Signs and symptoms

Adults
The most-common symptoms of GERD are:

Heartburn Regurgitation Trouble swallowing (dysphagia)

Less-common symptoms include:

Pain with swallowing/sore throat (odynophagia) Increased salivation (also known as water brash) Nausea[2] Chest pain

GERD sometimes causes injury of the esophagus. These injuries may include:

Reflux esophagitis necrosis of esophageal epithelium causing ulcers near the junction of the stomach and esophagus. Esophageal strictures the persistent narrowing of the esophagus caused by refluxinduced inflammation. Barrett's esophagus intestinal metaplasia (changes of the epithelial cells from squamous to intestinal columnar epithelium) of the distal esophagus.[3] Esophageal adenocarcinoma a rare form of cancer.[2]

Several other atypical symptoms are associated with GERD, but there is good evidence for causation only when they are accompanied by esophageal injury. These symptoms are:

Chronic cough Laryngitis (hoarseness, throat clearing) Asthma Erosion of dental enamel Dentine hypersensitivity Sinusitis and damaged teeth[4] Pharyngitis Globus pharingeus and globus hystericus (condition of feeling of choking, foreign object in throat)

Some people have proposed that symptoms such as sinusitis, recurrent ear infections, and idiopathic pulmonary fibrosis are due to GERD; however, a causative role has not been established.[2]

Children

GERD may be difficult to detect in infants and children, since they cannot describe what they are feeling and indicators must be observed. Symptoms may vary from typical adult symptoms. GERD in children may cause repeated vomiting, effortless spitting up, coughing, and other respiratory problems such as wheezing. Inconsolable crying, refusing food, crying for food and then pulling off the bottle or breast only to cry for it again, failure to gain adequate weight, bad breath, and belching or burping are also common. Children may have one symptom or many; no single symptom is universal in all children with GERD. It is estimated that of the approximately 4 million babies born in the U.S. each year, up to 35% of them may have difficulties with reflux in the first few months of their life, known as spitting up.[5] One theory for this is the "4th trimester theory" which notes that most animals are born with significant mobility, but humans are relatively helpless at birth, and suggests that there may have once been a fourth trimester, but that children began to be born earlier, evolutionarily, to accommodate the development of larger heads and brains and allow them to pass through the birth canal [6] and this leaves them with partially undeveloped digestive systems. Most children will outgrow their reflux by their first birthday. However, a small but significant number of them will not outgrow the condition. This is particularly true where there is a family history of GERD present.

Barrett's esophagus
Main article: Barrett's Esophagus GERD may lead to Barrett's esophagus, a type of intestinal metaplasia,[3] which is in turn a precursor condition for carcinoma. The risk of progression from Barrett's to dysplasia is uncertain but is estimated at about 20% of cases.[7] Due to the risk of chronic heartburn progressing to Barrett's, EGD every five years is recommended for patients with chronic heartburn, or who take drugs for chronic GERD.[citation needed]

Diagnosis

Endoscopic image of peptic stricture, or narrowing of the esophagus near the junction with the stomach. This is a complication of chronic gastroesophageal reflux disease and can be a cause of dysphagia or difficulty swallowing.

X-ray of the abdomen and chest in a patient with a gastrostomy. Radiocontrast was injected into the stomach and quickly seen migrating upwards through the entire esophagus. The patient had severe reflux esophagitis (Los Angeles grade D). A detailed historical knowledge is vital for an accurate diagnosis. Useful investigations may include ambulatory Esophageal pH Monitoring, barium swallow X-rays, esophageal manometry, and Esophagogastroduodenoscopy (EGD). The current gold standard for diagnosis of GERD is esophageal pH monitoring. It is the most objective test to diagnose the reflux disease and it also allows to monitor GERD patients in regards of their response to medical or surgical treatment. One practice for diagnosis of GERD is a short-term treatment with proton pump inhibitors, with improvement in symptoms suggesting a positive diagnosis. According to a systematic review, short-term treatment with proton pump inhibitors may help predict abnormal 24-hr pH monitoring results among patients with symptoms suggestive of GERD.[8] In this study, the positive likelihood ratio of a symptomatic response detecting GERD ranged from 1.63 to 1.87, with sensitivity of 0.78 though specificity was only 0.54. In general, an EGD is done when the patient either does not respond well to treatment or has alarm symptoms including dysphagia, anemia, blood in the stool (detected chemically), wheezing, weight loss, or voice changes. Some physicians advocate either once-in-a-lifetime or 5/10-yearly endoscopy for patients with longstanding GERD, to evaluate the possible presence of dysplasia or Barrett's esophagus, a precursor lesion for esophageal adenocarcinoma.[9] Esophagogastroduodenoscopy (EGD) (a form of endoscopy) involves insertion of a thin scope through the mouth and throat into the esophagus and stomach (often while the patient is sedated) in order to assess the internal surfaces of the esophagus, stomach, and duodenum.

