Introduction
This information will help you understand your choices, whether you share in the decision-making process or rely on your doctor's recommendation.
If you are looking for more general information, go to the topic Gastroesophageal Reflux Disease (GERD).
If you are looking for general information about hiatal hernias, go to the topic Hiatal Hernia.
Key points in making your decision
Consider the following when making your decision:
- Treatment for your symptoms of gastroesophageal reflux disease (GERD) usually begins with making lifestyle changes, such as quitting smoking, losing weight, and taking nonprescription antacids, or nonprescription medicines that reduce or block acid. These include H2 blockers (for example, Pepcid) or a proton pump inhibitor (for example, Prilosec OTC). You may be able to control GERD symptoms with home treatment alone.
- If your symptoms are more severe, you may need stronger prescription medications. Besides relieving your symptoms, medications can allow the esophagus to heal if it's been damaged, and prevent complications of GERD such as inflammation or narrowing of the esophagus.
- You may consider surgery for GERD if your symptoms are caused by a hiatal hernia, if medications do not completely relieve your symptoms, if you can't or don't want to take medications, or if you have abnormal symptoms, including asthma or hoarseness, that do not adequately improve with treatment.
Medical Information
What is gastroesophageal reflux disease (GERD)?
Gastroesophageal reflux disease (GERD) develops when stomach acid and juices back up, or reflux, into the esophagus when the valve between the lower end of the esophagus and the stomach (the lower esophageal sphincter) does not close tightly enough. The most common symptoms are an uncomfortable feeling of burning, warmth, heat, or pain just behind the breastbone, commonly referred to as heartburn, or a sour taste in the mouth.
See an illustration of how reflux happens.
GERD most commonly occurs when the lower esophageal sphincter relaxes at the wrong time—that is, when you are not swallowing—and remains open too long. Normally, the valve opens for only a few seconds when you swallow. However, certain foods may relax the valve so that it does not close as tightly, making reflux more likely. These foods include chocolate, onions, peppermint, coffee, high-sugar foods, and possibly high-fat foods. Smoking may also affect your symptoms.
Other factors that can allow stomach juices to back up into the esophagus include:
- Hormonal changes during pregnancy. The valve may not close as tightly during pregnancy because of hormonal changes.1 Heartburn is common during pregnancy because hormones cause the digestive system to slow down. Increased abdominal pressure caused by the growing fetus in the woman's body may also make reflux and heartburn symptoms worse.
- A weak lower esophageal sphincter. If this valve is weak, it will not close properly, and reflux will occur frequently. This is a rare cause of mild GERD, but among people who have severe GERD, about 25% have this problem.1
- Hiatal hernia. GERD is common among people with a hiatal hernia. GERD symptoms in people with a hiatal hernia can vary from mild to severe. However, even though a hiatal hernia may increase the likelihood of developing GERD, it is not necessary to have a hiatal hernia to have GERD, and not everyone who has a hiatal hernia develops GERD.
- Slow digestion. If food stays in your stomach too long before it goes to the small intestine (because it does not empty properly, called delayed gastric emptying), the stomach contents are more likely to get pushed up into the esophagus and cause heartburn.
- Overfull stomach. Having a very full stomach—such as from eating a very large meal—increases the likelihood that the lower esophageal sphincter will relax and allow stomach juices to back up (reflux) into your esophagus.
Treatment for GERD is aimed at reducing the reflux of stomach acid and juices into the esophagus; preventing injury to the lining of the esophagus or helping it to heal if injury has already occurred; preventing GERD from reoccurring; and preventing other conditions that might arise as complications of GERD.
How effective are medications for GERD symptoms?
The effectiveness of medications used to control symptoms of GERD depends on the severity of your symptoms. Nonprescription medications may not be strong enough to control your symptoms, and you may need prescription medications. Keep in mind that some of these medications are not as effective for some people; they may need to try other medications or consider surgery. If your symptoms cannot be controlled with medications, or if you have severe symptoms caused by the regurgitation of stomach juices into the esophagus, surgery may be necessary.
The following nonprescription and prescription drugs may be used to treat GERD:
- Antacids (such as Gaviscon, Mylanta, Tums, or Rolaids) neutralize stomach acid and relieve heartburn. Making lifestyle changes and taking antacids are usually the first steps to try when symptoms of GERD are infrequent and mild.
- H2 blockers, such as nizatidine (Axid), famotidine (Pepcid), cimetidine (Tagamet), or ranitidine (Zantac), reduce the amount of acid in the stomach. They are available in both nonprescription and prescription strengths. Generally most people with mild to moderate GERD symptoms who take H2 blockers find their symptoms get better. Taking H2 blockers and making lifestyle changes often help people with more frequent GERD symptoms. H2 blockers are not as effective as proton pump inhibitors in treating moderate to severe cases of GERD that have caused inflammation or wearing away (erosion) of the lining of the esophagus (esophagitis).
