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Gastroesophageal Reflux Disease

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Gastroesophageal Reflux Disease (GERD; or GORD when spelling &oelig;sophageal, the <a title="British English" href="http://en.wikipedia.org/wiki/British_English">BrE</a> form) is defined as chronic symptoms or <a title="Mucosa" href="http://en.wikipedia.org/wiki/Mucosa">mucosal</a> damage produced by the abnormal reflux in the <a title="Esophagus" href="http://en.wikipedia.org/wiki/Esophagus">esophagus</a><a title="" href="http://en.wikipedia.org/wiki/Gastroesophageal_reflux_disease#_note-0">[1]</a>.

This is commonly due to transient or permanent changes in the barrier between the esophagus and the <a title="Stomach" href="http://en.wikipedia.org/wiki/Stomach">stomach</a>. This can be due to incompetence of the <a title="Lower esophageal sphincter" href="http://en.wikipedia.org/wiki/Lower_esophageal_sphincter">lower esophageal sphincter</a> (LES), transient LES relaxation, impaired expulsion of gastric reflux from the esophagus, or a <a title="Hiatal hernia" href="http://en.wikipedia.org/wiki/Hiatal_hernia">hiatal hernia</a>.

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<h2>Symptoms</h2>

<h3>Adults</h3>

<a title="Heartburn" href="http://en.wikipedia.org/wiki/Heartburn">Heartburn</a> is the major symptom of acid in the esophagus, characterized by burning discomfort behind the breastbone (<a title="Sternum" href="http://en.wikipedia.org/wiki/Sternum">sternum</a>). Findings in GERD include <a title="Esophagitis" href="http://en.wikipedia.org/wiki/Esophagitis">esophagitis</a> (reflux esophagitis) — <a title="Inflammation" href="http://en.wikipedia.org/wiki/Inflammation">inflammatory</a> changes in the esophageal lining (mucosa) —, <a title="Stenosis" href="http://en.wikipedia.org/wiki/Stenosis">strictures</a>, difficulty swallowing (<a title="Dysphagia" href="http://en.wikipedia.org/wiki/Dysphagia">dysphagia</a>), and chronic <a title="Chest pain" href="http://en.wikipedia.org/wiki/Chest_pain">chest pain</a>. Patients may have only one of those findings. Typical GERD symptoms include cough, hoarseness, voice changes, chronic ear ache, burning chest pains, nausea or <a title="Sinusitis" href="http://en.wikipedia.org/wiki/Sinusitis">sinusitis</a>. GERD complications include stricture formation, <a title="Barrett's esophagus" href="http://en.wikipedia.org/wiki/Barrett%27s_esophagus">Barrett's esophagus</a>, <a class="new" title="Esophageal ulcer~~" class="new~~" href="http://en.wikipedia.org/w/index.php?title=Esophageal_ulcer&action=edit">esophageal ulcers</a>, and possibly even lead to <a title="Esophageal cancer" href="http://en.wikipedia.org/wiki/Esophageal_cancer">esophageal cancer</a>, especially in adults over 60 years old.

Occasional heartburn is common but does not necessarily mean one has GERD. Patients with heartburn symptoms more than once a week are at risk of developing GERD. A hiatal hernia is usually <a title="Asymptomatic" href="http://en.wikipedia.org/wiki/Asymptomatic">asymptomatic</a>, but the presence of a hiatal hernia is a risk factor for developing GERD.

<h2>Diagnosis</h2>

<a title="Gastroscopy" href="http://en.wikipedia.org/wiki/Gastroscopy">Endoscopic</a> image of peptic stricture, or narrowing of the <a title="Esophagus" href="http://en.wikipedia.org/wiki/Esophagus">esophagus</a> near the junction with the <a title="Stomach" href="http://en.wikipedia.org/wiki/Stomach">stomach</a>. This is a complication of chronic gastroesophageal reflux disease, and can be a cause of <a title="Dysphagia" href="http://en.wikipedia.org/wiki/Dysphagia">dysphagia</a> or difficulty swallowing</div>

</div>

<a title="Biopsy" href="http://en.wikipedia.org/wiki/Biopsy">Biopsies</a> can be performed during gastroscopy and these may show:

<ul>

<li>Edema and basal hyperplasia (non-specific inflammatory changes)</li> <li>Lymphocytic inflammation (non-specific)</li> <li>Neutrophilic inflammation (usually due to reflux or <a title="Helicobacter" href="http://en.wikipedia.org/wiki/Helicobacter">Helicobacter</a> <a title="Gastritis" href="http://en.wikipedia.org/wiki/Gastritis">gastritis</a>)</li> <li>Eosinophilic inflammation (usually due to reflux)</li> <li>Goblet cell intestinal metaplasia or Barretts esophagus.</li> <li>Elongation of the papillae</li> <li>Thinning of the squamous cell layer</li> <li><a title="Dysplasia" href="http://en.wikipedia.org/wiki/Dysplasia">Dysplasia</a> or pre-cancer.</li> <li><a title="Carcinoma" href="http://en.wikipedia.org/wiki/Carcinoma">Carcinoma</a>.</li>

</ul>

Factors that can contribute to GERD are:

<ul>

<li><a title="Hiatus hernia" href="http://en.wikipedia.org/wiki/Hiatus_hernia">Hiatus hernia</a>, which increases the likelihood of GERD due to mechanical and motility factors<a title="" href="http://en.wikipedia.org/wiki/Gastroesophageal_reflux_disease#_note-pmid17573791">[2]</a></li> <li><a title="Obesity" href="http://en.wikipedia.org/wiki/Obesity">Obesity</a>: increasing <a title="Body mass index" href="http://en.wikipedia.org/wiki/Body_mass_index">body mass index</a> is associated with more severe GERD<a title="" href="http://en.wikipedia.org/wiki/Gastroesophageal_reflux_disease#_note-pmid175737910">[3]</a></li> <li><a title="Zollinger-Ellison syndrome" href="http://en.wikipedia.org/wiki/Zollinger-Ellison_syndrome">Zollinger-Ellison syndrome</a>, which can be present with increased gastric acidity due to <a title="Gastrin" href="http://en.wikipedia.org/wiki/Gastrin">gastrin</a> production</li> <li><a title="Hypercalcemia" href="http://en.wikipedia.org/wiki/Hypercalcemia">Hypercalcemia</a>, which can increase <a title="Gastrin" href="http://en.wikipedia.org/wiki/Gastrin">gastrin</a> production, leading to increased acidity</li> <li><a title="Scleroderma" href="http://en.wikipedia.org/wiki/Scleroderma">Scleroderma</a> and <a title="Systemic sclerosis" href="http://en.wikipedia.org/wiki/Systemic_sclerosis">systemic sclerosis</a>, which can feature esophageal dysmotility</li>

</ul>

GERD has been linked to <a title="Laryngitis" href="http://en.wikipedia.org/wiki/Laryngitis">laryngitis</a>, chronic <a title="Cough" href="http://en.wikipedia.org/wiki/Cough">cough</a>, <a title="Pulmonary fibrosis" href="http://en.wikipedia.org/wiki/Pulmonary_fibrosis">pulmonary fibrosis</a>, <a title="Earache" href="http://en.wikipedia.org/wiki/Earache">earache</a>, and <a title="Asthma" href="http://en.wikipedia.org/wiki/Asthma">asthma</a>, even when not clinically apparent, as well as to <a class="new" title="Laryngopharyngeal reflux~~" class="new~~" href="http://en.wikipedia.org/w/index.php?title=Laryngopharyngeal_reflux&action=edit">laryngopharyngeal reflux</a> and ulcers of the <a title="Vocal cords" href="http://en.wikipedia.org/wiki/Vocal_cords">vocal cords</a>. There appears to be an association with <a title="Sleep apnea" href="http://en.wikipedia.org/wiki/Sleep_apnea">obstructive sleep apnea</a>, although its conjectural relationship with GERD remains unproven.<a title="" href="http://en.wikipedia.org/wiki/Gastroesophageal_reflux_disease#_note-1">[4]</a> and <a class="external" title="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17198758~~" class="external~~" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17198758">PMID 17198758</a>.

