Feel the burn, when diet and lifestyle wrecks havoc on your gut.
Gastroesophageal reflux disease (GERD) is a chronic gastrointestinal disorder with a reflux of stomach contents into the esophagus. For most, GERD can be managed with diet and lifestyle changes, but for some medications may be needed. Besides symptom management, the main concern associated with this condition is that long term uncontrolled GERD is linked to changes in the esophagus lining and even esophageal cancer.
The most classic symptom of GERD is heartburn, which is a burning sensation in the upper chest and throat along, possibly accompanied by the regurgitation of food or fluid into the back of the throat and mouth. Less common symptoms include a chronic cough, vomiting, and difficulty swallowing, all of which are signs of more acute GERD.
GERD can present with erosive reflux disease (ERD) and non-erosive reflux disease (NERD) as defined by the presence or absence of esophageal mucosal damage observed by endoscopy.
How common is GERD?
GERD is a very common condition; according to the Gallup Organization Nation Survey, 24-40% of adults in the United States are affected by GERD. Another recent study reported that the GERD prevalence is between 18%-27% in North America, 9%-25% in Europe, 3%-8% in East Asia, 8%-33.% in the Middle East, 11.6% in Australia, and 23.0% in South America.
The economic burden of GERD is high, with estimated direct cost of $9 to $10 billion per year. In addition, GERD affects the quality of life and work productivity. GERD has been reported to be equal in males and females, but more common in overweight individuals.
Causes of GERD
Several mechanisms have been identified as etiologic factors in the development of GERD. Some of the common factors include LES relaxation, Hiatal hernia, esophageal peristalsis, increased intra-abdominal pressure, and lifestyle.
Lower Esophageal Sphincter (LES) Relaxation: The most common cause of GERD is the transient relaxation of lower esophageal sphincter (LES). The lower esophageal sphincter is located where the gut meets the esophagus and is responsible for preventing food and acidic fluids in the gut and out of the esophagus. Other LES pressure abnormalities such as reduction in resting lower esophageal sphincter (LES) pressure or the shorter length of LES also play a role in the development of GERD.
Hiatal Hernia: GERD can also be caused by hiatal hernia. Hiatal hernia may lead to dysfunctional LES, frequent transient LES relaxations, defective peristalsis, and increased esophageal acid exposure.
Esophageal Peristalsis: According to a study, about 20% of patients with GERD were shown to have an ineffective esophageal motility(IEM)[3]. This may lead to slower acid clearance, with more severe symptoms heartburn, respiratory symptoms, and mucosal injury in patients with IEM.
Increased intraabdominal pressure: This may be more apparent in obese people and pregnant women. Studies show a direct correlation between pressure, body mass index, and waist circumference.
Lifestyle: The following are shown to cause GERD: obesity, narcotics, alcohol, nicotine, chocolate, peppermint, calcium channel blockers. In addition, lying down right after a meal and/or having a late dinner are shown to increase incidence of GERD.
Symptoms
GERD symptoms can be categorised into typical and atypical symptoms. With 60-85% of patients experiencing the classic symptoms of heartburn and or regurgitation.
Typical GERD Symptoms
The economic burden of GERD is high, with estimated direct cost of $9 to $10 billion per year. In addition, GERD affects the quality of life and work productivity. GERD has been reported to be equal in males and females, but more common in overweight individuals.
Causes of GERD
Several mechanisms have been identified as etiologic factors in the development of GERD. Some of the common factors include LES relaxation, Hiatal hernia, esophageal peristalsis, increased intra-abdominal pressure, and lifestyle.
Lower Esophageal Sphincter (LES) Relaxation: The most common cause of GERD is the transient relaxation of lower esophageal sphincter (LES). The lower esophageal sphincter is located where the gut meets the esophagus and is responsible for preventing food and acidic fluids in the gut and out of the esophagus. Other LES pressure abnormalities such as reduction in resting lower esophageal sphincter (LES) pressure or the shorter length of LES also play a role in the development of GERD.
Hiatal Hernia: GERD can also be caused by hiatal hernia. Hiatal hernia may lead to dysfunctional LES, frequent transient LES relaxations, defective peristalsis, and increased esophageal acid exposure.
