Welcome. You're watching Medicine with Dr. Moran. I'm Dr. Keith Moran. Today I'm
going to review the treatment of gastroesophageal reflux in adults. This is a
very common disorder. Many patients refer to it simply as acid
reflux or heartburn. In medicine we use the term GERD. This is an acronym
for gastroesophageal reflux. Many of my patients who take medications for this
understandably want to come off their medications. This video will review the
lifestyle modifications that patients can do so that they can come off their
medications. Even if they can't come off the medications a lot of these things
will allow them to minimize their medications. As always I recommend that
patients review their symptoms with their healthcare providers. gastro esophageal reflux also known as acid reflux occurs when
stomach contents reflux back up into the esophagus or into the mouth. Reflux is a
normal process that occurs in healthy infants, children, and adults. Most
episodes are brief and do not cause bothersome symptoms or complications. In
contrast people with gastro esophageal reflux disease or GERD experience
symptoms as a result of the reflux. This is the esophageal anatomy. When we eat
food is transported from the mouth all the way down here into the stomach and
this section here is the esophagus. It's a tube like structure approximately
10 inches long and one inch wide. Or in metric 25 centimeters long and 2.5
centimeters wide. It connects the back of the throat and then subsequently
connects to the stomach as you can see on this picture. The esophagus is made of
tissue and muscle layers that expand and contract to move the food all the way
down into the stomach through a series of wave-like movements which we call
peristalsis. At the lower end of the esophagus where it
joins the stomach there is a circular ring of muscle called the lower
esophageal sphincter or LES. After swallowing the LES relaxes to allow
food to pass into the stomach and then contracts to prevent the back up of food
and acid into the esophagus. However sometimes the les can be weak or it can
become relaxed because the stomach has distended allowing liquids in the
stomach to regurgitate back into the esophagus. This occurs occasionally in
all individuals. Most of these episodes occur shortly after meals. They're brief
and they do not cause symptoms. Acid reflux occurs rarely when sleeping. Acid
reflux becomes esophageal gastroesophageal reflux disease when it
starts to cause bothersome symptoms or injury to the esophagus. The amount of
acid reflux required to cause gastro esophageal reflux symptoms varies from
person to person. In general damage to the esophagus is more likely to occur
when the reflux is very acidic. If the reflux occurs frequently or if the
esophagus is unable to clear away the acid quickly. Gastroesophageal reflux
symptoms. The most common symptoms associated with acid reflux or heartburn
which is a burning feeling in the chest.
regurgitation which is when undigested food or acid flows back into your throat
or mouth, nausea, belching, a sore throat, a raspy voice related to acid irritating
the vocal cords, causing reflux laryngitis unexplained cough, also
trouble swallowing, a sense of a lump in the throat, pain in the upper abdomen or
chest pain can occur. Chest pain obviously could represent heart disease
or other chest related diagnosis. As always it's best to see your healthcare
professional to review your specific symptoms. The different treatments of
GERD are designed to prevent these symptoms from occurring
and any complications from it. At the top of this image is an example of the
normal anatomy. You can see that the diaphragm is a large flat muscle at the
base of the lungs and contracts and relaxes as a person breathes in and out.
The esophagus passes through an opening in the diaphragm called the
diaphragmatic hiatus before it joins with the stomach. Normally the diaphragm
will contract which improves the strength of the lower esophageal
sphincter especially during bending, coughing, or straining. At the bottom of
the image a depiction of a hiatus hernia is shown. This develops if there's
weakening in the connective tissue attaching the esophagus and stomach to
the diaphragm at the hiatus and so part of the upper portion of the stomach can
slide up through the diaphragm into the chest forming the sliding hiatus hernia.