<h2>Treatment</h2>

Certain foods and lifestyle are considered to promote gastroesophageal reflux:

<ul>

<li><a title="Coffee" href="http://en.wikipedia.org/wiki/Coffee">Coffee</a>, <a title="Alcoholic beverage" href="http://en.wikipedia.org/wiki/Alcoholic_beverage">alcohol</a>, and excessive amounts of <a title="Vitamin C" href="http://en.wikipedia.org/wiki/Vitamin_C">Vitamin C</a> supplements stimulate gastric acid secretion. Taking these before bedtime especially can cause evening reflux. (Although a study published in 2006 by <a title="Stanford University" href="http://en.wikipedia.org/wiki/Stanford_University">Stanford University</a> researchers disputes the effect of coffee, acidic, spicy foods etc. as a myth.<a title="" href="http://en.wikipedia.org/wiki/Gastroesophageal_reflux_disease#_note-pmid16682569">[5]</a>)</li> <li><a title="Antacids" href="http://en.wikipedia.org/wiki/Antacids">Antacids</a> based on <a title="Calcium carbonate" href="http://en.wikipedia.org/wiki/Calcium_carbonate">calcium carbonate</a> (but not <a title="Aluminum hydroxide" href="http://en.wikipedia.org/wiki/Aluminum_hydroxide">aluminum hydroxide</a>) 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.<a title="" href="http://en.wikipedia.org/wiki/Gastroesophageal_reflux_disease#_note-2">[6]</a>.</li> <li>Foods high in fats and <a title="Tobacco smoking" href="http://en.wikipedia.org/wiki/Tobacco_smoking">smoking</a> reduce lower esophageal sphincter competence, so avoiding these tends to help. Fat also delays stomach emptying.</li> <li>Eating shortly before bedtime (For clinical purposes, this usually means 2-3 hours before going to bed).</li> <li>Large meals. Having more but smaller meals reduces GERD risk, as it means there is less food in the stomach at any one time.</li> <li>Soda or pop (regular or diet).</li> <li><a title="Chocolate" href="http://en.wikipedia.org/wiki/Chocolate">Chocolate</a> and <a title="Peppermint" href="http://en.wikipedia.org/wiki/Peppermint">peppermint</a>.</li> <li><a title="Acid" href="http://en.wikipedia.org/wiki/Acid">Acidic</a> foods, such as oranges and tomatoes</li> <li><a title="Cruciferous vegetables" href="http://en.wikipedia.org/wiki/Cruciferous_vegetables">Cruciferous vegetables</a>: onions, cabbage, cauliflower, broccoli, spinach, <a title="Brussel sprouts" href="http://en.wikipedia.org/wiki/Brussel_sprouts">brussel sprouts</a></li> <li><a title="Milk" href="http://en.wikipedia.org/wiki/Milk">Milk</a> and milk-based products contain calcium and fat, and should be avoided before bedtime.</li>

</ul>

<h3>Positional therapy</h3>

Sleeping on one's left side has been shown to drastically reduce nighttime reflux episodes in patients.<a title="" href="http://en.wikipedia.org/wiki/Gastroesophageal_reflux_disease#_note-3">[7]</a>.

Elevating the head of the bed is also effective. When combining drug therapy, food avoidance before bedtime, and elevation of the head of the bed, over 95% of patients will have complete relief[<a title="Wikipedia:Citing sources" href="http://en.wikipedia.org/wiki/Wikipedia:Citing_sources">citation needed</a>]. Additional conservative measures may be considered if there is incomplete relief. Another approach is to apply all conservative measures for maximum response. A <a title="Meta-analysis" href="http://en.wikipedia.org/wiki/Meta-analysis">meta-analysis</a> suggested that elevating the head of bed is an effective therapy, although this conclusion was only supported by nonrandomized studies <a title="" href="http://en.wikipedia.org/wiki/Gastroesophageal_reflux_disease#_note-pmid16682569">[5]</a>.

Elevating the head of the bed can be done by using various items: plastic or wooden bed risers that support bed posts or legs, a bed wedge pillow, or a wedge or an inflatable mattress lifter that fits in between mattress and box spring. The height of the elevation is critical and must be at least 6 to 8 inches (15 to 20 cm) in order to be at least minimally effective to prevent the backflow of gastric fluids. It should be noted that some innerspring mattresses do not work well when inclined and tend to cause back pain, thus foam based mattresses are to be preferred. Moreover, some use higher degrees of incline than provided by the commonly suggested 6 to 8 inches (15 to 20 cm) and claim greater success.

