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Complete Guide To Gastroesophageal Reflux Disease

Gastroesophageal reflux (GER or acid reflux) is a normal occurrence experienced occasionally by many people. According to a study, about 25%-40% of healthy adults in America experience symptomatic GERD at least once monthly. The most common symptom reported was heartburn (pyrosis). Moreover, about 7%-10% of adults in the United States experience GERD symptoms every day. 

Introduction 

The term “gastroesophageal” is made up of two words; ‘gastro’ meaning stomach and ‘esophageal’ for esophagus. The esophagus (food pipe) is a muscular tube that connects your mouth and your stomach. Thus, gastroesophageal reflux disease (or GERD) is a digestive disorder concerned with the lower esophageal sphincter (LES). The lower esophageal sphincter is a muscular junction between your esophagus and your stomach.

Physiologically, the body has defense mechanisms that help prevent GERD. These mechanisms include the activities of the lower esophageal sphincter (LES) and the normal peristalsis. They either control the amount of acid that flows into the esophagus or help clear the substance quickly. 

Gastroesophageal reflux disease (GERD) is a condition that is said to exist when acid reflux is persistent. It occurs when the quantity of gastric juice that flows back into the esophagus is beyond normal limits, causing symptoms. These symptoms may be with or without esophagitis (inflammation/injury of the esophageal mucosa).

Causes of GERD

The lower esophageal sphincter (LES) is the muscular junction between the esophagus and stomach. When you eat and swallow food, the food passes through the esophagus into the stomach. When it is to enter the stomach, the LES opens to allow food into your stomach. Then, it closes to prevent the backflow of food and digestive acids into the esophagus.

GERD occurs when the LES is weak or does not function normally. Thus, the stomach’s contents flow back into the esophagus when the LES does not get closed adequately. The contents of the stomach are acidic and irritate the lining of the esophagus.

Some conditions increase your risk of GERD and/or worsen it. They include:

Hiatal Hernia:

This condition occurs when your upper stomach moves into your chest through a small opening in your diaphragm. The diaphragm is the muscle that separates your belly from your chest. The opening in your diaphragm supports the lower segment of your esophagus and having a hiatal hernia may weaken the LES. Thus, increasing your chances of acid reflux.

A hiatal hernia results from increased pressure in your belly. This may be from coughing, vomiting, straining in the toilet, lifting something heavy, obesity, or pregnancy.

It is commonly seen in people ages 50 and above. It may not need treatment except there is a high risk of strangulation, twisting, severe GERD, and esophagitis.

Obesity:

Being obese or overweight causes the pressure in your abdomen to increase. The increased pressure can cause GERD.

Pregnancy:

The increasing weight of the child and other pregnancy factors increase pressure in your belly. This can also increase your chances of having GERD. Progesterone, the pregnancy hormone, can cause the LES to relax and result in GERD.

Gastroparesis:

When food is retained for long periods in the stomach, certain things begin to unfold. The stomach gets distended and stomach acid levels increase, affecting the function of the LES. When this happens for a while, it can cause or worsen GERD.

Connective tissue disorders:

This includes lupus, rheumatoid arthritis, Churg-Strauss syndrome, and scleroderma. Their disease processes can affect the lower segments of the esophagus, interfere with motility and cause GERD.

Smoking:

The nicotine contained in tobacco relaxes the LES. When it relaxes, there is a reflux of acidic stomach contents into the esophagus and then, GERD.

Diet and eating habits:

Eating certain foods and beverages such as fatty and fried meals, chocolate, coffee, and alcohol can cause GERD. Also, eating large meals or eating late at night can predispose you to GERD.

Certain medications:

These include aspirin, antihistamines, sedatives, calcium channel blockers, antidepressants, nitrates, anticholinergics, and some asthma medications.

Symptoms of GERD

The most common symptom of GERD is heartburn (acid indigestion). Most people experience it as a burning sensation in the chest. It is felt behind the breastbone radiating towards the throat and neck. Some people explain that it feels like food comes back into the mouth, leaving an acidic or bitter taste.

Other symptoms include:

  • Nausea 
  • Vomiting
  • Bad breath
  • Regurgitation (flow of food and fluids from the esophagus back into the mouth)
  • Dysphagia (difficulty swallowing)
  • Feeling a lump in your throat
  • Erosion (wearing away) of the enamel
  • Chronic cough and/or wheezing
  • Laryngitis (manifesting as sore throat/ hoarseness)
  • Otitis media
  • Sleep problems
  • Chest pain
  • New or aggravated asthma

Medication for GERD

Medications are used to treat GERD before considering other lines of treatment. They are aimed at reducing the amount of reflux or curb its effects on the lining of the esophagus. Examples include:

Proton pump inhibitors (PPI):

These are a major line of treatment for people with GERD. They are the most potent medication available for treating GERD. They decrease the production of acid in your stomach by blocking an essential protein. Examples include omeprazole (Prilosec), omeprazole/sodium bicarbonate (Zegerid), lansoprazole (Prevacid), esomeprazole (Nexium), pantoprazole, dexlansoprazole (Dexilant), and rabeprazole (Aciphex).