The presence of a hiatus hernia makes acid reflux more likely as part of the
stomach is actually up above the diaphragm into the chest. As we can see
here this part of the stomach is up into the chest and it slid up. The hiatus
hernia is more common in people over the age of 50. Obesity and pregnancy are also
contributing factors. The exact cause is unknown but is probably mentioned a few
minutes ago. It's likely related to loosening of the connective tissue
around the diaphragm that occurs with advancing age. There's no way to prevent
a hiatus hernia. Reflux treatment of mild symptoms. The initial treatment for mild
acid reflux includes lifestyle changes and non prescription medications
including antacids. Lifestyle changes have been recommended for many years a
literature review concluded that weight loss and elevating the head of your bed
may be helpful but other dietary changes were not found to be helpful in all
patients. So these recommendations may be helpful in some people with mild
symptoms of acid reflux. Weight loss. Losing weight may help
people who are overweight to reduce acid reflux. I see several patients a year who
will lose 20 or 30 pounds and tell me that their reflux symptoms improved
significantly. In addition weight loss has a number of other health benefits
including a reduced risk of type 2 diabetes and heart disease. Raise the
head of the bed 6 inches. While most people only have heartburn for the two
to three hour period after meals some people will wake up at night with
heartburn. People with nighttime heartburn can elevate the head of their
bed which raises the head and shoulders higher than the stomach and it allows
gravity to prevent acid reflux. Raising the head of the bed can be done with
blocks of wood under the legs of the bed or a special foam wedge under the
mattress. Several manufacturers have developed commercial products for this
purpose. However, it's not helpful to use
additional pillows. If you use additional pillows this can cause an unnatural bend
in the body that increases pressure on the stomach and this of course will
worsen acid reflux. Avoid acid reflux inducing foods. Some foods also cause
relaxation of the lower esophageal sphincter promoting reflux. Too much
caffeine, chocolate, alcohol, carbonated beverages, spicy foods, peppermint, and
fatty foods may cause bothersome acid reflux.
I recommend selective elimination of dietary triggers in patients who find
correlation with their symptoms and an improvement in symptoms with elimination.
Avoid large and late meals. Lying down with a full stomach may increase the
risk of acid reflux. By eating three or more hours before bedtime with no
evening snacking reflux can be reduced. In addition eating smaller meals may
prevent the stomach from becoming overdistended which can cause acid reflux.
Other measures that make sense but in studies have not been consistently shown
to be helpful include quitting smoking. Saliva helps to neutralize reflux acid
and smoking reduces the amount of saliva in the mouth and throat. Smoking can also
reduce the pressure in your lower esophageal sphincter and it can provoke
coughing which can also cause frequent episodes of acid reflux. Quitting smoking
can in some patients reduce or eliminate symptoms of mild reflux. Promotion of
salivation by using chewing gum or oral lozenger to neutralize acid that's
refluxed as well as to promote acid clearance from the esophagus when saliva
is swallowed. Avoid tight-fitting clothing at a minimum. Tight-fitting
clothing can increase discomfort but it may also increase pressure in the
abdomen forcing the stomach contents back up into the esophagus. This is a
recent study demonstrating that the intake of coffee tea or soda was
associated with an increased risk of GERD symptoms. In contrast consumption of
water, juice, or milk was not associated with reflux symptoms. The conclusion in
this study was that drinking water instead of coffee, tea, or soda can reduce
the risk of gastro esophageal reflux. Non prescription medications antacids do
not prevent GERD. Antacids are used for intermittent when needed short-term
relief of reflux symptoms. They include magnesium, aluminum or calcium all of
which neutralize gastric acid thereby reducing the acidity of any acid that
would come back up into the esophagus. They work within five minutes but have a
short duration of effect typically 30 to 60 minutes. The acid which is neutralized
very briefly so they're not very effective after more than one hour
Typical antacids that you might buy over-the-counter include Tums, Maalox, and
Mylanta. Histamine receptor antagonists. These medications block the histamine
receptor in the acid producing stomach cell. They're more effective than
antacids at relieving heartburn. Their effects last longer. These medications
include over-the-counter Ranitidine which is brand-name Zantac and
Famotidine brand-name Pepcid. These have a slower onset of action with peak
concentrations occurring 2 to 3 hours after a dose and typically last 4 to 10
hours.
Reflux treatment of moderate to severe symptoms. In addition to the above
treatments more potent acid suppression medication can be used if symptoms are
not well controlled. These are the Proton Pump Inhibitors otherwise known as the
PPIs. They block the hydrogen potassium acid pump in the stomach cell. Compared
to the histamine receptor antagonists these provide faster symptom relief and
are much better at relieving GERD symptoms. They also heal damage within
the esophagus much more effectively. The proton pump inhibitors Rabeprazole also known as Pariet Omeprazole going by brand name of Losec
or Dexlansoprazole with brand name Dexilant.
