A Family Doctor's Tale - GERD

DOC I HAVE GASTROESOPHAGEAL REFLUX DISEASE

GERD is a very common illness in many elderly women where the symptoms are felt worst at night. It is important that the patient must sleep in a elevated position in order for the acid not to flow so easily into the throat from the stomach. Medicines alone will not prevent GERD. The other important part of treatment is to reduce the weight.


Gastroesophageal reflux disease(GERD) is a chronic disease of the esophagus whose mucosa is damaged by abnormal reflux of gastric acid from the stomach to the esophagus.



1.Incompetant Lower Esophageal Sphincter(LES) allow the acid and gastric juice to reflux up the esophagus


2.Hiatus hernia - hole in diaphragm separating esophagus from stomach is enlarged allowing the easier flow of acid up the esophagus


3.Obesity and pregnancy: increased body weight cause pressure in the abdomen to push gastric contents upwards towards esophagus


4.Zollinger-Ellison syndrome- this condition typically increase gastric acid


5.Hypercalcemia, increase gastrin production, leading to increased acidity


6.Corticosteroids like prednisolone - can irritate the stomach mucosa and increase gastric acid


7.Scleroderma and Multiple sclerosis with esophageal involvement


8.Obstructive sleep apnea


9.Gallstones which can impede the flow of bile and digestion of fats

Factors which has been associated with GERD :

1.incompetence of the cardia(junction between the stomach and esophagus),


2.transient cardia relaxation,


3.impaired expulsion of gastric reflux from the esophagus


4.hiatus hernia.


If the reflux affects the throat and larynx, it is called laryngopharyngeal reflux disease.


The most common symptoms are

1.Heartburn - there is a burning discomfort behind the breastbone due to acid flow up the esophagus


2.difficulty in swallowing (dysphagia)- due to narrowing of the esophagus (persistent implies stricture while intermittent implies spasm)


3.chronic chest pain - pain is behind the central sternum as a result of acid in the esophagus


4.cough - the acid flow up the esophagus can irritate the larynx and spark off the cough reflex


5.hoarseness- due to inflammation of the vocal cords from the acid reflux


6.voice changes- as above


7.chronic ear ache- inflammation of the throat from acid reflux an also affect the eustachian tube of the middle ear resulting in pain


8.burning chest pains- again due to the gastric acid in esophagus


9.nausea and belching- too much acid to the throat can cause the nausea and expulsion of air effect


10.sinusitis - acid can also find its way up the throat and into the sinuses.


11.esophagitis (reflux esophagitis)- acid low up the esophagus causing pain
worse on lying down


12.strictures are narrowing of the esophagus resulting from acid in the esophagus,


A detailed history of acid reflux into the esophagus.


Useful investigations may include

1.barium swallow X-rays,


2.esophageal manometry - measures the pressure in the esophagus


3.24-hour esophageal pH monitoring - measures the acidity of the esophagus


4.Esophagogastroduodenoscopy (EGD) involves insertion of a thin scope through the mouth and throat into the esophagus and stomach in order to assess the internal surfaces of the esophagus, stomach, and duodenum.


In general, an EGD is done when:
1.the patient does not respond well to treatment,


2.has danger symptoms including:
dysphagia,


anemia,


blood in the stool (detected chemically),


wheezing,


weight loss,


voice changes.


Esophagogastroduodenoscopy can show peptic stricture, or narrowing of the esophagus near the junction with the stomach.
This can cause dysphagia or difficulty in swallowing


Biopsies done during gastroscopy may show:

1.Edema and basal hyperplasia (non-specific)
2.Lymphocytic inflammation (non-specific)
3.Neutrophilic inflammation (usually due to reflux or Helicobacter Gastroesophageal reflux disease)
4.Eosinophilic inflammation (usually due to reflux)
5.Goblet cell intestinal metaplasia or Barretts esophagus.
6.Elongation of the papillae
7.Thinning of the squamous cell layer
8.Dysplasia or pre-cancer.
9.Carcinoma.
10.Reflux changes may be non-erosive in nature, leading to the non-erosive reflux disease.


