Health Library Should I Use Medications or Surgery to Treat Gastroesophageal Reflux Disease (GERD)?From Healthwise

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 if needed, and taking nonprescription medicines that reduce or block acid. These include antacids (for example, Tums), H2 blockers (for example, Pepcid), and proton pump inhibitors (for example, Prilosec OTC). You may be able to control GERD symptoms with home treatment alone.
• If you have been using nonprescription medicines to treat your symptoms for longer than 2 weeks, talk to your doctor. If you have GERD, the stomach acid could be causing damage to your esophagus. Your doctor can help you find the right treatment.
• If your symptoms are not controlled by nonprescription medicines, or are more severe, you may need prescription medicines. Besides relieving your symptoms, medicines can allow the esophagus to heal if it's been damaged. Medicines can also prevent complications of GERD such as inflammation or narrowing of the esophagus.
• You may consider surgery for GERD if medicines do not completely relieve your symptoms, if you can't or don't want to take medicines, or if you have abnormal symptoms, including asthma or hoarseness, that do not adequately improve with medicines.
• If you have a hiatal hernia and you decide to have surgery for GERD, your hernia will be fixed during the surgery.

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 a sour taste in the mouth or an uncomfortable feeling of burning, warmth, heat, or pain just behind the breastbone. This feeling is commonly referred to as heartburn.

See a picture 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. But 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 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. But if you have GERD, it does not mean that you have a hiatal hernia for sure. And some people who have a hiatal hernia never have any GERD symptoms.
• 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 to prevent injury to the lining of the esophagus or to help the esophagus heal if injury has already occurred, to prevent GERD from reoccurring, and to prevent other conditions that might arise as complications of GERD.

How effective are medicines for GERD symptoms?

The effectiveness of medicines used to control symptoms of GERD depends on the severity of your symptoms. Nonprescription medicines may not be strong enough to control your symptoms, and you may need prescription medicines. Keep in mind that some of these medicines are not as effective for some people who may need to try other medicines or consider surgery. If your symptoms cannot be controlled with medicines, 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, Rolaids, or Tums) 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 medicines that reduce the amount of acid in the stomach. These medicines 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. But if you have been using Prilosec OTC to treat your symptoms for longer than 2 weeks, talk to your doctor. If you have GERD, the stomach acid could be causing damage to your esophagus. Your doctor can help you find the right treatment.
• 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 how bad your symptoms are, medicines 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 medicines for GERD?

To be effective, the medicines need to be taken regularly. If you forget to take your medicine, your symptoms will return.

While the medicines 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. Many antacid preparations combine active ingredients to balance side effects. For example, antacids may contain both magnesium and aluminum to prevent diarrhea and constipation. 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. Also, these medicines may interfere slightly with the actions of warfarin (such as Coumadin) or phenytoin (such as Dilantin). So if you are taking warfarin or phenytoin, talk with your doctor about the effect of taking a proton pump inhibitor for GERD. Proton pump inhibitors may also reduce the amount of calcium your body absorbs. This may be linked to an increased risk of broken bones.²
• Prokinetic agents cause side effects in up to 3 out of 10 people taking them, depending on which prokinetic agent is being taken.³ 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. Lifestyle changes and antacids are usually tried first to treat pregnant women who have GERD. Antacids are safe to use for heartburn symptoms during pregnancy. If lifestyle changes and antacids don't help control your symptoms, talk to your doctor about using other medicines. Most of the time, symptoms get better after the baby is born.

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 most often done using a laparoscopic surgical technique.

Studies show that laparoscopic fundoplication improves GERD symptoms in about 6 to 9 out of 10 people who have the surgery (depending on how experienced the surgeon is). But no studies have proven that laparoscopic fundoplication surgery will work to keep the esophagus from getting irritated or inflamed again over the long term.⁴

A successful surgery does not guarantee that you will never have symptoms again. Some studies show that only about 1 out of 10 people who have fundoplication surgery done by an experienced surgeon have symptoms come back in the 2 years after surgery.¹ But there isn't much research on how many people have symptoms come back after more than 2 years.

But compared to people who do not have surgery, people who have surgery are less likely to need medicine every day and have less severe symptoms when they stop taking medicine. Also, people who have surgery for GERD seem to be happy with the results, even if their symptoms do come back and they have to take medicine again.⁵

About 2 or 3 out of 10 people who have surgery to relieve GERD symptoms have new problems (such as difficulty swallowing, intestinal gas, or bloating) after the surgery.¹ These new symptoms may or may not respond to treatment with medicines.

What new problems could develop if I have surgery for GERD?

All major surgical procedures have a slight risk caused by the anesthesia as well as a risk of 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 medicines.⁴

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).

What might happen if I decide not to take medicines 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 medicines or have surgery to manage your symptoms. 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:

1. Use medicines to treat GERD symptoms.
2. Have surgery to strengthen your lower esophageal sphincter and, if you have one, correct your hiatal hernia.

The decision about whether to use medicines or surgery to treat GERD takes into account your personal feelings and the medical facts.

These personal stories may help you make your 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 medicines or surgery to treat GERD. Discuss the worksheet with your doctor.

Circle the answer that best applies to you.

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 medicines or surgery to treat GERD.

Check the box below that represents your overall impression about your decision.

Return to the topic Gastroesophageal Reflux Disease (GERD).

Citations

1. Richter JE (2006). Gastroesophageal reflux disease and its complications. In M Feldman et al., eds., Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 8th ed., vol. 1, pp. 905–936. Philadelphia: Saunders Elsevier.

2. Yang YX, et al. (2006). Long-term proton pump inhibitor therapy and risk of hip fracture. JAMA, 296(24): 2947–2953.

3. Lowe RM, et al. (2006). Gastroesophageal reflux disease. In MM Wolfe et al., eds., Therapy of Digestive Disorders, 2nd ed., pp. 191–208. Philadelphia: Saunders Elsevier.

4. Kahrilas PJ (2001). Management of GERD: Medical versus surgical. Seminars in Gastrointestinal Disease, 12(1): 3–15.

5. 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.

Author:	Monica Rhodes	Last Updated: March 31, 2008
Medical Review:	Kathleen Romito, MD - Family Medicine Jerome B. Simon, MD, FRCPC, FACP - Gastroenterology
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