Gastroesophageal Reflux Disease (GERD) (cont.)
How is GERD treated?
Life-style changes
One of the simplest treatments for GERD is referred to as life-style changes,
a combination of several changes in habit, particularly related to eating.
As discussed above, reflux of acid is more injurious at night than during the
day. At night, when individuals are lying down, it is easier for reflux to
occur. The reason that it is easier is because gravity is not opposing the
reflux, as it does in the upright position during the day. In addition, the lack
of an effect of gravity allows the refluxed liquid to travel further up the
esophagus and remain in the esophagus longer. These problems can be overcome
partially by elevating the upper body in bed. The elevation is accomplished
either by putting blocks under the bed's feet at the head of the bed or, more
conveniently, by sleeping with the upper body on a wedge. These maneuvers raise
the esophagus above the stomach and partially restore the effects of gravity. It
is important that the upper body and not just the head be elevated. Elevating
only the head does not raise the esophagus and fails to restore the effects of
gravity.
Elevation of the upper body at night generally is recommended for all
patients with GERD. Nevertheless, most patients with GERD have reflux only
during the day and elevation at night is of little benefit for them. It is not
possible to know for certain which patients will benefit from elevation at night
unless acid testing clearly demonstrates night reflux. However, patients who
have heartburn, regurgitation, or other symptoms of GERD at night are probably
experiencing reflux at night and definitely should use upper body elevation.
Reflux also occurs less frequently when patients lie on their left rather than
their right sides.
GERD Diet
Several changes in eating habits can be beneficial in treating GERD. Reflux is worse following meals. This probably is so because the stomach is distended with food at that time and transient relaxations of the lower esophageal sphincter are more frequent. Therefore, smaller and earlier evening meals may reduce the amount of reflux for two reasons. First, the smaller meal results in lesser distention of the stomach. Second, by bedtime, a smaller and earlier meal is more likely to have emptied from the stomach than is a larger one. As a result, reflux is less likely to occur when patients with GERD lie down.
Certain foods are known to reduce the pressure in the lower esophageal
sphincter and thereby promote reflux. These foods should be avoided and include:
Fatty foods (which
should be decreased) and smoking (which should be stopped) also reduce the
pressure in the sphincter and promote reflux.
In addition, patients with GERD
may find that other foods aggravate their symptoms. Examples are spicy or
acid-containing foods, like citrus juices, carbonated beverages, and tomato juice. These foods should also be avoided.
One novel approach to the treatment of GERD is chewing gum. Chewing gum stimulates the production of more bicarbonate-containing saliva and increases the rate of swallowing. After the saliva is swallowed, it neutralizes acid in the esophagus. In effect, chewing gum exaggerates one of the normal processes that neutralizes acid in the esophagus. It is not clear, however, how effective chewing gum actually is in treating heartburn. Nevertheless, chewing gum after meals is certainly worth a try.
Antacids
Despite the development of potent medications for the treatment of GERD,
antacids remain a mainstay of treatment. Antacids neutralize the acid in the
stomach so that there is no acid to reflux. The problem with antacids is that
their action is brief. They are emptied from the empty stomach quickly, in less
than an hour, and the acid then re-accumulates. The best way to take antacids,
therefore, is approximately one hour after meals or just before the symptoms of
reflux begin after a meal. Since the food from meals slows the emptying from the
stomach, an antacid taken after a meal stays in the stomach longer and is
effective longer. For the same reason, a second dose of antacids approximately
two hours after a meal takes advantage of the continuing post-meal slower
emptying of the stomach and replenishes the acid-neutralizing capacity within
the stomach.
Antacids may be aluminum, magnesium, or calcium based. Calcium-based antacids
(usually calcium carbonate), unlike other antacids, stimulate the release of
gastrin from the stomach and duodenum. Gastrin is the hormone that is primarily
responsible for the stimulation of acid secretion by the stomach. Therefore, the secretion of acid rebounds after the direct acid-neutralizing effect of the calcium carbonate is exhausted. The rebound is due to the release of gastrin,
which results in an overproduction of acid. Theoretically at least, this
increased acid is not good for GERD.
