By Richard A Krause, M.D.
Everyone has heartburn if they overeat and lie down. Not everyone has GERD (gastroesophageal reflux disease). If you have heartburn more than twice a week, you may have GERD.
Seven percent of the US population has daily heartburn. Close to 40% have at least one episode of heartburn per month.
WHAT ARE THE SYMPTOMS OF GERD?
Heartburn, regurgitation, difficulty swallowing, pain with swallowing, or vomiting of blood are all signs of GERD. Atypical or extra-esophageal symptoms include chronic hoarseness, chronic dental problems, chronic pulmonary problems (asthma, chronic cough, bronchitis), chest pain very similar to a heart attack.
WHAT CAUSES GERD?
- Weak muscles at the junction of the esophagus and stomach
- Hiatal hernia (but not all patients with this develop heartburn)
- Poor muscle contraction of the esophagus (delayed emptying)
- Poor emptying of the stomach
- Physical conditions that predispose to GERD include obesity and pregnancy.
- Social and dietary factors in GERD include cigarette smoking, alcohol, coffee, peppermint, and chocolate. These all tend to lower the pressure in the valve between the esophagus and stomach. Fatty foods on the other hand tend to decrease emptying of the stomach. Medications that may exacerbate GERD include pain medication, tranquilizers, pulmonary medications such as Theophylline, cardiac medication such as calcium blockers, and antispasm or muscle relaxers.
WHEN SHOULD YOU GO TO THE DOCTOR WITH GERD SYMPTOMS?
- GERD symptoms for over 5 years.
- All patients over the age of 50 especially white males (higher risk of cancer).
- Difficulty swallowing, pain with swallowing, bleeding from the GI tract, Weight loss, extra esophageal problems such as chest pain and respiratory problems.
- If you have classic heartburn less than twice a week responding easily to antacids or over the counter medication, you probably do not have to see a doctor unless the problem persists.
WHAT TESTS WILL YOUR DOCTOR RUN TO FURTHER EVALUATE YOUR GERD PROBLEM?
- X-ray of the esophagus (barium swallow with or without food).
- Upper edoscopy under sedation.
- 24 hour pH monitoring of the esophagus (small probe placed in the esophagus to measure the amount of acid regurgitation).
- Esophageal motility or manometry study (small probe placed in the esophagus to measure pressure and muscle contraction).
HOW DO WE TREAT GERD WITHOUT PRESCRIPTION MEDICATION?
- Elevate the head of the bed on blocks rather than sleeping on pillows.
- Stop smoking.
- Avoid foods and medications that may exacerbate your reflux.
- Dietary changes that include reducing size of meals, avoiding bedtime snacks, and of course, avoiding food that irritates the esophagus.
- Over the counter medication which would include antacids and especially Gaviscon which tends to work more for reflux than ordinary ulcer symptoms.
- Over the counter H2 blockers such as Pepcid AC, Zantac, Tagamet, Axid, etcetera.
- PPI’s such as OTC, Omeprazole, Prevacid, and Nexium.
- Lose 10 pounds.
- Prokinetic drugs are drugs that empty the stomach (Reglan, Domperidone, and previously Propulsid, which are no longer available.
ACID SUPPRESSION MEDICATION:
- H2 blockers (Tagamet, Zantac, Pepcid, Axid).
- Proton pump Inhibitors (Prilosec, Prevacid, Aciphex, Protonix, Dexilant and Nexium).
WHAT IS THE DIFFERENCE BETWEEN AN H2 BLOCKER AND A PROTON PUMP INHIBITOR?
H2 blockers prevent the stimulation of the cells that produce acid while proton pump inhibitors actually block acid production in the cell. PPIs (proton pump inhibitors) are much more effective in controlling acid and therefore, healing the esophagus than G2 blockers are. However, both may control symptoms.
WHAT IS A HIATAL HERNIA?
Weakening of muscle between chest and abdomen that allows stomach to move up into the chest resulting in a weak valve and risk of reflux.
HOW ARE PPIS DIFFERENT THAN OTHER MEDICATION IN CONTROLLING HEARTBURN?
PPI effect on acid control may last up to 72 hours. However, the meication must be taken 1 hour before meals in order to be effective. Many of the PPIs require several days of daily dosage before they meet maximum effect. In other words, they should not be taken intermittently or p.r.n. When taken appropriately, PPIs heal acid damage in over 90% of the patients.
WHEN SHOULD YOU CONSIDER SURGERY FOR ACID REGURGITATION?
- The best candidate for surgery would be a young patient who responds well to PPI but does not want to take medication indefinitely.
- The worst patient for surgery would be a patient who does not respond to PPI therapy twice a day. These patients frequently have a rather poor response and complications.
- Other patients that have chronic cough, chronic hoarseness, and asthma related to reflux may respond to surgery, but not as well as those patients that just have heartburn.
- Preventing Barrett’s esophagus or cancer is not an indication for surgery since it is ineffective.
MENU FOR SUCCESSFUL GERD SURGERY:
- Experienced surgeon.
- Diagnosis well established
- No history of poor emptying of the stomach and no history of belching or bloating since these problems will tend to get worse.
WHAT ARE OTHER ENDOSCOPIC OPTIONS WITH REFERENCE TO TREATING REFLUX?
- Streta procedure uses microwave technology to increase muscle tone at the junction between the esophagus and stomach. Procedure indicated only for mild symptoms with small hiatal hernia. Long-term data unavailable.
- Endoscopic suturing of the valve, potential complications, no long term studies – probably not a good option.
- Injection of a chemical to strengthen the valve. Preliminary studies are promising but not available at this time.
WHAT IS BARRETT’S ESOPHAGUS?
Barrett’s esophagus occurs in 10% of chronic reflux patients. It is the growth of atypical stomach tissue up into the esophagus. It is important because this increases the risk of developing cancer of the esophagus, 40 times the normal risk. However, it is still a relatively rare cancer. Barrett’s can be diagnosed only by biopsy, and repeat biopsies are suggested every 2 to 3 years.
TREATMENT GOALS FOR GERD INCLUDE:
- Eliminating symptoms as soon as possible
- Maintaining remission
- Healing any acid damage
- Managing or preventing complications
For more information on esophageal reflux including the possibility of entering one of our research studies, please contact our office at (423) 698-4584.