Overview: Gastroesophageal Reflux Disease (GERD)

• Gastro-esophageal reflux disease (GERD) occurs when there is abnormal passage of acidic stomach contents, or refluxate, into the esophagus, causing symptoms or complications.

• It is one of the primary causes of the informal name and symptom “heartburn,” and GERD is a common phenomenon. Estimates are that 15% to 20% of people in the United States have heartburn or regurgitation at least once a week, and 7% of people suffer from those symptoms daily.

• Symptoms of GERD may include any or all of the following: retrosternal burning, acid regurgitation, nausea, vomiting, chest pain, laryngitis, cough, and dysphagia.

• The injury to the esophagus can include esophagitis, stricture, the development of columnar metaplasia (Barrett esophagus), and adenocarcinoma.

• A poor correlation exists between the severity of symptoms and the pathophysiologic findings in the esophagus.

• For example, GERD is not the only phenomenon in the differential diagnosis of heartburn.

• Many people with GERD do not have endoscopic evidence of esophagitis, and up to 40% of people with Barrett esophagus in one study did not report heartburn.

• The confusing nature of this condition makes it a challenge to develop concrete screening recommendations for advanced disease.

• National Health Interview Survey, based on 31,044 interviews in the United States, documented that 3.7% of people used complementary and alternative medicine for stomach or intestinal illnesses.

You would be surprised at the benefits received from simply using an abs-roller to strengthen your core abdominal muscles.

And also finish your meals before 7 PM.

Importants Points to Consider

• Cow's milk protein is a common cause of gastroesophageal reflux disease in infants, and a trial of elimination should be considered.

• The prolonged use of decoctions or infusions of dried, unprocessed licorice root can cause hypertension, hypokalemia, and edema because of the mineralocorticoid action of a saponin glycyrrhizin, also called glycyrrhizic acid.

• Aggressive, long-term acid suppression can decrease the absorption of vitamin B12. Consider regular intramuscular injections of vitamin B12 for those individuals requiring long-term treatment with histamine-2 receptor blockers or proton pump inhibitors. Use of these drugs can also lead to iron malabsorption, increased risk of hip fracture, and community-acquired pneumonia.

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For Practitioners Trying To Help Patients Taper Proton Pump Inhibitors

Prevention Prescription

• Avoid foods and supplements, and, when possible, medications known to decrease lower esophageal sphincter tone.

• Ab Roller Exercises

• Maintain ideal body weight. Reduce stress as much as possible, through lifestyle change and stress management and mind-body techniques.

• Avoid large meals and consuming large quantities of liquids with meals.

• Avoid late night meals. Take last meal 3 hours prior to sleeping.

Therapeutic Review

This summary of possible therapies is for patients with mild to moderate, short-term GERD. Patients with long-standing, more severe GERD should undergo an appropriate diagnostic workup, which may include a referral to a gastroenterologic specialist and upper endoscopy to rule out esophagitis, ulcers, Barrett esophagus, or adenocarcinoma.

Removal of Exacerbating Factors

• Avoid foods, supplements, and, when possible, medications known to decrease lower esophageal sphincter tone.

• If applicable, quit smoking.

• If applicable, lose weight.

Lifestyle

• For nocturnal symptoms, elevate the head of the bed 4 to 6 inches.

• Avoid large meals and consuming large quantities of liquids with meals.

• Take last meal 3 hours prior to sleeping.

• Ab Roller Exercises to strengthen abdominal muscles

Mind-Body Medicine

• Practice stress management and relaxation techniques.

Botanical Medicines

• Deglycyrrhizinated licorice: two to four 380-mg tablets before meals

• Slippery elm: 1 to 2 tablespoons of powdered root in a glass of water, three to four times daily

• Other botanical medicines that have potential benefit include chamomile, marshmallow, skullcap, and valerian (see Table 41-2).

Pharmaceuticals

• Start with a proton pump inhibitor, both for symptomatic relief and for diagnostic purposes.

• Histamine-2 receptor antagonists

• Over-the-counter antacids, such as calcium carbonate, aluminum hydroxide, and magnesium hydroxide, can be helpful.

Surgery

• For people with intractable symptoms, fundoplication should be considered.

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Key Web Sources

• American College of Gastroenterology clinical updates: www.acg.gi.org/physicians/clinicalupdates.asp.

References

• Goyal RK. Diseases of the esophagus. In: Kasper DL, Braunwald E, Fauci AS, et al, eds. Harrison's Principles of Internal Medicine. 16th ed. New York: McGraw-Hill; 2004.