Lansoprazole, brand name Prevacid, Pantoprazole brand name Pantoloc and Tecta.and Esomeprozole brand name Nexium. One can buy these over the counter as well as by
prescription. They are dosed typically once a day but can be taken twice a day in
severe cases. I recommend 30 to 60 minutes before breakfast and if needed
at the same time before supper. You try to use the lowest dose of the medication
to keep your symptoms under control. Sometimes patients are able to
discontinue the medication and just use it when they need. Some patients
can take PPIs for several days just three or four times a year when reflux
is more of a problem. Other people need to take it every
second day or even once a day. I tell people that they can always adjust their
medication to provide the best control.
If symptoms do not improve on PPIs we call this refractory GERD. Investigations
are clearly needed if that occurs and of course if they've not been done at this
point options might include increasing the dose of the PPI or switching to a
different PPI. I will often split the dose of the PPI by giving two smaller
doses rather than one large dose daily. Other medications can be added if
symptoms are suboptimaly controlled on the above medications Domperidone or
Metoclopramide can be added to further improve them both of these
medications. Domperidone and Metoclopramide improve the muscle tone
of the lower esophageal sphincter to reduce reflux and they also improve the
esophageal muscles contraction to squeeze and improve acid clearance from
the esophagus. Further testing may be required to either confirm GERD or rule
out other problems. Depending on your symptoms surgical treatment for GERD can
be considered. Doctors consider anti reflux procedures an equally effective
alternative to medical therapy for chronic GERD symptoms. We do this and
offer this to patients when we have an appropriately skilled surgeon who can do
the procedure. Typical indications are symptoms incompletely controlled by
the medications I've just mentioned. There are many different surgical
options. Surgery though has a failure rate of ten to fifteen percent with
symptoms of recurrent reflux or difficulty with swallowing. Five to ten
percent of people who have surgery will need redo surgery down the road.
Optimal medical management compared to standard surgical treatment provides
similar five-year remission rates for controlling GERD symptoms.
This is an image demonstrating what the operation looks like if the patient in
question has a hiatus hernia. The surgeon will bring the hernia down into the
abdomen from the chest first then the upper part of the stomach which we call
the fundus is wrapped or as we often call it placated around the esophagus
and then it's stitched together as shown. In the picture you can see how it's
wrapped around and placated together. This provides a barrier against reflux.
If the barrier is too tight people have trouble swallowing. So one needs to
measure this closely at the time of the operation. This procedure can be done
laparoscopically through small incisions in the upper abdomen.
The procedure is called a laparoscopic fundoplication. This is the
most common surgical treatment for GERD. The vast majority of patients certainly
over 99% with reflux or managed though with current medical treatment without
surgery. PPI side effects. PPIs are the most common medications
utilized for GERD. These medications can be taken safely for many years and those
that need the medication we always try to use the lowest dose possible. Safety
data has been collected 25 years out on PPI usage. It is clear that PPIs can
cause low magnesium and low B12 due to reduced intestinal absorption. Magnesium
and B12 levels should be followed in patients on long-term PPIs. PPIs
are associated with a slightly increased risk of a colon infection known as C
difficile colitis. It's known that the PPIs can reduce the absorption of
certain types of calcium products such as calcium carbonate. If calcium
supplementation is necessary calcium supplement that does not require acid
for absorption such as calcium citrate can be given. PPIs can cause acute
inflammation within the kidney called acute interstitial nephritis. This is
uncommon but I have seen a few cases given how many patients over the years
I've seen on PPIs. There is conflicting data on whether PPI
usage is associated with dementia, pneumonia, and bone fracture. I frequently
get asked about these three things and because it's not clear from studies that
these are definitely associated I feel that the risk if anything would be very
small. I hope you've learned a great deal about
what you can do to manage gastroesophageal reflux disease. Thank you for
watching. If you liked the video please consider subscribing and click the bell to
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basis. Thank you for joining me on Medicine with Dr. Moran. I'm Dr. Keith
Moran. Get healthy stay healthy.