Biopsies can be performed during gastroscopy and these may show:

Edema and basal hyperplasia (non-specific inflammatory changes) Lymphocytic inflammation (non-specific) Neutrophilic inflammation (usually due to reflux or Helicobacter gastritis) Eosinophilic inflammation (usually due to reflux). The presence of intraepithelial eosinophils may suggest a diagnosis of eosinophilic esophagitis (EE)if eosinophils are present in high enough numbers. Less than 20 eosinophils per high-power microscopic field in the distal esophagus, in the presence of other histologic features of GERD, is more consistent with GERD than EE.[10] Goblet cell intestinal metaplasia or Barretts esophagus Elongation of the papillae Thinning of the squamous cell layer Dysplasia or pre-cancer Carcinoma

Reflux changes may be non-erosive in nature, leading to the entity "non-erosive reflux disease".

Causes
GERD is caused by a failure of the cardia. In healthy patients, the "Angle of His"the angle at which the esophagus enters the stomachcreates a valve that prevents duodenal bile, enzymes, and stomach acid from traveling back into the esophagus where they can cause burning and inflammation of sensitive esophageal tissue. Factors that can contribute to GERD:

Hiatal hernia, which increases the likelihood of GERD due to mechanical and motility factors.[11][12] Obesity: increasing body mass index is associated with more severe GERD.[13] In a large series of 2000 patients with symptomatic reflux disease, it has been shown that 13 % of changes in esophageal acid exposure is attributable to changes in body mass index.[14] Zollinger-Ellison syndrome, which can be present with increased gastric acidity due to gastrin production. Hypercalcemia, which can increase gastrin production, leading to increased acidity. Scleroderma and systemic sclerosis, which can feature esophageal dysmotility. The use of medicines such as prednisolone. Visceroptosis or Glnard syndrome, in which the stomach has sunk in the abdomen upsetting the motility and acid secretion of the stomach.

GERD has been linked to a variety of respiratory and laryngeal complaints such as laryngitis, chronic cough, pulmonary fibrosis, earache, and asthma, even when not clinically apparent. These atypical manifestations of GERD is commonly referred to as laryngopharyngeal reflux or as extraesophageal reflux disease (EERD). Factors that have been linked with GERD, but not conclusively:

Obstructive sleep apnea[15][16] Gallstones, which can impede the flow of bile into the Duodenum, which can affect the ability to neutralize gastric acid

In 1999, a review of existing studies found that, on average, 40% of GERD patients also had H. pylori infection.[17] The eradication of H. pylori can lead to an increase in acid secretion,[18] leading to the question of whether H. pylori-infected GERD patients are any different than noninfected GERD patients. A double-blind study, reported in 2004, found no clinically significant difference between these two types of patients with regard to the subjective or objective measures of disease severity.[19]

Prevention
GERD is largely preventable through changes in lifestyle, which are also used as treatment (see below). Sleep on the left side, or with your upper body raised. Relief is often found by raising the head of the bed to 30 degrees, raising the upper body with pillows, or sleeping sitting up.[20] The upper body must be raised, not just the head; pillows that only raise the head do little for heartburn and put strain on the neck. Sleeping on the left side also keeps gravity working for you, keeping your stomach below your esophagus.[21] Eat smaller meals. Eating a big meal causes excess stomach acid production, so attacks can be minimized by eating smaller meals. It is also important to avoid eating shortly before bedtime.[12] Lose weight. Gaining even a few pounds increases your risk of heartburn.[20] Exactly why isn't clear, but the leading theory is that more body fat puts more pressure on the stomach, which can cause highly acidic stomach contents to reflux to the lower esophageal sphincter. For the same reason, tight clothing around the abdomen can also increase the risk of heartburn. Avoid acidic and rich foods. Though less well supported by evidence,[20] a sufferer may benefit from avoiding foods that trigger their symptoms. These commonly include acidic fruit or juices, fatty foods, coffee, tea, onions, peppermint, chocolate, especially shortly before bedtime.[22] Avoid consuming irritating substances that can trigger heartburn symptoms such as caffeine, nicotine, and alcohol

Treatment
Three types of treatments exist for GERD. These include lifestyle modifications, medications, and surgery.