Acid rebound, however, has not been shown to be clinically important. That is, treatment with calcium carbonate has not been shown to be less effective or safe than treatment with antacids not containing calcium carbonate. Nevertheless, the phenomenon of acid rebound is theoretically harmful. In practice, therefore, calcium-containing antacids such as Tums and Rolaids are not recommended. The occasional use of these calcium carbonate-containing antacids, however, is not believed to be harmful. The advantages of calcium carbonate-containing antacids are their low cost , the calcium they add to the diet, and their convenience as compared to liquids.
Aluminum-containing antacids have a tendency to cause constipation, while
magnesium-containing antacids tend to cause diarrhea. If diarrhea or
constipation becomes a problem, it may be necessary to switch antacids or
alternately use antacids containing aluminum and magnesium.
Histamine antagonists
Although antacids can neutralize acid, they do so for only a short period of
time. For substantial neutralization of acid throughout the day, antacids would
need to be given frequently, at least every hour.
The first medication developed for more effective and convenient treatment of
acid-related diseases, including GERD, was a histamine antagonist, specifically
cimetidine (Tagamet). Histamine is an important chemical because it stimulates
acid production by the stomach. Released within the wall of the stomach, histamine attaches to
receptors (binders) on the stomach's acid-producing cells and stimulates the
cells to produce acid. Histamine antagonists work by blocking the receptor for
histamine and thereby preventing histamine from stimulating the acid-producing
cells. (Histamine antagonists are referred to as H2 antagonists because the
specific receptor they block is the histamine type 2 receptor.)
Because histamine is particularly important for the stimulation of acid after
meals, H2 antagonists are best taken 30 minutes before meals. The reason for
this timing is so that the H2 antagonists will be at peak levels in the body
after the meal when the stomach is actively producing acid. H2 antagonists also
can be taken at bedtime to suppress nighttime production of acid.
H2 antagonists are very good for relieving the symptoms of GERD, particularly
heartburn. However, they are not very good for healing the inflammation
(esophagitis) that may accompany GERD. In fact, they are used primarily for the
treatment of heartburn in GERD that is not associated with inflammation or
complications, such as erosions or ulcers, strictures, or Barrett's esophagus.
Four different H2 antagonists are available by prescription, including
cimetidine (Tagamet), ranitidine (Zantac), nizatidine (Axid), and famotidine,
(Pepcid). All four are also available over-the-counter (OTC), without the need
for a prescription. However, the OTC dosages are lower than those available by
prescription.
Proton pump inhibitors
The second type of drug developed specifically for acid-related diseases,
such as GERD, was a proton pump inhibitor (PPI), specifically, omeprazole
(Prilosec). A PPI blocks the secretion of acid into the stomach by the
acid-secreting cells. The advantage of a PPI over an H2 antagonist is that the
PPI shuts off acid production more completely and for a longer period of time.
Not only is the PPI good for treating the symptom of heartburn, but it also is
good for protecting the esophagus from acid so that esophageal inflammation can
heal.
PPIs are used when H2 antagonists do not relieve symptoms adequately or when
complications of GERD such as erosions or ulcers, strictures, or Barrett's
esophagus exist. Five different PPIs are approved for the treatment of GERD,
including omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex),
pantoprazole (Protonix), and esomeprazole (Nexium). A fifth PPI product consists of a combination of omeprazole and
sodium bicarbonate (Zegerid). PPIs (except for Zegarid) are best taken an hour
before meals. The reason for this timing is that the PPIs work best when the
stomach is most actively producing acid, which occurs after meals. If the PPI is
taken before the meal, it is at peak levels in the body after the meal when the
acid is being made.
Pro-motility drugs
Pro-motility drugs work by stimulating the muscles of the gastrointestinal
tract, including the esophagus, stomach, small intestine, and/or colon. One
pro-motility drug, metoclopramide (Reglan), is approved for GERD. Pro-motility
drugs increase the pressure in the lower esophageal sphincter and strengthen the
contractions (peristalsis) of the esophagus. Both effects would be expected to
reduce reflux of acid. However, these effects on the sphincter and esophagus are
small. Therefore, it is believed that the primary effect of metoclopramide may
be to speed up emptying of the stomach, which also would be expected to reduce
reflux.
Pro-motility drugs are most effective when taken 30 minutes before meals and
again at bedtime. They are not very effective for treating either the symptoms
or complications of GERD. Therefore, the pro-motility agents are reserved
either for patients who do not respond to other treatments or are added to
enhance other treatments for GERD.