A number of drugs are registered for GERD treatment, and they are among the most-often-prescribed forms of <a title="Medication" href="http://en.wikipedia.org/wiki/Medication">medication</a> in most Western countries. They can be used in combination with other drugs, although some antacids can interfere with the function of other drugs:

<ul>

<li><a title="Proton pump inhibitor" href="http://en.wikipedia.org/wiki/Proton_pump_inhibitor">Proton pump inhibitors</a> 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.</li> <li><a title="Antacid" href="http://en.wikipedia.org/wiki/Antacid">Antacids</a> before meals or symptomatically after symptoms begin can reduce gastric acidity (increase <a title="PH" href="http://en.wikipedia.org/wiki/PH">pH</a>).</li> <li><a title="Alginic acid" href="http://en.wikipedia.org/wiki/Alginic_acid">Alginic acid</a> (<a title="Gaviscon" href="http://en.wikipedia.org/wiki/Gaviscon">Gaviscon</a>) may coat the mucosa as well as increase pH and decrease reflux. A <a title="Meta-analysis" href="http://en.wikipedia.org/wiki/Meta-analysis">meta-analysis</a> of <a title="Randomized controlled trials" href="http://en.wikipedia.org/wiki/Randomized_controlled_trials">randomized controlled trials</a> suggests <a title="Alginic acid" href="http://en.wikipedia.org/wiki/Alginic_acid">alginic acid</a> may be the most effective of non-prescription treatments with a <a title="Number needed to treat" href="http://en.wikipedia.org/wiki/Number_needed_to_treat">number needed to treat</a> of 4 <a title="" href="http://en.wikipedia.org/wiki/Gastroesophageal_reflux_disease#_note-pmid17229239">[8]</a>.</li> <li>Gastric <a title="H2 antagonist" href="http://en.wikipedia.org/wiki/H2_antagonist">H2 receptor blockers</a> such as <a title="Ranitidine" href="http://en.wikipedia.org/wiki/Ranitidine">ranitidine</a> or <a title="Famotidine" href="http://en.wikipedia.org/wiki/Famotidine">famotidine</a> can reduce gastric secretion of acid. These drugs are technically <a title="Antihistamine" href="http://en.wikipedia.org/wiki/Antihistamine">antihistamines</a>. They relieve complaints in about 50% of all GERD patients. Compared to placebo (which also is associated with symptom improvement), they have a <a title="Number needed to treat" href="http://en.wikipedia.org/wiki/Number_needed_to_treat">number needed to treat</a> of eight (8) <a title="" href="http://en.wikipedia.org/wiki/Gastroesophageal_reflux_disease#_note-pmid17229239">[8]</a>.</li> <li><a title="Prokinetic" href="http://en.wikipedia.org/wiki/Prokinetic">Prokinetics</a> strengthen the LES and speed up gastric emptying. <a title="Cisapride" href="http://en.wikipedia.org/wiki/Cisapride">Cisapride</a>, a member of this class, was withdrawn from the market for causing <a title="Long QT syndrome" href="http://en.wikipedia.org/wiki/Long_QT_syndrome">Long QT syndrome</a>.</li> <li><a title="Sucralfate" href="http://en.wikipedia.org/wiki/Sucralfate">Sucralfate</a> (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.</li>

</ul>

<h3>Endoluminal fundoplication</h3>

<tbody>

<tr>

</tbody>

</table>

In June 2006 EndoGastric Solutions introduced <a ~~rel~~class="~~nofollow~~external text" title="http://www.egseurope.eu" ~~class~~rel="~~external text~~nofollow" href="http://www.egseurope.eu/">EsophyX ELF</a> in the Europe Union as an alternative to surgical and pharmaceutical approaches for GERD treatment. EsophyX ELF is intended to deliver similar benefits as the time-proven laparoscopic fundoplication procedures, by reducing hiatal hernia, recreating the Angle of His, and creating a GastroEsophageal Valve (GEV). The key differences are that EsophyX ELF is an endoscopic non-invasive procedure that is performed transorally (through the mouth), does not require incisions, and does not dissect any part of the natural anatomy.Previous endoluminal treatments focused predominantly on the LES. However, failure to effectively treat reflux long-term with endoluminal therapies that focused only on the Lower Esophageal Sphincter (LES) combined with the fact that surgical approaches like Nissen fundoplication recreate the GEV and have excellent long-term efficacy, has led to an awareness that the GEV is probably the most powerful component of the Anti-Reflux Barrier. The device has been designed to deploy multiple tissue fasteners to create a robust and durable valve and is intended to restore the geometry of the GastroEsophageal Junction and recreate the natural, unidirectional valve mechanism necessary to prevent GERD. <a ~~rel~~class="~~nofollow~~external text" title="http://www.endogastricsolutions.com/index.php?src=news&submenu=News&refno=19" ~~class~~rel="~~external text~~nofollow" href="http://www.endogastricsolutions.com/index.php?src=news&submenu=News&refno=19">EsophyX ELF has recently been cleared by the US FDA</a> and is now available in the U.S.