Lifestyle
Diet

Certain foods and lifestyle are considered to promote gastroesophageal reflux, but a 2006 review suggested that evidence for most dietary interventions is anecdotal; only weight loss and elevating the head of the bed were supported by evidence.[20] A subsequent randomized crossover study showed benefit by avoiding eating two hours before bedtime.[12] The following may exacerbate the symptoms of GERD:

Antacids based on calcium carbonate (but not aluminium hydroxide) were found to actually increase the acidity of the stomach. However, all antacids reduced acidity in the lower esophagus, so the net effect on GERD symptoms may still be positive.[23] Smoking reduces lower esophageal sphincter competence, thus allowing acid to enter the esophagus.

Position Sleeping on the left side has been shown to reduce nighttime reflux episodes in patients.[21] A meta-analysis suggested that elevating the head of the bed is an effective therapy, although this conclusion was only supported by nonrandomized studies.[20] The head of the bed can be elevated by plastic or wooden bed risers that support bed posts or legs, a therapeutic bed wedge pillow, a wedge or an inflatable mattress lifter that fits in between mattress and box spring or a hospital bed with an elevate feature. The height of the elevation is critical and must be at least 6 to 8 inches (15 to 20 cm) to be at least minimally effective to prevent the backflow of gastric fluids. Some innerspring mattresses do not work well when inclined and may cause back pain; some prefer foam mattresses. Some practitioners use higher degrees of incline than provided by the commonly suggested 6 to 8 inches (15 to 20 cm) and claim greater success.

Medications
A number of drugs are approved to treat GERD, and are among the most prescribed medication in Western countries. Helicobacter pylori previously named Campylobacter pyloridis, is a Gram-negative, microaerophilic bacterium found in the stomach, has been implicated with GERD and can be easily treated with antibiotics.

Proton pump inhibitors (such as omeprazole, esomeprazole, pantoprazole, lansoprazole, and rabeprazole) are the most effective in reducing gastric acid secretion. These drugs stop acid secretion at the source of acid production, i.e., the proton pump. Gastric H2 receptor blockers (such as ranitidine, famotidine and cimetidine) can reduce gastric secretion of acid. These drugs are technically antihistamines. They relieve complaints in about 50% of all GERD patients. Compared to placebo (which also is associated with symptom improvement), they have a number needed to treat (NNT) of eight (8).[24] Antacids before meals or symptomatically after symptoms begin can reduce gastric acidity (increase pH).

Alginic acid (Gaviscon) may coat the mucosa as well as increase pH and decrease reflux. A meta-analysis of randomized controlled trials suggests alginic acid may be the most effective of non-prescription treatments with a NNT of four.[24] Prokinetics strengthen the lower esophageal sphincter (LES) and speed up gastric emptying. Cisapride, a member of this class, was withdrawn from the market for causing long QT syndrome. Reglan (metoclopramide) is a prokinetic with a better side-effect profile. Sucralfate (Carafate) is also useful as an adjunct in helping to heal and prevent esophageal damage caused by GERD, however it must be taken several times daily and at least two (2) hours apart from meals and medications. Mosapride citrate is a 5-HT4 receptor agonist used outside the United States largely as a therapy for GERD and dyspepsia.[25] Baclofen is an agonist of GABAB receptor. In addition to its skeletal muscle relaxant properties, it has also been shown to decrease transient lower esophageal sphincter relaxations at a dose of 10mg given four times daily. Reductions in esophageal relaxation clinically reduce episodes of reflux.[26]