Foam barriers
Foam barriers provide a unique form of treatment for GERD. Foam barriers are
tablets that are composed of an antacid and a foaming agent. As the tablet
disintegrates and reaches the stomach, it turns into foam that floats on the top
of the liquid contents of the stomach. The foam forms a physical barrier to the
reflux of liquid. At the same time, the antacid bound to the foam neutralizes
acid that comes in contact with the foam. The tablets are best taken after meals
(when the stomach is distended) and when lying down, both times when reflux is
more likely to occur. Foam barriers are not often used as the first or only
treatment for GERD. Rather, they are added to other drugs for GERD when the
other drugs are not adequately effective in relieving symptoms. There is only
one foam barrier, which is a combination of aluminum hydroxide gel, magnesium
trisilicate, and alginate (Gaviscon).
Surgery
The drugs described above usually are effective in treating the symptoms and
complications of GERD. Nevertheless, sometimes they are not. For example,
despite adequate suppression of acid and relief from heartburn, regurgitation,
with its potential for complications in the lungs, may still occur. Moreover,
the amounts and/or numbers of drugs that are required for satisfactory treatment
are sometimes so great that drug treatment is unreasonable. In such situations,
surgery can effectively stop reflux.
The surgical procedure that is done to prevent reflux is technically known as
fundoplication and is called reflux surgery or anti-reflux surgery. During
fundoplication, any hiatal hernial sac is pulled below the diaphragm and
stitched there. In addition, the opening in the diaphragm through which the
esophagus passes is tightened around the esophagus. Finally, the upper part of
the stomach next to the opening of the esophagus into the stomach is wrapped
around the lower esophagus to make an artificial lower esophageal sphincter. All
of this surgery can be done through an incision in the abdomen (laparotomy) or
using a technique called laparoscopy. During laparoscopy, a small viewing device
and surgical instruments are passed through several small puncture sites in the
abdomen. This procedure avoids the need for a major abdominal incision.
Surgery is very effective at relieving symptoms and treating the
complications of GERD. Approximately 80% of patients will have good or excellent
relief of their symptoms for at least 5 to 10 years. Nevertheless, many patients
who have had surgery—perhaps as many as half—will continue to take drugs for
reflux. It is not clear whether they take the drugs because they continue to
have reflux and symptoms of reflux or if they take them for symptoms that are being caused
by problems other than GERD. The most common complication of fundoplication is
swallowed food that sticks at the artificial sphincter. Fortunately, the
sticking usually is temporary. If it is not transient, endoscopic treatment to
stretch (dilate) the artificial sphincter usually will relieve the problem. Only
occasionally is it necessary to re-operate to revise the prior surgery.
Endoscopy
Very recently, endoscopic techniques for the treatment of GERD have been developed and tested. One type of endoscopic treatment involves suturing (stitching) the area of the lower esophageal sphincter, which essentially tightens the sphincter.
A second type involves the application of radio-frequency waves to the lower part of the esophagus just above the sphincter. The waves cause damage to the tissue beneath the esophageal lining and a scar (fibrosis) forms. The scar shrinks and pulls on the surrounding tissue, thereby tightening the sphincter and the area above it.
A third type of endoscopic treatment involves the injection of materials into the esophageal wall in the area of the LES. The injected material is intended to increase pressure in the LES and thereby prevent reflux. In one treatment the injected material was a polymer. Unfortunately, the injection of polymer led to serious complications, and the material for injection is no longer available. Another treatment involving injection of expandable pellets also was discontinued. Limited information is available about a third type of injection which uses gelatinous polymethylmethacrylate microspheres.
Endoscopic treatment has the advantage of not requiring surgery. It can be performed without hospitalization. Experience with endoscopic techniques is limited. It is not clear how effective they are, especially long-term. Because the effectiveness and the full extent of potential complications of endoscopic techniques are not clear, it is felt generally that endoscopic treatment should only be done as part of experimental trials.
Prevention of transient LES relaxation
Transient LES relaxations appear to be the most common way in which acid
reflux occurs. Although there are available drugs that prevent
relaxations, they have too many side effects to be generally useful. Much attention
is being directed at the development of drugs that prevent these relaxations
without accompanying side effects.
Next: What is a reasonable approach to the management of GERD? »
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