<h3>Other treatments</h3>

In 2000 , the U.S. <a title="Food and Drug Administration" href="http://en.wikipedia.org/wiki/Food_and_Drug_Administration">Food and Drug Administration</a> (FDA) approved two <a title="Endoscopy" href="http://en.wikipedia.org/wiki/Endoscopy">endoscopic</a> devices to treat chronic heartburn. One system, Endocinch, puts stitches in the LES to create little pleats that help strengthen the muscle. Another, the <a title="Stretta procedure" href="http://en.wikipedia.org/wiki/Stretta_procedure">Stretta Procedure</a>, 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 FDA cleared for the 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 Plicator is currently marketed by NDO Surgical, Inc. <a ~~rel~~class="~~nofollow~~external autonumber" title="http://www.ndosurgical.com" ~~class~~rel="~~external autonumber~~nofollow" href="http://www.ndosurgical.com/">[1]</a>.

Another treatment that involved injection of a solution during endoscopy into the lower esophageal wall was available for about one year ending in late 2005. It was marketed under the name Enteryx. It was removed from the market due to several reports of complications from misplaced injections.

<h2>References</h2>

<li id="_note-0"><a title="" href="http://en.wikipedia.org/wiki/Gastroesophageal_reflux_disease#_ref-0">^</a> DeVault KR, Castell DO. Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. The Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol 1999;94:1434-42. <a class="external" title="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10364004~~" class="external~~" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10364004">PMID 10364004</a>.</li> <li id="_note-pmid17573791">^ <a title="" href="http://en.wikipedia.org/wiki/Gastroesophageal_reflux_disease#_ref-pmid17573791_0">a</a> <a title="" href="http://en.wikipedia.org/wiki/Gastroesophageal_reflux_disease#_ref-pmid17573791_1">b</a> <cite style="~~font~~FONT-~~style~~STYLE: normal;">Piesman M, Hwang I, Maydonovitch C, Wong RK (2007). "Nocturnal reflux episodes following the administration of a standardized meal. Does timing matter?". Am. J. Gastroenterol. 102 (10): 2128-2134. <a title="Digital object identifier" href="http://en.wikipedia.org/wiki/Digital_object_identifier">DOI</a>:<a ~~rel~~class="~~nofollow~~external text" title="http://dx.doi.org/10.1111/j.1572-0241.2007.01348.x" ~~class~~rel="~~external text~~nofollow" href="http://dx.doi.org/10.1111/j.1572-0241.2007.01348.x">10.1111/j.1572-0241.2007.01348.x</a>. <a class="external" title="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17573791~~" class="external~~" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17573791">PMID 17573791</a>.</cite><span class="Z3988" title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.atitle=Nocturnal+reflux+episodes+following+the+administration+of+a+standardized+meal.+Does+timing+matter%3F&rft.jtitle=Am.+J.+Gastroenterol.&rft.date=2007&rft.volume=102&rft.issue=10&rft.au=Piesman+M%2C+Hwang+I%2C+Maydonovitch+C%2C+Wong+RK&rft.pages=2128-2134&rft_id=info:pmid/17573791&rft_id=info:doi/10.1111%2Fj.1572-0241.2007.01348.x" ~~class="Z3988">~~> </li> <li id="_note-pmid175737910"><a title="" href="http://en.wikipedia.org/wiki/Gastroesophageal_reflux_disease#_ref-pmid175737910_0">^</a> <cite style="~~font~~FONT-~~style~~STYLE: normal;">Ayazi S, Crookes P, Peyre C, (2007). "Objective documentation of the link between gastroesophageal reflux disease and obesity". Am. J. Gastroenterol. 102 (S): 138-139.</cite><span class="Z3988" title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.atitle=Objective+documentation+of+the+link+between+gastroesophageal+reflux+disease+and+obesity&rft.jtitle=Am.+J.+Gastroenterol.&rft.date=2007&rft.volume=102&rft.issue=S&rft.au=Ayazi+S%2C+Crookes+P%2C+Peyre+C%2C&rft.pages=138-139~~" class="Z3988~~"> </li> <li id="_note-1"><a title="" href="http://en.wikipedia.org/wiki/Gastroesophageal_reflux_disease#_ref-1">^</a> <cite style="~~font~~FONT-~~style~~STYLE: normal;">Morse CA, Quan SF, Mays MZ, Green C, Stephen G, Fass R (2004). "Is there a relationship between obstructive sleep apnea and gastroesophageal reflux disease?". Clin. Gastroenterol. Hepatol. 2 (9): 761–8. <a class="external" title="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15354276~~" class="external~~" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15354276">PMID 15354276</a>.</cite><span class="Z3988" title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.atitle=Is+there+a+relationship+between+obstructive+sleep+apnea+and+gastroesophageal+reflux+disease%3F&rft.jtitle=Clin.+Gastroenterol.+Hepatol.