will not help in the diagnosis of GERD. However, sometimes the lining of the esophagus appears inflamed (esophagitis). Moreover, if erosions (superficial breaks in the esophageal lining) or ulcers (deeper breaks in the lining) are seen, a diagnosis of GERD can be made. Endoscopy will also identify several of the complications of GERD, specifically, ulcers, strictures, and Barrett's esophagus. Biopsies also may be obtained. Finally, other problems that may be causing GERD-like symptoms-for example ulcers, inflammation, or cancers-can be diagnosed in the stomach or duodenum.

Symptoms and response to treatment (therapeutic trial)

The usual way that GERD is diagnosed-or at least suspected-is by its characteristic symptom, heartburn. Heartburn is most frequently described as a sub-sternal (under the middle of the chest) burning that occurs after meals and often worsens when lying down. To confirm the diagnosis, physicians often treat patients with medications to suppress the production of acid by the stomach. If the heartburn then is diminished to a large extent, the diagnosis of GERD is considered confirmed. This approach of making a diagnosis on the basis of a response of the symptoms to treatment is commonly called a therapeutic trial.

There are problems with this approach, however, primarily because it does not include diagnostic tests. For instance, patients who have conditions that can mimic GERD, specifically duodenal or gastric (stomach) ulcers, also can actually respond to such treatment. In this situation, if the physician assumes that the problem is GERD, he or she will not look for the cause of the ulcer disease. For example, a type of infection called Helicobacter pylori, or non-steroidal anti-inflammatory drugs (e.g., ibuprofen), can also cause ulcers and these conditions would be treated differently from GERD.

Moreover, as with any treatment, there is perhaps a 20% placebo effect, which means that 20% of patients will respond to a placebo (inactive) pill or, indeed, to any treatment. This means that 20% of patients who have causes of their symptoms other than GERD (or ulcers) will have a decrease in their symptoms after receiving the treatment for GERD. Thus, on the basis of their response to treatment (the therapeutic trial), these patients then will continue to be treated for GERD, even though they do not have GERD. What's more, the true cause of their symptoms will not be pursued further.

Importance of non-acidic reflux

Acid reflux clearly is injurious to the esophagus. What about non-acid reflux? As previously discussed, there are potentially injurious agents that can be refluxed other than acid, for example, bile. Esophageal acid testing accurately identifies acid reflux and has been extremely useful in studying the injurious effects of acid. Until recently, however, it has been impossible or difficult to accurately identify non-acid reflux and, therefore, to study whether or not non-acid reflux is injurious or can cause symptoms. A new technology allows the accurate determination of non-acid reflux. This technology uses the measurement of impedence changes within the esophagus to identify reflux of liquid, be it acid or non-acid. By combining measurement of impedence and ph it is possible to identify reflux and to tell if the reflux is acid or non-acid. It is too early to know how important non-acid reflux is in causing esophageal damage, symptoms, or complications, but there is little doubt that this new technology will be able to resolve the issues surrounding non-acid reflux.
GERD At A Glance

* GERD is a condition in which the acidified liquid contents of the stomach backs up into the esophagus.
* The causes of GERD include an abnormal lower esophageal sphincter, hiatal hernia, abnormal esophageal contractions, and slow emptying of the stomach.
* GERD may damage the lining of the esophagus, thereby causing inflammation (esophagitis), although usually it does not.
* The symptoms of uncomplicated GERD are heartburn, regurgitation, and nausea.
* Complications of GERD include ulcers and strictures of the esophagus, Barrett's esophagus, cough and asthma, throat and laryngeal inflammation, inflammation and infection of the lungs, and collection of fluid in the sinuses and middle ear.
* Barrett's esophagus is a pre-cancerous condition that requires periodic endoscopic surveillance for the development of cancer.
* GERD may be diagnosed or evaluated by a trial of treatment, endoscopy, biopsy, x-ray, examination of the throat and larynx, 24 hour esophageal acid testing, esophageal motility testing, emptying studies of the stomach, and esophageal acid perfusion.
* GERD is treated with life-style changes, antacids, histamine antagonists (H2 blockers), proton pump inhibitors (PPIs), pro-motility drugs, foam barriers, surgery, and endoscopy.

Management of Barrett's esophagus

Only 10% of patients with GERD have Barrett's esophagus. Some physicians have suggested that all patients with GERD should be screened with endoscopy for the presence of Barrett's. Then, if they have Barrett's, they can undergo regular endoscopic surveillance for the development of cancer. For most physicians, however, screening all patients with GERD seems unreasonable since it would require a tremendous increase in the cost of care for patients with GERD. One study suggested that cancer of the esophagus develops more often in patients who have had heartburn more frequently and/or for a longer period of time. Accordingly, perhaps screening for Barrett's esophagus is realistic only for those GERD patients with frequent and long-standing heartburn. However, studies have yet to demonstrate the value of this approach.

Periodic surveillance for cancer is recommended in patients with Barrett's esophagus. Yet, there also may be a role for other treatments. For example, since reflux is believed to be the cause of Barrett's esophagus, it is possible that early and aggressive treatment of GERD (elimination of virtually all reflux) will prevent the progression of Barrett's esophagus to cancer. Additionally, newer experimental techniques that destroy the Barrett's cells (e.g., laser or electrocautery) also may prevent the progression to cancer. Studies are needed in Barrett's to evaluate both the aggressive therapy of GERD and the destructive therapy of Barrett's for the prevention of esophageal cancer.

Although Barrett's esophagus clearly is a pre-cancerous condition, only a minority of patients with Barrett's esophagus will develop cancer. Moreover, periodic endoscopic surveillance for cancer is expensive and each endoscopy puts a patient at a slight risk for complications of endoscopy. Thus, investigators are seeking better ways of determining which patients with Barrett's are more likely to develop cancer and need more frequent endoscopic surveillance and which patients need infrequent surveillance or, perhaps, no surveillance. Accordingly, they are evaluating newer techniques (for example, analysis of the cells' DNA) to examine in more detail the altered cells in the esophagus of patients with Barrett's. In this way, the investigators are trying to identify cellular changes that can predict the later development of cancer.

The standard treatment for early cancers in Barrett's esophagus is surgical removal of a portion of the esophagus (esophagectomy). This is major surgery. However, several experimental procedures that do not require surgery are being evaluated for treating early cancers. For example, photodynamic therapy is a procedure in which the cancers are destroyed with light after they have been sensitized to the light by the intravenous injection of light-sensitizing chemicals.