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Gastroesophageal Reflux Disease (GERD) - Symptoms, Treatment, & Causes

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New treatments underway for GERD

As the name implies, gastroesophageal reflux disease means reflux of the contents of the stomach including hydrochloric acid and gastric enzymes into the esophagus. Occasional episodes of reflux are normal in healthy people but when this reflux occurs more often leading to inflammation of the esophagus, then it takes the form of a disease known as GERD.  About 30% of the general population is affected by this disease.

Cause and Risk Factors for Gastroesophageal Reflux Disease (GERD)

The esophagus is normally contracted at its lower end with a smooth muscle called the sphincter. When there is abnormal relaxation of this sphincter, it causes reflux of acid from the stomach into the esophagus. The factors contributing to abnormal relaxation of the lower esophageal sphincter are:
  • Dietary and environmental factors: Alcohol, tea, coffee, chocolate, peppermint, and dietary fat
  • Increased pressure inside the abdomen in pregnancy, obesity
  • Defect in emptying of the stomach into the small bowel
  • Hiatal hernia: sliding of a part of the stomach from the abdomen into the thorax
  • Drugs: calcium channel blockers, sleeping pills, antidepressants
 

Clinical features of Gastroesophageal Reflux Disease (GERD)

Patients with GERD commonly complain of a burning sensation in the chest and waterbrash (salivation after acid enters into the mouth). These symptoms are provoked by lying down, bending, and straining. Some patients may also experience hoarseness of voice due to the gastric acid irritating the larynx, chronic cough, asthma, erosion of teeth enamel, and chest infections. Chronic GERD can lead to inflammation of the esophagus and if left untreated it can even cause cancer of the esophagus. In long-standing cases of GERD, patients may have difficulty swallowing food and water. Some health conditions associated with GERD include pharyngitis, chronic bronchitis, chronic sinusitis, fibrosis of the lung, and sleep apnea (pause in breathing while sleeping).

Diagnosing Gastroesophageal Reflux Disease (GERD)

Young patients without severe symptoms such as difficulty swallowing, weight loss, and signs of an occult blood loss can be treated without investigations. Investigation is required if symptoms are atypical or any complication is suspected or the patient is over 50-55 years of age. In these patients, an endoscopy is done to rule out any disease that may be mimicking GERD and to identify any complications. Some health problems mimicking GERD include esophagitis (pill-induced or infection-induced), peptic ulcer disease, esophageal motility disorders, colicky pain due to gall stone, and dyspepsia. Elderly patients presenting with chest pain should be evaluated for coronary heart disease as heart diseases such as angina (decreased blood supply to the heart muscle)  can also mimic GERD symptoms. 

24-hour pH monitoring may be advised by the physician if the diagnosis is not clear. In this procedure, a probe is placed inside the esophagus and the pH within the gastric lumen is recorded while the patient goes about his daily routine. If pH is found to be less than 4 for 6-7% of the recorded time, then the patient is diagnosed as having GERD. If a diagnosis can not be made with standard pH testing, then impedance testing is done, which is a technique to measure the amount and type of gastroesophageal reflux.

Management of Gastroesophageal Reflux Disease (GERD)

Management of GERD is done in a stepwise manner. Treatment of GERD is targeted at symptomatic relief, healing of esophagitis, and prevention of further complications.

Change in lifestyle measures is recommended for GERD patients such as weight loss, avoidance of food that triggers symptoms, avoidance of acidic foods (e.g., tomato, citrus fruit), and avoiding taking meals late at night. Using multiple pillows while sleeping to raise the level of the head from the bed may also be beneficial for some.
If symptoms do not respond to lifestyle measures, then proton pump inhibitors (PPIs) such as Esomeprazole which decreases acid production are usually prescribed by physicians for the short term. However, in many cases, symptoms recur as soon as the drug intake is stopped. In such cases, PPI may be taken for longer durations to achieve symptom resolution. 

Another drug called Domperidone may also be prescribed by your physician to improve any abnormal motility of the esophagus. Alginates and antacids may also improve symptoms. Although H2 blockers commonly known by its generic name as Ranitidine can improve symptoms, it has not been shown to help in the healing of esophagitis. 

There are some side effects related to long-term use of acid-suppressing medications like malabsorption of vitamin B12, iron, magnesium, and increased risk of osteoporotic fracture. These drugs also predispose to infection of the gut with salmonella and clostridium difficile. If a patient requires PPI for more than a year, then Helicobacter pylori eradication may be required if the patient tests positive for the bacteria via diagnostic tests such as a Rapid Urease Test. 

Patients who fail to respond to medical therapy may be advised to undergo laparoscopic anti-reflux surgery. Most patients treated surgically notice an improvement in symptoms but can develop gas bloat syndrome which is an inability to vomit and abdominal bloating as a side effect.

Clinical Trials Exploring New Treatments for GERD

  • Fexofenadine: Fexofenadine is an antihistamine group of drugs. Histaminic blockers relieve gastroesophageal reflux symptoms that are refractory to treatment with PPIs by reducing pain perception. A study is underway to assess the effectiveness of fexofenadine for the treatment of GERD symptoms in patients refractory to PPIs.
  • Upper esophageal sphincter (UES) assist device: UES augmentation via the UES assist device relieves GERD associated laryngeal symptoms. In a pilot trial, there was a significant reduction in symptoms following 2 weeks of UES assist device. A clinical trial is currently underway to evaluate the efficacy of this device as an adjunct to PPIs in symptomatic patients.
  • Domperidone: Domperidone enhances forward contractility of stomach and bowel and inhibits reflux of stomach contents into the esophagus. A clinical trial on this drug is also being conducted to evaluate changes in disease severity after the use of domperidone in children aged 12-21 years who are refractory to standard therapies. Another study is also going on to evaluate how well domperidone helps in relieving symptoms of GERD.
  • Gracie diet: The objective of this diet plan is to combine foods in meals so that the overall pH of food becomes neutral. It is based on the principle of not mixing cereals together, acidic foods with any other type, and fats with sugars. The National Institute of Health endorses dietary modification as a first line of treatment of GERD. A clinical trial is underway to assess whether Gracie diet is effective in relieving GERD symptoms.
   
References
Kahrilas PJ: Clinical practice. Gastroesophageal reflux disease. N Engl
J Med 359:1700, 2008.

Kahrilas PJ et al: American Gastroenterological Association Institute
technical review on the management of gastroesophageal reflux disease. Gastroenterology 135:1392, 2008.

Shaheen NJ et al: Diagnosis and Management of Barrett’s Esophagus.
Am J Gastroenterol 111:30, 2016.

Spechler SJ, Souza RF: Barrett’s esophagus. N Engl J Med 371:836,
2014

     

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