- Proton pump inhibitors, such as esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec ), pantoprazole (Protonix), or rabeprazole (Aciphex), are prescription medications that reduce the amount of acid in the stomach. These medications often help when H2 blockers have failed to control symptoms of GERD. They are also used to treat severe inflammation of the esophagus (esophagitis). A nonprescription version of omeprazole (Prilosec OTC) is available for treatment of frequent heartburn. However, omeprazole for treatment of more serious conditions including peptic ulcers and GERD can only be prescribed by a doctor. Making lifestyle changes is still an important part of treatment when using proton pump inhibitors.
- Prokinetic agents such as metoclopramide (Reglan) have several effects. They make the lower esophageal sphincter close more tightly, which helps prevent stomach juices from getting into the esophagus. They also increase the rate at which the stomach empties. Prokinetic agents are sometimes combined with an H2 blocker, but their use is limited by frequent, sometimes severe side effects.
Depending on the severity of your symptoms, medications may need to be taken daily or only occasionally when GERD symptoms occur. Long-term—often lifelong—medication treatment is usually needed for GERD symptoms that are more severe, because symptoms tend to return when medication treatment is stopped.
What new problems could develop if I take medications for GERD?
To be effective, the medications need to be taken regularly. If you forget to take your medication, your symptoms will return.
While the medications used to treat GERD symptoms are generally safe, each has a different chance of causing side effects.
- Antacids are made with many different ingredients. Antacids that contain aluminum may cause constipation. Antacids that contain magnesium may cause diarrhea. You should not use antacids that contain aluminum or magnesium if you have serious kidney problems.
- H2 blockers have been in use since the late 1960s; they are well-studied and are considered very safe. But they sometimes cause headache, dizziness, diarrhea or constipation, or nausea and vomiting.
- Proton pump inhibitors are generally well-tolerated by the people who take them. Headache and diarrhea are the most frequent side effects that may occur. These medications may interfere slightly with the actions of warfarin (such as Coumadin and Panwarfin) or phenytoin (such as Dilantin) if you are also taking these medications. For some people, long-term use of a proton pump inhibitor may increase the risk of developing a vitamin B12 deficiency.
- Prokinetic agents cause side effects in 10% to 30% of the people taking them, depending on which prokinetic agent is being taken.2 The side effects include cramping abdominal pain, belching, nausea, diarrhea, jumpiness, sleeplessness, irregular heart rhythms, depression, or movement problems, especially in older adults.
Pregnant women often have symptoms of GERD during pregnancy. Heartburn is common during pregnancy because hormones cause the digestive system to slow down. The muscles that push food down the esophagus also move more slowly during pregnancy. In addition, as the uterus grows, it pushes on the stomach and sometimes forces stomach acid up into the esophagus. Some medications used to treat symptoms of GERD in nonpregnant women may not be used during pregnancy. But most proton pump inhibitors (acid blockers) and all H2 blockers have been classified as safe for use by pregnant women.
How effective is surgery in treating GERD?
Surgery to control the symptoms of GERD, called fundoplication surgery, usually includes wrapping part of the stomach around the esophagus to strengthen it. The same procedure is often done to correct a hiatal hernia that may be causing some of the GERD symptoms. This procedure is often done using a laparoscopic surgical technique.
When done by a highly experienced surgeon, surgery is successful in 50% to 90% of cases.3 Outcomes of the laparoscopic technique are best when the surgery is done by a surgeon with experience using this procedure. Successful surgery relieves GERD symptoms and inflammation of the esophagus (esophagitis). About 10% to 20% of the people who have surgery to control GERD symptoms continue to have symptoms or develop new problems (such as difficulty swallowing, intestinal gas, or bloating) after the surgery. These continuing or new symptoms may or may not respond to treatment with medications. Also, one study showed that 16% of the people needed second operations within 10 to 12 years to deal with complications caused by the first surgery.4
Surgery often does not completely eliminate the need to take medications to control remaining GERD symptoms. One study showed that 62% of people who had surgery were still taking medications to control GERD symptoms. But they were less likely to need to take medications regularly; and when they did not take medications, their remaining symptoms were likely to be less severe.4
Fundoplication surgery using a laparoscopic technique is being done more often than the older open fundoplication surgical technique, which requires a large incision and has a longer recovery time. Although some studies indicate that laparoscopic fundoplication improves GERD symptoms in 76% to 98% of people who have the surgery, no studies have proven that laparoscopic fundoplication surgery is effective in maintaining healing of the esophagus over the long term.3, 5
What new problems could develop if I have surgery for GERD?