Antacids:

This group of drugs helps neutralize the acids in your esophagus and stomach with alkaline chemicals. They, thus stop heartburn and provide relief. Prolonged use of antacids can cause side effects such as diarrhea, altered calcium and magnesium, and constipation. Examples of antacids are aluminum hydroxide (ALternaGEL, Amphojel) and magnesium hydroxide (Phillips Milk of Magnesia, Phillips Chewable).

H2 blockers:

This group of medications helps block acid production in the stomach. They are the first-line agents for people with mild to moderate symptoms of GERD and esophagitis. H2 blockers include cimetidine (Tagamet), ranitidine, nizatidine, and famotidine (Pepcid). They are prescribed majorly for chronic heartburn and reflux.

Prokinetics:

These drugs help your stomach empty faster so that you do not have much acid in it. They may also target other symptoms like bloating, nausea, and vomiting. Side effects include diarrhea, nausea, and anxiety. Examples of this class of drugs include metoclopramide (Reglan) and domperidone.

Erythromycin:

This medication is an antibiotic that helps empty the stomach.

Surgeries Available for GERD

Ins severe cases of GERD, surgeries may be needed. Surgery is recommended if medication and lifestyle changes do not improve your symptoms or provide desirable outcomes. Surgical treatments include:

Fundoplication. The surgery involves increasing pressure to the lower end of the esophagus (LES). The surgeon sews the top of the stomach around the LES. The procedure tightens the muscle, increases pressure at the lower esophagus, and succeeds in reducing reflux.

Fundoplication can be carried out through laparoscopy (crating small holes through the abdomen) or through open surgery.

Endoscopic procedures:

This is a range of procedures that include several techniques using the endoscope (a small tube with a camera). They are less invasive, require lesser treatment time, provide lesser pain, and ensure faster recovery than laparoscopy. They include:

  • Transoral incisionless fundoplication (TIF):
    • This surgery involves the use of an endoscope to wind the stomach around the LES with tweezers and plastic fasteners. 
  • Stretta procedure:
    • The use of low radiofrequency heat to produce burns to tighten the muscle of the LES. The doctor achieves this by passing a small tube down the esophagus.

LINX surgery:

The surgeon uses a device to reinforce the LES. The device is a flexible band of interlinked magnetic titanium beads. Using a laparoscope, the band is placed around the junction of your esophagus and stomach. The magnetic attraction of the beads breaks temporarily to make food pass and enter the stomach. However, it is tight enough to prevent reflux.

Lifestyle Changes for GERD

Stay away from food triggers:

Avoid foods, beverages, and drinks that can relax the LES. Examples include fatty and fried foods, spicy foods, chocolate, peppermint, and beverages that contain caffeine and alcohol. Also, foods that irritate the inflamed esophageal lining and worsen symptoms should be avoided. Such foods include pepper, citrus fruits and juices, onion, garlic, and tomato-based products.

Eat moderate amounts of food:

Have smaller meal servings per time to improve your symptoms. Avoid poor eating habits such as overeating, eating close to bedtime, and eating too fast. Chew your food thoroughly as well. 

Good eating habits help reduce the amount of acid in your stomach and prevent excess reflux. Eating 2 to 3 hours before sleeping ensures your stomach is not too full when going to bed.

Quit or avoid smoking:

Tobacco contains nicotine that weakens the LES. Quitting and avoiding smoking helps prevent and improve GERD symptoms.

Lose extra weight:

If you are overweight or obese, the weight around your abdomen can push your stomach upwards. This only worsens your symptoms.  Losing the extra pounds provide relief and improve your health.

Wear loose clothes:

Wearing tight clothes, especially around your abdomen can worsen your symptoms. They increase pressure on your belly and the lower end of your esophagus. Avoid clothes and clothing accessories like tight-fitting pants, tight belts, and corsets. Also, avoid doing sit-up exercises as they put pressure on your belly.

Elevate your head:

Raise the head of your bed by 8 inches or sleep with your head on specially designed wedge pillows. This lets the gravity prevent acid reflux into your esophagus. Be careful not to use pillows because they increase pressure on your stomach.

Improving posture:

Avoid positions like stooping or bending. When sitting, ensure you are doing so straighter.