Clinical trials which compare GERD treatments head-to-head provide physicians with critical information. Unfortunately most pharmaceutical-company sponsored studies are conducted versus placebo and not an active control. However, the DIAMOND has shown rough equivalence of efficacy between a "step-up" approach to therapy (antacids, followed by histamine antagonists, followed by PPIs) and a "step-down" approach (the reverse). The primary endpoint of the study was treatment success after six months, and was achieved for 70% of patients in "step-down" versus 72% of patients in "step-up."[27]

Surgery
The standard surgical treatment is the Nissen fundoplication. In this procedure the upper part of the stomach is wrapped around the lower esophageal sphincter (LES) to strengthen the sphincter and prevent acid reflux and to repair a hiatal hernia. The procedure is often done laparoscopically.[28] When compared to medical management laparoscopic fundoplication had better results at 1 year.[29] In addition, laparoscopic fundoplication may reduce SF-36 score (quality of life questionnaire) among patients with gastro-esophageal reflux disease as compared to medical management according to a Cochrane systematic review of randomized controlled trials.[30] There were statistically significant improvements in quality of life at 3 months and 1 year after surgery compared to medical therapy, with an SF-36 general health score mean difference of -5.23 in favor of surgery.[citation needed] An obsolete treatment is vagotomy ("highly selective vagotomy"), the surgical removal of vagus nerve branches that innervate the stomach lining. This treatment has been largely replaced by medication. Another treatment is transoral incisionless fundoplication (TIF) with the use of a device called Esophyx, which allows doctors to rebuild the valve between the stomach and the esophagus by going through the esophagus.[31]

Other
In 2000 the U.S. Food and Drug Administration (FDA) approved two endoscopic devices to treat chronic heartburn. One system, Endocinch, puts stitches in the LES to create little pleats that help strengthen the muscle. However, long-term results were disappointing, and the device is no longer sold by Bard. Another, the Stretta Procedure, uses electrodes to apply radio frequency energy to the LES. The long-term outcomes of both procedures compared to a Nissen fundoplication are still being determined. Subsequently the NDO Surgical Plicator was cleared by the FDA for endoscopic GERD treatment. The Plicator creates a plication, or fold, of tissue near the gastroesophageal junction, and fixates the plication with a suture-based implant. The company ceased operations in mid 2008, and the device is no longer on the market.

What is GERD?
Gastroesophageal reflux disease (GERD) is a more serious form of gastroesophageal reflux (GER), which is common. GER occurs when the lower esophageal sphincter (LES) opens spontaneously, for varying periods of time, or does not close properly and stomach contents rise up into the esophagus. GER is also called acid reflux or acid regurgitation, because digestive juicescalled acidsrise up with the food. The esophagus is the tube that carries food from the mouth to the stomach. The LES is a ring of muscle at the bottom of the esophagus that acts like a valve between the esophagus and stomach. When acid reflux occurs, food or fluid can be tasted in the back of the mouth. When refluxed stomach acid touches the lining of the esophagus it may cause a burning sensation in the chest or throat called heartburn or acid indigestion. Occasional GER is common and does not necessarily mean one has GERD. Persistent reflux that occurs more than twice a week is considered GERD, and it can eventually lead to more serious health problems. People of all ages can have GERD. [Top]

What are the symptoms of GERD?

The main symptom of GERD in adults is frequent heartburn, also called acid indigestion burning-type pain in the lower part of the mid-chest, behind the breast bone, and in the midabdomen. Most children under 12 years with GERD, and some adults, have GERD without heartburn. Instead, they may experience a dry cough, asthma symptoms, or trouble swallowing. [Top]

What causes GERD?

The reason some people develop GERD is still unclear. However, research shows that in people with GERD, the LES relaxes while the rest of the esophagus is working. Anatomical abnormalities such as a hiatal hernia may also contribute to GERD. A hiatal hernia occurs when the upper part of the stomach and the LES move above the diaphragm, the muscle wall that separates the stomach from the chest. Normally, the diaphragm helps the LES keep acid from rising up into the esophagus. When a hiatal hernia is present, acid reflux can occur more easily. A hiatal hernia can occur in people of any age and is most often a normal finding in otherwise healthy people over age 50. Most of the time, a hiatal hernia produces no symptoms. Other factors that may contribute to GERD include

obesity pregnancy smoking

Common foods that can worsen reflux symptoms include

citrus fruits chocolate drinks with caffeine or alcohol fatty and fried foods garlic and onions mint flavorings spicy foods tomato-based foods, like spaghetti sauce, salsa, chili, and pizza

[Top]

What is GERD in children?