&rft.date=2004&rft.volume=2&rft.issue=9&rft.au=Morse+CA%2C+Quan+SF%2C+Mays+MZ%2C+Green+C%2C+Stephen+G%2C+Fass+R&rft.pages=761%E2%80%938&rft_id=info:pmid/15354276~~" class="Z3988~~"> </li> <li id="_note-pmid16682569">^ <a title="" href="http://en.wikipedia.org/wiki/Gastroesophageal_reflux_disease#_ref-pmid16682569_0">a</a> <a title="" href="http://en.wikipedia.org/wiki/Gastroesophageal_reflux_disease#_ref-pmid16682569_1">b</a> <a title="" href="http://en.wikipedia.org/wiki/Gastroesophageal_reflux_disease#_ref-pmid16682569_2">c</a> <a title="" href="http://en.wikipedia.org/wiki/Gastroesophageal_reflux_disease#_ref-pmid16682569_3">d</a> <cite style="~~font~~FONT-~~style~~STYLE: normal;">Kaltenbach T, Crockett S, Gerson LB (2006). "Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach". Arch. Intern. Med. 166 (9): 965–71. <a title="Digital object identifier" href="http://en.wikipedia.org/wiki/Digital_object_identifier">DOI</a>:<a ~~rel~~class="~~nofollow~~external text" title="http://dx.doi.org/10.1001/archinte.166.9.965" ~~class~~rel="~~external text~~nofollow" href="http://dx.doi.org/10.1001/archinte.166.9.965">10.1001/archinte.166.9.965</a>. <a class="external" title="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16682569~~" class="external~~" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16682569">PMID 16682569</a>.</cite><span class="Z3988" title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.atitle=Are+lifestyle+measures+effective+in+patients+with+gastroesophageal+reflux+disease%3F+An+evidence-based+approach&rft.jtitle=Arch.+Intern.+Med.&rft.date=2006&rft.volume=166&rft.issue=9&rft.au=Kaltenbach+T%2C+Crockett+S%2C+Gerson+LB&rft.pages=965%E2%80%9371&rft_id=info:pmid/16682569&rft_id=info:doi/10.1001%2Farchinte.166.9.965~~" class="Z3988~~"> </li> <li id="_note-2"><a title="" href="http://en.wikipedia.org/wiki/Gastroesophageal_reflux_disease#_ref-2">^</a> Decktor DL, Robinson M, Maton PN, Lanza FL, Gottlieb S. Effects of Aluminum/Magnesium Hydroxide and Calcium Carbonate on Esophageal and Gastric pH in Subjects with Heartburn. Am J Ther 1995;2:546-552. <a class="external" title="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11854825" ~~class="external" href~~href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11854825">PMID 11854825</a>.</li> <li id="_note-3"><a title="" href="http://en.wikipedia.org/wiki/Gastroesophageal_reflux_disease#_ref-3">^</a> Khoury RM, Camacho-Lobato L, Katz PO, Mohiuddin MA, Castell DO. Influence of spontaneous sleep positions on nighttime recumbent reflux in patients with gastroesophageal reflux disease. Am J Gastroenterol 1999;94:2069-73. <a class="external" title="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10445529~~" class="external~~" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10445529">PMID 10445529</a>.</li> <li id="_note-pmid17229239">^ <a title="" href="http://en.wikipedia.org/wiki/Gastroesophageal_reflux_disease#_ref-pmid17229239_0">a</a> <a title="" href="http://en.wikipedia.org/wiki/Gastroesophageal_reflux_disease#_ref-pmid17229239_1">b</a> <cite style="~~font~~FONT-~~style~~STYLE: normal;">Tran T, Lowry A, El-Serag H (2007). "Meta-analysis: the efficacy of over-the-counter gastro-oesophageal reflux disease drugs". Aliment Pharmacol Ther 25 (2): 143-53. <a title="Digital object identifier" href="http://en.wikipedia.org/wiki/Digital_object_identifier">DOI</a>:<a ~~rel~~class="~~nofollow~~external text" title="http://dx.doi.org/10.1111/j.1365-2036.2006.03135.x" ~~class~~rel="~~external text~~nofollow" href="http://dx.doi.org/10.1111/j.1365-2036.2006.03135.x">10.1111/j.1365-2036.2006.03135.x</a>. <a class="external" title="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17229239~~" class="external~~" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17229239">PMID 17229239</a>.</cite><span class="Z3988" title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.atitle=Meta-analysis%3A+the+efficacy+of+over-the-counter+gastro-oesophageal+reflux+disease+drugs&rft.jtitle=Aliment+Pharmacol+Ther&rft.date=2007&rft.volume=25&rft.issue=2&rft.au=Tran+T%2C+Lowry+A%2C+El-Serag+H&rft.pages=143-53&rft_id=info:doi/10.1111%2Fj.1365-2036.2006.03135.x~~" class="Z3988~~"> </li> <li id="_note-Abbas_2004"><a title="" href="http://en.wikipedia.org/wiki/Gastroesophageal_reflux_disease#_ref-Abbas_2004_0">^</a> <cite style="~~font~~FONT-~~style~~STYLE: normal;">Abbas A, Deschamps C, Cassivi SD, et al. (2004). "The role of laparoscopic fundoplication in Barrett’s esophagus". Annals of Thoracic Surgery 77 (2): 393-396. <a class="external" title="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14759403~~" class="external~~" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14759403">PMID 14759403</a>.</cite><span class="Z3988" title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.atitle=The+role+of+laparoscopic+fundoplication+in+Barrett%E2%80%99s+esophagus&rft.jtitle=Annals+of+Thoracic+Surgery&rft.date=2004&rft.volume=77&rft.issue=2&rft.au=Abbas+A%2C+Deschamps+C%2C+Cassivi+SD%2C+et+al.&rft.pages=393-396&rft_id=info:pmid/14759403~~" class="Z3988~~"> </li>