Detox Cleanse:

Try out Natural Colon for a cleanse followed up by a detox diet to give your stomach time to heal. This might help out in the short term but it’s always best to figure out which foods trigger GERD and avoid them as much as possible. 

Untreated and Long-term Consequences of GERD

If left untreated, GERD can worsen and have consequences. Complications include:

Esophagitis:

This is the inflammation or irritation of the esophagus, also known as esophageal mucosal damage. It is the most common complication of GERD. When the esophagus gets inflamed, it is difficult to swallow and you may feel chest pain. Esophagitis can progress to esophageal stricture, tearing of the esophageal tissue, and Barrett’s esophagus.

Esophageal stricture:

Esophageal strictures are the advanced forms of esophagitis. According to the Savary-Miller classification of degrees of esophagitis, esophageal strictures fall to Grade IV, the highest class. 

In this condition, prolonged deep injury results in fibrotic scarring and abnormal tissue growth (neoplasia). The esophagus becomes narrow, making it difficult to swallow. At this point of GERD, surgery is the main line of treatment.

Esophageal ulcer:

Acidic gastric contents can erode the lining of your esophagus and cause a sore. An esophageal ulcer is a painful sore located at the junction of the esophagus and the stomach. They make it hard to swallow (dysphagia) and can have serious complications. These include bleeding ulcers, esophageal stricture, or perforation of the esophagus.

Barrett’s esophagus:

This is the most serious complication of untreated GERD. In this condition, the lining of the esophagus becomes thicker and reddened. The chronic acid reflux then makes the cells lining the esophagus change and become like the cells lining the intestine. It increases your chance of developing esophageal cancer. 

Lung problems: 

If the reflux goes as far as the back of your throat, it can cause irritation and pain. From there, it can be aspirated (breathed into the lungs) which can result in several respiratory problems. These include postnasal drip, chest congestion, hoarseness, and laryngitis. When it affects the lungs, there can be chronic cough, asthma, bronchitis, and pneumonia.

Upcoming Treatments/Medication

IW-3718

IW-3718 is an upcoming medication under investigation. Proton pump inhibitors (PPIs) are the most widely used drugs for GERD. However, about 30 percent of people with GERD still experience symptoms despite being on once-a-day PPI therapy.

This baseline information prompted clinicians to come with alternatives. These included off-label, twice-daily dosing of the PPI or adding another class of reflux medication, such as H2 blockers. While PPIs inhibit the adverse effects of gastric juices, they do not inhibit the effects of bile. Other reflux medicines also target the inhibition of acid production without addressing the problem of bile reflux.

IW-3718 binds to bile acids in the stomach. Bile acids can damage the lining of the esophagus, stomach, and intestine. It is proposed that the drug may provide relief for patients with severe and chronic cases of gastroesophageal reflux (GERD). IW-3718 may be used as an adjunct therapy to PPIs in severe or non-responsive cases of GERD. 

Studies have been carried to evaluate the safety and efficacy of its doses. IW-3728 is formulated as a tablet with a special technology that controls its release in the gastrointestinal tract. In the stomach, it slowly releases a bile sequestrant which binds bile and prevents its reflux into the esophagus. 

Results from the clinical trials were positive. They revealed that introducing bile sequestration as a drug mechanism was effective in treating refractory GERD. Heartburn symptoms were significantly low in groups that received 1,500mg of the drug twice daily. Regurgitation symptoms were also reduced and no drug-related adverse effects were recorded.

With a drug like IW-3718, chronic GERD can be prevented and treated. Thus, the long-term consequences of GERD can be averted and the quality of life of GERD patients improved.

Conclusion

About 20 percent of adults in the United States adults report experiencing GERD-related symptoms weekly. Many more U.S. adults report having GERD symptoms daily. These symptoms include heartburn (burning sensation and pain in the chest), dysphagia (difficulty swallowing), and regurgitation of food and fluids.

When left untreated, GERD can have serious complications including esophagitis, esophageal ulcers, and stricture. It can result in severe respiratory problems such as asthma, chronic cough, bronchitis, and pneumonia. As a long-term consequence, Barrett’s esophagus increases the risk of esophageal cancer.

Thus, a prompt visit to the doctor and treatment is important. Also, upcoming treatments are necessary to address severe GERD cases.

External Links

MedScape website. Gastroesophageal Reflux Disease. https://emedicine.medscape.com/article/176595 

Vanderbilt University Medical Center Website. GERD Drug Offers New Approach to Relieve Chronic Symptoms. https://discover.vumc.org/2020/03/gerd-drug-offers-new-approach-to-relieve-chronic-symptoms/ 

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