Distinguishing between normal, physiologic reflux and GERD in children is important. Most infants with GER are happy and healthy even if they frequently spit up or vomit, and babies usually outgrow GER by their first birthday. Reflux that continues past 1 year of age may be GERD. Studies show GERD is common and may be overlooked in infants and children. For example, GERD can present as repeated regurgitation, nausea, heartburn, coughing, laryngitis, or respiratory problems like wheezing, asthma, or pneumonia. Infants and young children may demonstrate irritability or arching of the back, often during or immediately after feedings. Infants with GERD may refuse to feed and experience poor growth. Talk with your childs health care provider if reflux-related symptoms occur regularly and cause your child discomfort. Your health care provider may recommend simple strategies for avoiding reflux, such as burping the infant several times during feeding or keeping the infant in an upright position for 30 minutes after feeding. If your child is older, your health care provider may recommend that your child eat small, frequent meals and avoid the following foods:

sodas that contain caffeine

chocolate peppermint spicy foods acidic foods like oranges, tomatoes, and pizza fried and fatty foods

Avoiding food 2 to 3 hours before bed may also help. Your health care provider may recommend raising the head of your child's bed with wood blocks secured under the bedposts. Just using extra pillows will not help. If these changes do not work, your health care provider may prescribe medicine for your child. In rare cases, a child may need surgery. For information about GER in infants, children, and adolescents, see the Gastroesophageal Reflux in Infants and Gastroesophageal Reflux in Children and Adolescents fact sheets from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). [Top]

How is GERD treated?

See your health care provider if you have had symptoms of GERD and have been using antacids or other over-the-counter reflux medications for more than 2 weeks. Your health care provider may refer you to a gastroenterologist, a doctor who treats diseases of the stomach and intestines. Depending on the severity of your GERD, treatment may involve one or more of the following lifestyle changes, medications, or surgery. Lifestyle Changes

If you smoke, stop. Avoid foods and beverages that worsen symptoms. Lose weight if needed. Eat small, frequent meals. Wear loose-fitting clothes. Avoid lying down for 3 hours after a meal. Raise the head of your bed 6 to 8 inches by securing wood blocks under the bedposts. Just using extra pillows will not help.

Medications Your health care provider may recommend over-the-counter antacids or medications that stop acid production or help the muscles that empty your stomach. You can buy many of these medications without a prescription. However, see your health care provider before starting or adding a medication. Antacids, such as Alka-Seltzer, Maalox, Mylanta, Rolaids, and Riopan, are usually the first drugs recommended to relieve heartburn and other mild GERD symptoms. Many brands on the market use different combinations of three basic salts magnesium, calcium, and aluminum with hydroxide or bicarbonate ions to neutralize the acid in your stomach. Antacids, however,

can have side effects. Magnesium salt can lead to diarrhea, and aluminum salt may cause constipation. Aluminum and magnesium salts are often combined in a single product to balance these effects. Calcium carbonate antacids, such as Tums, Titralac, and Alka-2, can also be a supplemental source of calcium. They can cause constipation as well. Foaming agents, such as Gaviscon, work by covering your stomach contents with foam to prevent reflux. H2 blockers, such as cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR), and ranitidine (Zantac 75), decrease acid production. They are available in prescription strength and over-thecounter strength. These drugs provide short-term relief and are effective for about half of those who have GERD symptoms. Proton pump inhibitors include omeprazole (Prilosec, Zegerid), lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex), and esomeprazole (Nexium), which are available by prescription. Prilosec is also available in over-thecounter strength. Proton pump inhibitors are more effective than H2 blockers and can relieve symptoms and heal the esophageal lining in almost everyone who has GERD. Prokinetics help strengthen the LES and make the stomach empty faster. This group includes bethanechol (Urecholine) and metoclopramide (Reglan). Metoclopramide also improves muscle action in the digestive tract. Prokinetics have frequent side effects that limit their usefulness fatigue, sleepiness, depression, anxiety, and problems with physical movement. Because drugs work in different ways, combinations of medications may help control symptoms. People who get heartburn after eating may take both antacids and H2 blockers. The antacids work first to neutralize the acid in the stomach, and then the H2 blockers act on acid production. By the time the antacid stops working, the H2 blocker will have stopped acid production. Your health care provider is the best source of information about how to use medications for GERD. [Top]

What if GERD symptoms persist?