Esophageal Peristalsis: According to a study, about 20% of patients with GERD were shown to have an ineffective esophageal motility(IEM)[3]. This may lead to slower acid clearance, with more severe symptoms heartburn, respiratory symptoms, and mucosal injury in patients with IEM.
Increased intraabdominal pressure: This may be more apparent in obese people and pregnant women. Studies show a direct correlation between pressure, body mass index, and waist circumference.
Lifestyle: The following are shown to cause GERD: obesity, narcotics, alcohol, nicotine, chocolate, peppermint, calcium channel blockers. In addition, lying down right after a meal and/or having a late dinner are shown to increase incidence of GERD.
Symptoms GERD symptoms can be categorised into typical and atypical symptoms. With 60-85% of patients experiencing the classic symptoms of heartburn and or regurgitation.
Typical GERD Symptoms
- Heartburn or a burning sensation in the throat and upper chest
- Regurgitation of food from the stomach into the back of the mouth
- Burning sensation in the chest 30-60mins after eating or on laying down
Atypical GERD symptoms: can induce GERD
- Asthma
- Chronic cough
- Hoarseness
- Aspiration (choking on regurgitated foods)
- Shortness of breath.
In addition, chronic damage to the esophagus may increase the risk of developing Barrett’s esophagus (BE) and esophageal adenocarcinoma in patients with GERD. In a 5-year follow-up of subjects enrolled in the ProGERD study, it was seen that under routine clinical care, approximately 6% of patients with NERD progressed to BE. Obesity is the major risk factor for developing GERD.
Diagnosis Diagnosis of GERD is based on symptoms and clinical studies such as PPI trial, upper gastrointestinal endoscopy, PH monitoring, and barium swallow.
Proton Pump Inhibitor (PPI) trialProton pump inhibitors are commonly used for the treatment of GERD. Thus, if PPI course for 6-8 weeks relieves heartburn and regurgitation, this strongly suggests GERD. While this is not a very specific method, this test is more cost effective than other diagnostic tests. The diagnostic tests listed below are typically reserved for atypical or severe cases of GERD.
Upper Gastrointestinal Endoscopy
Endoscopy, which is guiding a camera into the esophagus to view the tissue and search for damage is performed to confirm a clinical diagnosis of GERD. Many GERD patients do not have an esophageal damage making this test of limited value. However, endoscopy is the “gold standard” for ruling out associated pathologies such as eosinophilic esophagitis, gastritis, peptic ulcers, and Barrett esophagus.
Ambulatory pH monitoring
According to the Gastrointestinal Medical Association ambulatory pH monitoring is the gold standard for diagnosing GERD. It quantifies the degree of reflux and allows for correlation between symptoms and episodes of reflux. Reflux monitoring may be useful in distinguishing etiologies driving a lack of response to PPI therapy.
Barium swallow
A patient drinks contrast dye and then an X-ray is performed to view structures of the esophagus. This provides information about the anatomy of the esophagus and also associated conditions such as the size and type of hiatal hernia. Barium Swallow is not a direct diagnosis of GERD.
Treatment with Lifestyle and Diet Modifications
Lifestyle and diet changes should be used for all patients as a first step in treating GERD. Food choices, the weight you are, how often you eat, and how what time you have dinner all have a direct impact on your GI system and the occurrence of GERD. Thus, before reaching for those pills, which have side effects, you should start by changing your habits. Some lifestyle modification may help with the symptoms of GERD.
Avoid foods/drinks that lower LES
- Such as chocolate, high acid foods like tomato, peppermint, fatty foods, spicy food, caffeine and carbonated beverages
- Avoid smoking and alcohol
Pay attention to timing of your meals
- Avoid late night meals and sleep with head elevated to reduce the chance of food regurgitation or aspiration
Try fasting and food combining
- Every time we eat we are dumping caustic acid into our stomachs, fasting and intermittent fasting allows for our stomach and esophagus to have a break from this acid and heal
- In addition the different types of foods we eat impact the amount of acid that enters our stomach. A salad for example requires much less acid and digestion time than a steak would. Pairing vegetables with meats allows for efficient digestion, while pairing meat with carbohydrates, which also take longer and more acid to digest, will lead to more aggressive and slower digestion.