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<h2>External links</h2>

<ul>

<li><a ~~rel~~class="~~nofollow~~external text" title="http://digestive.niddk.nih.gov/ddiseases/pubs/gerd/" ~~class~~rel="~~external text~~nofollow" href="http://digestive.niddk.nih.gov/ddiseases/pubs/gerd/">GERD patient information page</a> at <a title="NIH" href="http://en.wikipedia.org/wiki/NIH">NIH</a></li> <li><a ~~rel~~class="~~nofollow~~external text" title="http://kidshealth.org/teen/diseases_conditions/digestive/gerd.html" ~~class~~rel="~~external text~~nofollow" href="http://kidshealth.org/teen/diseases_conditions/digestive/gerd.html">KidsHealth GERD Information for Kids</a></li> <li><a ~~rel~~class="~~nofollow~~external text" title="http://www.mayoclinic.org/gerd/" ~~class~~rel="~~external text~~nofollow" href="http://www.mayoclinic.org/gerd/">Mayo Clinic review of diagnosis and treatment options</a></li> <li><a ~~rel~~class="~~nofollow~~external text" title="http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/gastro/acidpeptic/acidpeptic.htm" ~~class~~rel="~~external text~~nofollow" href="http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/gastro/acidpeptic/acidpeptic.htm">Overview</a> at <a title="Cleveland Clinic" href="http://en.wikipedia.org/wiki/Cleveland_Clinic">Cleveland Clinic</a></li>

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