• Kahrilas PJ. Gastroesophageal reflux disease. N Engl J Med. 2008;359: 1700–1707. Wileman SM, McCann S, Grant AM, et al. Medical versus surgical management for gastro-oesophageal reflux disease (GORD) in adults. Cochrane Database Syst Rev. 2010;(3):CD003243.

• Barnes P, Powel-Griner E, McFann K, Nahin RL. Complementary and Alternative Medicine Use among Adults: United States, 2002. Advance data from vital and health statistics no. 343. Hyattsville, MD: National Center for Health Statistics; 2004.

• Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 17th ed.Philadelphia: Saunders; 2004.

• Van Deventer G, Kamemoto E, Kuznicki JT, et al. Lower esophageal sphincter pressure, acid secretion, and blood gastrin after coffee con- sumption. Dig Dis Sci. 1992;37:558–569.

• Thomas FB, Steinbaugh JT, Fromkes JJ, et al. Inhibitory effect of coffee on lower esophageal sphincter pressure. Gastroenterology. 1980;79:1262–1266.

• Feldman M, Barnett C. Relationships between the acidity and osmolality of popular beverages and reported postprandial heartburn. Gastroenterology. 1995;108:125–131.

• Dennish GW, Castell DO. Caffeine and the lower esophageal sphincter. Am J Dig Dis. 1972;17:993–996.

• Pizzorno JE, Murray ME, eds. Textbook of Natural Medicine. 2nd ed. Edinburgh: Churchill Livingstone; 1999.

• MacDonald-Haile J, Bradley LA, Bailey MA, et al. Relaxation training reduces symptom reports and acid exposure in patients with gastroesophageal reflux disease. Gastroenterology. 1994;107:61–69.

• Bradley LA, Richter JE, Pulliam TJ, et al. The relationship between stress and symptoms of gastroesophageal reflux: the influence of psychologi- cal factors. Am J Gastroenterol. 1993;88:11–19.

• Oranu AC, Vaezi MF. Noncardiac chest pain: gastroesophageal reflux disease. Med Clin North Am. 2010;94:233–234.

• Iacono G, Carroccio A, Cavataio F, et al. Gastroesophageal reflux and cow's milk allergy in infants: a prospective study. J Allergy Clin Immunol. 1996;97:822–827. 15.

• Forget P, Arends JW. Cow's milk protein allergy and gastro-oesophageal reflux. Eur J Pediatr. 1985;144:298–300. 16.

• Yarnell E. Naturopathic Gastroenterology. Sisters, OR: Naturopathic Medical Press; 2000. 17.

• Mills S, Bone K. Principles and Practice of Phytotherapy: Modern Herbal Medicine. Edinburgh: Churchill Livingstone; 2000. 18.

• Johnson LP. Pocket Guide to Herbal Medicines. Malden, MA: Blackwell Science; 2002. 19. Brinker F. Herb Contraindications and Drug Interactions. 3rd ed. Sandy, OR: Eclectic Medical Productions; 2001. 20.

• van Pinxteren B, Numans ME, Bonis PA, Lau J. Short-term treatment with proton pump inhibitors, H2-receptor antagonists and prokinetics for gastro-oesophageal reflux disease–like symptoms and endoscopy nega- tive reflux disease. Cochrane Database Syst Rev. 2006;(3): CD002095. 21.

• Hershcovici T, Fass R. Management of gastroesophageal reflux dis- ease that does not respond well to proton pump inhibitors. Curr Opin Gastroenterol. 2010;26:367–378. 22.

• Lockie A. The Family Guide to Homeopathy. New York: Simon and Schuster; 1989. 23.

• Dickman R, Schiff E, Holland A, et al. Clinical trial: acupuncture vs. doubling the proton pump inhibitor dose in refractory heartburn. Aliment Pharmacol Ther. 2007;26:1333–1344. 24.

• Michelfelder AJ, Lee KC, Bading EM. Integrative medicine and gastro- intestinal disease. Prim Care. 2010;37:255–267. 25.

• Broeders JA, Mauritz FA, Ahmed Ali U, et al. Systematic review and meta-analysis of laparoscopic Nissen (posterior total) versus Toupet (posterior partial) fundoplication for gastro-oesophageal reflux disease. Br J Surg. 2010;97:1318–1330. 26.

• Craig WR, Hanlon-Dearman A, Sinclair C, et al. Metoclopramide, thick- ened feedings, and positioning for gastro-oesophageal reflux in children under two years. Cochrane Database Syst Rev. 2005;(2): CD003502. 27.

• Werbach MR, Murray MT. Botanical Influences on Illness: A Sourcebook of Clinical Research. 2nd ed. Tarzana, CA: Third Line Press; 2000.