Weight loss
- Weight loss in case of obese or overweight people is needed as weight is directly related to the severity of GERD symptoms.
Alternative treatments
- Foods and herbs linked to reduced heartburn include; peppermint, aloe, ginger, oatmeal, lean meats, fish, and greens.
Treatment with Medications
The most common treatment for GERD is the use of proton pump inhibitors or PPI, however H2 antagonist are also effective and have less side effects. In many cases a trial of H-2 receptors will be used for 2 weeks, and if symptoms of GERD still persist, then the patient will be switched into a PPI for 4-8 weeks.
Proton Pump Inhibitors Commonly used PPIs include omeprazole, lansoprazole, rabeprazole, pantoprazole, and esomeprazole. PPIs work by suppressing the production of gastric acid thereby relieving the symptoms of GERD. PPI relieve heartburn, but do not decrease the reflux episodes and so do not control regurgitation in a large percentage of patients.
PPIs are associated with side effects of increased risk fractures, cardiac dysfunction, and gastrointestinal infections. Studies have found positive association of PPIs with small intestinal bacterial overgrowth and also for increase the risk for Clostridium difficile infection. Due to side effects, it is best not to take PPI for more than 4-8 weeks if possible.
H2 receptor antagonistsThese include ranitidine cimetidine, nizatidine, and famotidine. Long term use of these medications is not recommended as the body develops tolerance in 1-2 weeks. Moreover, they are not as effective as PPI in mitigating the symptoms.
Procedures
In the case where diet and lifestyle changes as well as medication treatments are not enough to control symptoms, or in the case of chageses in the esophagus lining the following procedures may be recommended.
Radiofrequency ablation of the LES is used to decrease reflux episodes by increasing LES pressure and decreasing LES relaxations. In one study, a radiofrequency ablation technique called Stretta was found to be insignificant in GERD patients. Stretta was found to be associated with adverse effects such as pneumonia, gastroparesis, esophageal perforation, cardiac arrest, and even death.
Surgery is an option for patients with symptoms refractory to other treatments or for those who have further complications. Fundoplication is the anti-reflux surgery and is an effective treatment option. Fundoplication has been shown to improve quality of life in patients with chronic symptoms. The failure rate of fundoplication ranges from 3% to 16%. Surgery comes with its own complications including bloating, gas, dysphagia, and recurrent symptoms over time. Moreover, failure of the anti-reflux surgery may require a revisional surgery.
Laparoscopic fundoplication is the gold standard for surgical treatment of GERD. Different types of fundoplication include, Nissen, Anterior, and Toupet fundoplication. To make sure that surgery is the best option for treatment, it is important to take into account all the factors such as obesity.
Complications of GERD
Chronic uncontrolled GERD can lead to Esophagitis, Stricture, Barrett’s esophagus (BE) and even esophageal adenocarcinoma.
Esophagitis is the initial stage mucosal damage, where there is a breakdown in the integrity of the mucosal lining of the esophagus due to chronic exposure to stomach acids. Esophagitis can lead to fibrosis or stricture, which is the hardening of the tissue in the throat. Stricture can cause difficulty swallowing and vomiting.
Barrett’s esophagus appears with advanced damage from years of poorly controlled GERD . Is a condition in which there are abnormal changes in the cells of tissue of the esophagus. The normal tissue cells that line the esophagus are replaced with cells similar to those that line the intestine. This is known as metaplasia of the esophagus, which over time can lead to high grade dysplasia of cells and eventually adenocarcinoma or more commonly known, cancer. Barrett’s esophagus is closely associated with esophageal adenocarcinoma.
Outlook
Gastroesophageal reflux disease is a highly prevalent disease, but remains a common and challenging condition. Treatments should including lifestyle modification and if needed, medications.
Warning signs to watch out for include difficulty swallowing, vomiting, vomiting blood, palpable masses, severe chest pain, unexplained weight loss. Notify your doctor immediately if experience any of these symptoms.
