Gastroesophageal Reflux Disease (GERD)
By James R. Gray, MD, FRCP(C), Clinical Associate Professor, Faculty of Medicine, Division of Gastroenterology, University of British Columbia, Chairperson, Medical Advisory Council for The Canadian Society of Intestinal Research
Gastroesophageal reflux disease can be an important factor in causing or aggravating asthma or cough symptoms, particularly in people who do not respond to standard asthma treatment. If you are diagnosed with, and treated for, GERD you will experience better symptom control of your GERD and a possible reduction of your asthma symptoms. Sometimes these two conditions co-exist and, left untreated, this combination can worsen the severity of each condition. Each illness requires separate treatments. This article focuses on GERD.
Gastroesophageal reflux occurs when the upper portion of the digestive tract is not functioning properly. The esophagus is a muscular tube linking the mouth to the stomach. In normal digestion, a specialized ring of muscle at the bottom of the esophagus called the lower esophageal sphincter, or LES, opens to allow food to pass into the stomach and then quickly closes to prevent backflow into the esophagus. The LES can malfunction, allowing contents from the stomach, including food and digestive juices such as hydrochloric acid, to push up into the esophagus. In gastroesophageal reflux disease (GERD), this backflow is ongoing.
Acid reflux is responsible for the majority of the symptoms and/or damage to the esophagus. More than 20% of Canadians experience recurring GERD symptoms. Research studies reveal that GERD has a significant negative impact on well-being and quality of life.
Heartburn is the most common symptom of GERD. It usually feels like a burning pain in the chest, beginning behind the breastbone and moving toward the neck and throat. It often worsens after eating and while lying down, and can last as long as two hours at a time. The pain results from the irritating effects of stomach acid on the esophagus wall, which does not have the same natural protection from acid as does the stomach.
A number of individuals also describe a sensation of food or liquid coming up into the throat or mouth (regurgitation), especially when bending over or lying down and this can leave a bitter or sour taste in the mouth. While many Canadians experience occasional heartburn or regurgitation, these symptoms are frequent in persons with GERD.
GERD patients can also experience atypical symptoms, including persistent sore throat, hoarseness, chronic coughing, difficult or painful swallowing, asthma, unexplained chest pain, bad breath, a feeling of a lump in the throat, and an uncomfortable feeling of fullness after meals.
In some cases, the acid may travel all the way up the esophagus past the upper esophageal sphincter, or UES, and into the throat, damaging the structures in the throat. Known as laryngopharyngeal reflux disease, or LPR, this has now become an important diagnosis for physicians to consider in patients with chronic throat clearing, coughing, and a feeling of a lump in the throat. Sometimes, the acid lingering in the throat is breathed into the lungs, irritating the delicate tissues there causing symptoms to mimic those common in lung diseases diagnoses.
Too much stomach acid reflux can result in inflammation of the esophagus (esophagitis), which can lead to esophageal bleeding or ulcers. Chronic scarring may narrow the esophagus and interfere with a person’s ability to swallow, requiring surgery. A few patients may develop a condition known as Barrett’s esophagus, which is severe damage to the cells lining the bottom of the esophagus. Doctors believe Barrett’s esophagus may increase the chance of developing esophageal cancer. Please talk to your physician if your GERD symptoms change.
In most cases, if your symptoms are primarily heartburn or acid regurgitation, your doctor can accurately diagnose GERD. However, at times testing may be required to confirm the diagnosis or to determine the degree of esophageal damage from GERD. Testing also rules out other possible causes of your symptoms. These tests may include an upper GI series, an upper GI endoscopy, and 24-hour pH monitoring. Other less frequently performed tests include the Bernstein test and esophageal manometry.
Lifestyle and dietary changes Although clinical evidence suggests that lifestyle and dietary modifications are usually not sufficient to bring chronic GERD under control, your physician might make dietary recommendations to increase your comfort. Irritating foods vary from person to person, so try limiting foods that cause you discomfort. Avoiding large portions at mealtime and eating smaller, more frequent meals may aid in symptom control. Many overweight individuals find symptom relief when they lose weight, as it seems that the excess pounds put pressure on the digestive tract, negatively affecting its function. Smoking cessation is also important for reducing GERD symptoms as studies point to relaxation of the LES with smoking. GERD patients should avoid lying down right after eating and refrain from eating within two to three hours of bedtime. Elevating the head of the bed about six inches may also help, but do not do this by propping up your upper body with pillows as this bends the body, potentially increasing abdominal pressure.
Medications There are two main approaches to treating GERD with medications; neutralizing acid or blocking its production.
For neutralizing acid, over-the-counter medications such as Maalox®, Tums®, and bismuth (Pepto-Bismol®) may subdue symptoms. Some find that these non-prescription antacids provide quick, temporary, or partial relief but they do not prevent heartburn. Consult your physician if you are using antacids for more than 3 weeks.
Two classes of medication that suppress acid secretion are histamine-2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs).
H2RAs work by blocking the effect of histamine, which stimulates certain cells in the stomach to produce acid. These include cimetidine, ranitidine (Zantac®), famotidine (Pepcid®), and nizatidine (Axid®). H2RAs are all available by prescription and some are accessible in a lower dose non-prescription formulation.
PPIs work by blocking an enzyme necessary for acid secretion. These include omeprazole (Losec®), lansoprazole (Prevacid®), pantoprazole (Pantoloc®), esomeprazole (Nexium®), and rabeprazole (Pariet™). In Canada, PPIs are available only by prescription. PPIs have emerged as the most effective therapy for relieving symptoms and improving quality of life, as well as healing and preventing damage to the esophagus in persons with GERD. If you would prefer to drink the medicine, you may mix Nexium® in water and consume it as a drink. Some PPIs have formulations for children as young as one year old. To achieve full effectiveness, these medications should be taken once a day for at least eight weeks, but symptom relief is usually felt within a couple of days.
Treatments that reduce reflux by increasing LES pressure and downward esophageal contractions are metoclopramide and domperidone maleate. A plant-based prokinetic agent, Iberogast®, helps regulate digestive motility and improve GERD symptoms.
All of the medications discussed above have specific treatment regiments, which you must follow closely for maximum effect. Usually, a combination of these measures can successfully control the symptoms of acid reflux. Some medications and supplements may aggravate your symptoms so be sure to check with your physician or pharmacist with any specific questions.
Medications along with lifestyle and dietary changes successfully manage most cases of GERD and serious complications are rare. GERD is a chronic condition that can range from mild to severe.
This article is adapted from the patient information published by the Canadian Society of Intestinal Research, www.badgut.org. Printed here by permission CSIR© all rights reserved.
from Allergy & Asthma News, Issue 4 2008