GERD complications include


1.stricture formation,


2.Barrett's esophagus,


3.esophageal spasms,


4.esophageal ulcers,


5.esophageal cancer, especially in adults over 60 years old.


Treatment is aimed at
A. prevention of reflux:
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1.weight loss for the Obese


2.Positional therapy

a.Sleeping on the left side has been shown to drastically reduce nighttime reflux episodes in patients


b.Elevating the head of the bed is also effective.


The head of the bed can be raised by wooden bed risers that support bed posts or legs.


Elevation must be at least 6 to 8 inches (15 to 20 cm) to be able to prevent the backflow of gastric fluids.


c.bed wedge pillow will also help to raise the patient's body higher


3.Certain foods should be avoided to prevent gastroesophageal reflux:


a.Coffee,


b.alcohol,


c.Acidic foods, such as oranges,tomatoes and excess amounts of Vitamin C


d.Antacids based on calcium carbonate actually increase the acidity of the stomach. 


e.Foods high in fats -delay stomach emptying


f.Carbonated soft drinks with or without sugar.


g.Chocolate and peppermint.


h.Cruciferous vegetables: onions, cabbage, cauliflower, broccoli, spinach, brussels sprouts.


i.Milk and milk-based products containing calcium and fat,


j.Eating within 2 hours before bedtime.


k.Large meals- smaller meals reduces GERD risk, as it means there is less food in the stomach at any one time.


4.Smoking reduce lower esophageal sphincter competence, and should be avoided


5. Posture and GERD
Slouching causes a kink between the stomach and esophagus.

The esophageal muscles become twisted in a spasm.

Gas and acid get trapped in the spasm,causing irritation to the throat and the windpipe resulting in cough and asthmatic symptoms.


6.Avoid stress.

Learn to relax or meditate.


Adopt a healthy lifestyle with exercises to improve flow of food down the stomach.


B. Neutralizing the Gastric Acid Reflux
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1. Drug treatment

a.Proton pump inhibitors are the best drugs used in reducing gastric acid secretion. (eg Nexium, Losec)


b.Antacids taken before meals half hourly after symptoms begin can reduce gastric acidity (liquid antacid are more useful than tablets)


c.Alginic acid (Gaviscon) protects the mucosa as well as increase pH and decrease reflux.


d.Gastric H2 receptor blockers such as ranitidine or famotidine decrease gastric secretion of acid.


e.Sucralfate (Carafate) is used to help heal and prevent esophageal damage caused by GERD, however it must be taken several times daily and at least two hours apart from meals and medications.


2. Surgical treatment
The standard surgical treatment, done through the laparoscope, is the Nissen fundoplication.


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.


3.New treatments
Eight years ago some new endoscopic devices to treat chronic heartburn were approved:


a.The Endocinch apply stitches in the LES to help strengthen the muscle.


b.The Stretta Procedure uses electrodes to use radio frequency energy to strengthen the LES.


c.The Plicator creates a plication or fold of tissue near the gastroesophageal junction, and fix the fold using a suture-based implant.


Prevention:It is a chronic disease so treatment is lifelong and recurrences are common.


1.Prevent heartburn by limiting acidic foods, such as grapefruit, oranges, tomatoes, or vinegar


2.Spicy foods -Cut back on pepper or chilies.


3.Avoid lying down for two to three hours after meals.
When you are sitting up, gravity helps drain food and stomach acid into your stomach.


4.Eat lean meats and non-fatty foods.
Greasy foods (like French fries and cheeseburgers) can trigger heartburn.


5.Avoid GERD symptom triggers-chocolate, mint, citrus, tomatoes, pepper, vinegar,  and mustard.


6.Avoid drinks that can trigger reflux, such as alcohol, drinks with caffeine, and carbonated drinks.


7.Eat smaller meals to avoid triggering GERD symptoms.


8.Avoid stress.


Learn to relax or meditate.


Adopt a healthy lifestyle with exercises to improve flow of food down the stomach.