If your symptoms do not improve with lifestyle changes or medications, you may need additional tests.

Barium swallow radiograph uses x rays to help spot abnormalities such as a hiatal hernia and other structural or anatomical problems of the esophagus. With this test, you drink a solution and then x rays are taken. The test will not detect mild irritation, although stricturesnarrowing of the esophagusand ulcers can be observed. Upper endoscopy is more accurate than a barium swallow radiograph and may be performed in a hospital or a doctors office. The doctor may spray your throat to numb it and then, after lightly sedating you, will slide a thin, flexible plastic tube with a light and

lens on the end called an endoscope down your throat. Acting as a tiny camera, the endoscope allows the doctor to see the surface of the esophagus and search for abnormalities. If you have had moderate to severe symptoms and this procedure reveals injury to the esophagus, usually no other tests are needed to confirm GERD. The doctor also may perform a biopsy. Tiny tweezers, called forceps, are passed through the endoscope and allow the doctor to remove small pieces of tissue from your esophagus. The tissue is then viewed with a microscope to look for damage caused by acid reflux and to rule out other problems if infection or abnormal growths are not found.

pH monitoring examination involves the doctor either inserting a small tube into the esophagus or clipping a tiny device to the esophagus that will stay there for 24 to 48 hours. While you go about your normal activities, the device measures when and how much acid comes up into your esophagus. This test can be useful if combined with a carefully completed diary recording when, what, and amounts the person eatswhich allows the doctor to see correlations between symptoms and reflux episodes. The procedure is sometimes helpful in detecting whether respiratory symptoms, including wheezing and coughing, are triggered by reflux.

A completely accurate diagnostic test for GERD does not exist, and tests have not consistently shown that acid exposure to the lower esophagus directly correlates with damage to the lining. Surgery Surgery is an option when medicine and lifestyle changes do not help to manage GERD symptoms. Surgery may also be a reasonable alternative to a lifetime of drugs and discomfort. Fundoplication is the standard surgical treatment for GERD. Usually a specific type of this procedure, called Nissen fundoplication, is performed. During the Nissen fundoplication, the upper part of the stomach is wrapped around the LES to strengthen the sphincter, prevent acid reflux, and repair a hiatal hernia. The Nissen fundoplication may be performed using a laparoscope, an instrument that is inserted through tiny incisions in the abdomen. The doctor then uses small instruments that hold a camera to look at the abdomen and pelvis. When performed by experienced surgeons, laparoscopic fundoplication is safe and effective in people of all ages, including infants. The procedure is reported to have the same results as the standard fundoplication, and people can leave the hospital in 1 to 3 days and return to work in 2 to 3 weeks. Endoscopic techniques used to treat chronic heartburn include the Bard EndoCinch system, NDO Plicator, and the Stretta system. These techniques require the use of an endoscope to perform the anti-reflux operation. The EndoCinch and NDO Plicator systems involve putting stitches in the LES to create pleats that help strengthen the muscle. The Stretta system uses electrodes to create tiny burns on the LES. When the burns heal, the scar tissue helps toughen the muscle. The long-term effects of these three procedures are unknown.

[Top]

What are the long-term complications of GERD?

Chronic GERD that is untreated can cause serious complications. Inflammation of the esophagus from refluxed stomach acid can damage the lining and cause bleeding or ulcersalso called esophagitis. Scars from tissue damage can lead to strictures narrowing of the esophagusthat make swallowing difficult. Some people develop Barretts esophagus, in which cells in the esophageal lining take on an abnormal shape and color. Over time, the cells can lead to esophageal cancer, which is often fatal. Persons with GERD and its complications should be monitored closely by a physician. Studies have shown that GERD may worsen or contribute to asthma, chronic cough, and pulmonary fibrosis. For information about Barretts esophagus, see the Barretts Esophagus fact sheet from the NIDDK. [Top]

