Gastroesophageal Reflux Disease

Key Points

• Gastroesophageal reflux disease (GERD) is also known as heartburn or reflux.

• GERD is common in people with Down syndrome (DS).

• There are a variety of things that can be done at home to reduce or avoid GERD.

• Persistent or worsening symptoms warrant evaluation by a health care provider and possibly testing and/or treatment adjustment.

 

Video

Watch a video clip about GERD  from our webinar At-Home Treatments for Common Health Conditions.

 

What is GERD?

After swallowing food, it passes down through the esophagus into the stomach. At the bottom of the esophagus, the sphincter muscle relaxes to allow the food to pass into the stomach. After the food enters the stomach, the sphincter tightens again so food and stomach acid don’t pass back into the esophagus.

Gastroesophageal reflux disease (GERD), also known as acid reflux and heartburn, happens when acidic stomach contents move backwards from the stomach up into the esophagus. The stomach contents may only go up into the esophagus but may also go higher into the upper airway and throat and be aspirated into the lungs. When the contents go into the throat, the condition is called laryngopharyngeal reflux.

 

What are the symptoms of GERD?

• Pain or burning in the chest or upper stomach

• Chronic cough

• Regurgitation, or food traveling back up into the mouth

• Sore throat

• Sour taste

• Hoarse voice

• Loss of enamel on the teeth

• Sleep disruption

• Aspiration into the lungs causing inflammation, pneumonia, and/or wheezing

Symptoms typically occur after eating or at nighttime when lying down. In addition to uncomfortable symptoms, GERD can lead to more serious conditions if left untreated, including:

• Barrett's esophagitis (when there are changes in the lining of the esophagus that increase the risk of cancer)

• Scarring or narrowing of the esophagus that can lead to difficulties with food or liquid passing into the stomach

 

What are the risk factors for GERD (what makes it more likely to occur)?

Decreased muscle tone of the sphincter

The sphincter is the muscle at the bottom of the esophagus. Having Down syndrome (DS) contributes to decreased sphincter muscle tone.

Decreased muscle tone can be caused by certain medications such as:

• Anticholinergic medications such as those used for overactive bladder (e.g., oxybutynin/Ditropan) or irritable bowel syndrome (e.g., dicyclomine/Bentyl)

• Tricyclic anti-depressants (e.g., amitriptyline/Elavil, doxepin/Sinequan)

• Certain narcotics such as codeine and those containing hydrocodone and acetaminophen (e.g., Norco, Vicodin)

• Sedatives including benzodiazepines (e.g., diazepam/Valium, lorazepam/Ativan)

Decreased muscle tone can also be caused by foods and drinks that contain caffeine such as colas, Dr. Pepper, Mountain Dew, and chocolate.

Increased acid in the stomach

Increased acid in the stomach is another risk factor for GERD. Causes of increased acid in the stomach include:

• Certain medications

• Some antibiotics (e.g., tetracycline and clindamycin)

• Bisphosphonates used to treat osteoporosis (e.g., alendronate/Fosamax)

• Nonsteroidal anti-inflammatory medications (NSAIDs) (e.g., ibuprofen/Advil, naproxen/Naprosyn)

• Certain foods

• Acidic foods

• Fried foods

• Fast food

• Pizza

• Fatty meats

• Cheese

• Tomato-based sauces

• Citrus fruits

Distended or enlarged stomach

Distended or enlarged stomach can be caused by overeating or drinking carbonated (gas-containing) beverages.

Not taking advantage of gravity

Being upright after eating helps limit stomach contents from going backwards up into the esophagus. Lying down after eating can increase GERD.

Increased pressure in the abdomen

Increased pressure in the abdomen can be caused by:

• Abdominal obesity

• Any mass or fluid (ascites) in the abdominal cavity

• Tight clothing

Decreased pressure in the chest cavity

In obstructive sleep apnea, the airway is blocked, primarily with breathing in. The body's effort to overcome the obstruction results in lowered pressure in the chest cavity. If the pressure is low enough, the pressure in the abdominal cavity will, more likely, push the stomach contents back into the esophagus.

 

Why is GERD important in people with DS?

GERD is common in people with DS and is likely more common than in people without DS. There are several reasons for this:

• The tone of the sphincter muscle between the esophagus and the stomach is lower in people with DS. 

• There are several risk factors for GERD that are more common in people with DS:

  • Obesity

  • Sleep apnea

• Overeating, drinking caffeinated beverages, eating foods that increase GERD, and eating shortly before lying down for bed are frequent dietary choices that some people with DS (and their families) report.

