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 simply
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 the 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 the patients review their symptoms with their healthcare providers.
Gastroesophageal 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 Gastroesophageal 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. It's 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 backup of food and acid into
the esophagus. However sometimes the LES can be weak or it can become relaxed because the
stomach is 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 Gastroesophageal Reflux Disease
when it starts to cause bothersome symptoms or injury to the esophagus. The amount of
acid reflux required to cause Gastroesophageal 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 are 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, or 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 diagnoses 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 thereof.
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's slid up. A 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.
Thus 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
improve 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 six 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 over distended
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 lozenges 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 Gastroesophageal 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 is neutralized very briefly so that they're not very effective after more than one
hour. Typical antacids that you might buy over the counter include tums Malox and Mylanta.
Histamine Receptor Antagonists. These medications block the Histamine Receptor
in the acid-producing stomach cell. They are 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 two to three hours after a dose and typically last four to ten
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 Prilosec, Dexlansoprazole with brand name
Dexilant. Lansoprazole brand name Prevacid, Pantoprazole band name Pantoloc and Tecta,
and Esomeprazole brand name Nexium. One can buy these over the counter as well as by prescription.
They're 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 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 to.
So 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 taking two smaller doses rather than one
large dose daily. Other medications can be added if symptoms are suboptimally 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 I 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 10 to 15%
with symptoms of recurrent reflux or difficulty with swallowing. 5 to 10% 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 Plicated around the esophagus and then it's stitched together as shown in the picture.
You can see how it's wrapped around and Plicated 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 thus the procedure is called a Laparoscopic Fungal Glycation.
This is the most common surgical treatment for GERD. The vast majority of patients certainly
over 99% with reflux are 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 is 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.
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for joining me on Medicine with Dr. Moran. I'm Dr. Keith Moran. Get healthy and stay healthy.