Points to Remember

Frequent heartburn, also called acid indigestion, is the most common symptom of GERD in adults. Anyone experiencing heartburn twice a week or more may have GERD. You can have GERD without having heartburn. Your symptoms could include a dry cough, asthma symptoms, or trouble swallowing. If you have been using antacids for more than 2 weeks, it is time to see your health care provider. Most doctors can treat GERD. Your health care provider may refer you to a gastroenterologist, a doctor who treats diseases of the stomach and intestines. Health care providers usually recommend lifestyle and dietary changes to relieve symptoms of GERD. Many people with GERD also need medication. Surgery may be considered as a treatment option. Most infants with GER are healthy even though they may frequently spit up or vomit. Most infants outgrow GER by their first birthday. Reflux that continues past 1 year of age may be GERD. The persistence of GER along with other symptomsarching and irritability in infants, or abdominal and chest pain in older childrenis GERD. GERD is the outcome of frequent and persistent GER in infants and children and may cause repeated vomiting, coughing\

Symptoms of GERD

Heartburn is the most common symptom of GERD in kids and teens. It can last up to 2 hours and tends to be worse after meals. In infants and young children, GERD can lead to problems during and after feeding, including:

frequent regurgitation or vomiting, especially after meals choking or wheezing, if the contents of the reflux get into the windpipe and lungs wet burps or wet hiccups spitting up that continues beyond the first year of life (when it typically stops for most babies) irritability or inconsolable crying after eating refusal to eat, at all or in limited amounts failure to gain weight

Complications of GERD
Some children develop complications from GERD. The constant reflux of stomach acid can lead to:

breathing problems (if the stomach contents enter the trachea, lungs, or nose) redness and irritation in the esophagus, a condition called esophagitis bleeding in the esophagus scar tissue in the esophagus, which can make it difficult to swallow

Because these complications can make eating painful, GERD can interfere with proper nutrition. So if your child isn't gaining weight as expected or is losing weight, it's important to talk with your doctor.

Diagnosing GERD
In older kids, doctors usually can diagnose GERD by doing a physical exam and hearing about the symptoms. Try to keep track of the foods that seem to bring on symptoms in your child this information can help the doctor determine what's causing the problem. In younger children and babies, doctors might run these tests to diagnose GERD or rule out other problems:

Barium swallow. This is a special X-ray that can show the refluxing of liquid into the esophagus, any irritation in the esophagus, and abnormalities in the upper digestive tract. For the test, the child must swallow a small amount of a chalky liquid (barium). This liquid appears on the X-ray and shows the swallowing process. 24-hour impedance-probe study. This is considered the most accurate way to detect reflux and the number of reflux episodes. A thin, flexible tube is placed through the nose into the esophagus. The tip rests just above the esophageal sphincter to monitor the acid levels in the esophagus and to detect any reflux that occurs.

Milk scans. This series of X-ray scans tracks a special liquid as the child swallows it. The scans can show whether the stomach is slow to empty liquids and whether the refluxed liquid is being inhaled into the lungs. Upper endoscopy. In this test, doctors directly look at the esophagus, stomach, and a portion of the small intestines using a tiny fiberoptic camera. During the procedure, doctors may also biopsy or take a small sample of the lining of the esophagus to rule out other problems and determine whether GERD is causing other complications.

Treating GERD
Treatment for GERD depends on the type and severity of the symptoms. In babies, doctors sometimes suggest lightly thickening the formula or breast milk with rice cereal to reduce reflux. Making sure the baby is in a vertical position (seated or held upright) during feedings can also help. Older kids often get relief by avoiding foods and drinks that seem to trigger GERD symptoms, including:

citrus fruits chocolate foods with caffeine fatty and fried foods garlic and onions spicy foods tomato-based foods and sauces peppermint

Doctors may recommend raising the head of a child's bed 6 to 8 inches to minimize reflux that occurs at night. They may also try to address other conditions that can contribute to GERD symptoms, including obesity, alcohol consumption, smoking, and certain medications. If these measures don't help relieve the symptoms, the doctor may also prescribe medication, such as H2 blockers, which can help block the production of stomach acid, or proton pump inhibitors, which reduce the amount of acid the stomach produces. Medications called prokinetics are sometimes used to reduce the number of reflux episodes by helping the lower esophageal sphincter muscle work better and the stomach empty faster. In rare cases, when medical treatment alone doesn't help and a child is failing to grow or develops other complications, a surgical procedure called fundoplication might be an option. This involves creating a valve at the top of the stomach by wrapping a portion of the stomach around the esophagus.