Another issue for GERD in people with DS is the issue of underreporting mild symptoms. It seems it is not uncommon for people with DS to be experiencing but not report heartburn. The chronic inflammation related to persistent heartburn can cause scarring and then narrowing of the esophagus. In this situation, the first symptoms may be vomiting after eating, weight loss, or difficulty swallowing. The narrowed esophagus does not allow food to pass appropriately into the stomach. 

Another important issue in people with DS regarding not reporting the symptoms may be that the symptoms present in some other manner. 

• Since GERD more frequently occurs when lying down for sleep, the discomfort of GERD may present as sleep disturbance.

• Whether related to poor sleep or the discomfort, a behavioral change may be the presenting symptom.

 

How is GERD diagnosed?

Usually, a health provider diagnoses GERD based on the symptoms that a patient is having but sometimes further testing is necessary. An esophagogastroduodenoscopy (EGD) may be ordered. During an EGD, a tube with a small camera is placed through the mouth into the mouth and passed into the esophagus, stomach and first part of the small intestine. EGDs are most frequently done by a gastroenterologist. EGDs are more commonly done if there are persistent symptoms or symptoms suggestive of a more serious condition. Concerning symptoms may include:

• Weight loss

• Recurrent vomiting

• Difficulty or pain with swallowing

• Evidence of bleeding in the gastrointestinal tract

• Persistent symptoms despite treatment. This may indicate:

  • An underlying condition that requires further assessment or

  • Resistance to treatment. Confirmation of the diagnosis and treatment adjustment by a health provider may be needed.

Sometimes, a pH probe may be placed during an EGD. A pH probe measures the pH in the esophagus. A tube protrudes from the nose and the other end is in the esophagus. A low or intermittently low pH can indicate stomach acid is passing into the stomach. Typically, this is left in for 24-72 hours and, therefore, it can be a challenging test for some people with DS to tolerate.

Occasionally, other tests that may be done include:

• An esophagram

• An upper gastrointestinal x-ray test (that requires the individual to swallow barium)

• A nuclear medicine gastroesophageal reflux test (that requires the individual to swallow a small amount of radioactive liquid)

 

How is GERD treated?

At-home treatments

• Attaining or maintaining a healthy body weight

• Eating smaller meals and avoiding overeating

• Not eating anything 3-4 hours before lying down or going to sleep

• Elevating the head of the bed with a riser or blocks. Adding more pillows may make GERD worse because that causes flexion (forward bending) of the abdomen resulting in increased pressure in the abdomen. As noted above, increased abdominal pressure can increase GERD. Putting the head of the bed at an incline using an adjustable base, risers, or blocks is more effective. Also effective are incline mattresses that get gradually thicker from the feet end to the head end of the mattress.

• Eating less fatty, spicy, and citrus foods

• Drinking less caffeine or carbonated drinks like soda

• Avoiding medications that can make GERD worse

• Not wearing clothing that is tight around the abdomen

When lifestyle changes are not enough, there are several medications that are available without a prescription. Some medications are taken only as needed when a person gets symptoms. Examples of these are:

• Antacids such as calcium carbonate (e.g., Tums), calcium and magnesium (e.g., Rolaids), and calcium, magnesium, and simethicone (to reduce gas) (e.g., Maalox)

Other medications are usually taken daily to prevent symptoms. There are two main classes:

• Proton pump inhibitors, including omeprazole (Prilosec), lansoprazole (Prevacid), and esomeprazole (Nexium)

• H2 receptor blockers, including famotidine (Pepcid), ranitidine (Zantac), and cimetidine

Treatments from a health care provider

Medications that require a prescription from your health care provider include:

• Higher doses of the over-the-counter PPIs

• Proton pump inhibitors such as pantoprazole (Protonix)

• Metoclopramide/Reglan is used to increase the motility of the upper gastrointestinal tract to promote movement of food and liquid forward through the esophagus and stomach. This is infrequently prescribed due to the potential for problematic side effects.

When treatment is started, the health provider will follow up closely with a patient to make sure the symptoms are getting better. If symptoms do not get better, the person may need further testing and/or treatment adjustment. 

 

Additional resources

Gastroesophageal Reflux Disease  (Mayo Clinic)

 

Original article was written by Allison Schnitzler, MD in July 2017. Article was updated by Brian Chicoine, MD in September 2023.