All major surgical procedures have a slight risk for breathing problems caused by the anesthesia and for bleeding, infection, and pain. The risk of death from laparoscopic fundoplication has been estimated to be about 0.2%. There is no known risk of death from GERD treatments using medications.3
It is common for people to complain of abdominal bloating or excessive intestinal gas (flatulence) after the surgery.
If the stomach is wrapped too tightly, you may have difficulty swallowing. This complication may be more likely to occur in people who receive fundoplication surgery using a laparoscopic surgical technique. It is also possible for the stomach wrap to slide down around the stomach instead of staying around the esophagus. Either of these situations may require another surgery to correct the problem. Both of these are rare problems.
There is some risk that the stomach wrap will loosen, so that GERD symptoms return. This may require a second surgery to correct, which carries its own risks.
If you need more information, see the topic Gastroesophageal Reflux Disease (GERD).
Your Information
What might happen if I decide not to take medications or have surgery?
GERD symptoms will not get better on their own. If you do not use some type of treatment, you will continue to have GERD symptoms.
People with severe GERD symptoms may develop inflammation of the esophagus (esophagitis) from the constant contact with stomach acids and digestive juices. In the worst cases, additional problems in the esophagus may develop, such as sores (ulcers), narrow spots, or Barrett's esophagus, a change in the cells lining the esophagus that may lead to cancer (although this is rare).
What are my choices?
This information will be helpful if you have GERD symptoms and you are considering whether to take medications or have surgery to manage them. This discussion assumes that your symptoms are bothersome enough or are causing complications so that watchful waiting (no active treatment) is not an option and lifestyle changes have failed to control your symptoms.
In general, your choices are:
- Use medications to treat GERD symptoms.
- Have surgery to either strengthen your lower esophageal sphincter or, if you have one, correct your hiatal hernia.
The decision about whether to use medications or surgery to treat GERD takes into account your personal feelings and the medical facts.
| Reasons to use medications | Reasons to have surgery |
|---|---|
Are there other reasons you might want to use medications to treat GERD? |
Are there other reasons you might want to have surgery to treat GERD? |
These personal stories may help you make your decision.
Wise Health Decision
Use this worksheet to help you make your decision. After completing it, you should have a better idea of how you feel about using medications or surgery to treat GERD. Discuss the worksheet with your doctor.
Circle the answer that best applies to you.
| Lifestyle changes and medications relieve my symptoms. | Yes | No | Unsure |
| The side effects from medications are severe enough to make me want surgery. | Yes | No | Unsure |
| I am willing to take medications to control my symptoms for the rest of my life. | Yes | No | Unsure |
| The thought of having surgery bothers me too much to consider it. | Yes | No | Unsure |
| The long-term cost of medications is more troubling than the one-time cost of surgery. | Yes | No | Unsure |
| Taking time off from work for surgery is not a problem. | Yes | No | Unsure |
| I would be willing to take medications after having surgery if necessary. | Yes | No | Unsure |
| I have a hiatal hernia that requires treatment. | Yes | No | Unsure |
Use the following space to list any other important concerns you have about this decision.
What is your overall impression?
Your answers in the above worksheet are meant to give you a general idea of where you stand on this decision. You may have one overriding reason to use medications or surgery to treat GERD.
Check the box below that represents your overall impression about your decision.
|
Leaning toward medications |
Leaning toward surgery |
Return to the topic Gastroesophageal Reflux Disease (GERD).
References
Citations
Kahrilas PJ, Pandolfino JE (2002). Gastroesophageal reflux disease and its complications, including Barrett's metaplasia. In MH Sleisenger et al., eds., Gastrointestinal and Liver Disease, 7th ed., vol. 1, pp. 599–622. Philadelphia: W.B. Saunders.
Spechler SJ (2003). Gastroesophageal reflux disease and its complications. In SL Friedman et al., eds., Current Diagnosis and Treatment in Gastroenterology, 2nd ed., pp. 266–282. New York: McGraw-Hill.
Kahrilas PJ (2001). Management of GERD: Medical versus surgical. Seminars in Gastrointestinal Disease, 12(1): 3–15.
Spechler SJ, et al. (2001). Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease: Follow-up of a randomized controlled trial. JAMA, 285(18): 2331–2338.
Triadafilopoulos G, et al. (2001). Radiofrequency energy delivery to the gastroesophageal junction for the treatment of GERD. Gastrointestinal Endoscopy, 53(4): 407–415.
Credits
| Author | Merrill Hayden |
| Editor | Kathleen M. Ariss, MS |
| Editor | Katy E. Magee, MA |
| Associate Editor | Michele Cronen |
| Associate Editor | Pat Truman |
| Primary Medical Reviewer | Kathleen Romito, MD - Family Medicine |
| Specialist Medical Reviewer | Peter J. Kahrilas, MD - Gastroenterology |
| Last Updated | April 18, 2006 |
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