ACID REFLUX DISEASE

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Tuesday, October 18, 2011

Gastroesophageal / Acid Reflux Disease At A Glance


Gastroesophageal / Acid Reflux Disease At A Glance

* Gastroesophageal / Acid Reflux Disease is a condition in which the acidified liquid contents of the stomach backs up into the esophagus.

* The causes of GERD include an abnormal lower esophageal sphincter, hiatal hernia, abnormal esophageal contractions, and slow emptying of the stomach.

* Gastroesophageal / Acid Reflux Disease may damage the lining of the esophagus, thereby causing inflammation (esophagitis), although usually it does not.

* The symptoms of uncomplicated GERD are heartburn, regurgitation, and nausea.

* Complications of GERD include ulcers and strictures of the esophagus, Barrett's esophagus, cough and asthma, throat and laryngeal inflammation, inflammation and infection of the lungs, and collection of fluid in the sinuses and middle ear.

* Barrett's esophagus is a pre-cancerous condition that requires periodic endoscopic surveillance for the development of cancer.

* Gastroesophageal / Acid Reflux Disease may be diagnosed or evaluated by a trial of treatment, endoscopy, biopsy, x-ray, examination of the throat and larynx, 24 hour esophageal acid testing, esophageal motility testing, emptying studies of the stomach, and esophageal acid perfusion.

* GERD is treated with life-style changes, antacids, histamine antagonists (H2 blockers), proton pump inhibitors (PPIs), pro-motility drugs, foam barriers, surgery, and endoscopy.

Tuesday, October 11, 2011

What is a reasonable approach to the management of Gastroesophageal / Acid Reflux Disease?


What is a reasonable approach to the management of Gastroesophageal / Acid Reflux Disease?

There are several ways to approach the evaluation and management of Gastroesophageal / Acid Reflux Disease. The approach depends primarily on the frequency and severity of symptoms, the adequacy of the response to treatment, and the presence of complications.

For infrequent heartburn, the most common symptom of Gastroesophageal / Acid Reflux Disease, life-style changes and an occasional antacid may be all that is necessary. If heartburn is frequent, daily non-prescription-strength (over-the-counter) H2 antagonists may be necessary. A foam barrier also can be used with the antacid or H2 antagonist.

If life-style changes and antacids, non-prescription H2 antagonists, and a foam barrier do not adequately relieve heartburn, it is time to see a physician for further evaluation and to consider prescription-strength drugs. The evaluation by the physician should include an assessment for possible complications of GERD based on the presence of such symptoms or findings as:

* cough,
* asthma,
* hoarseness,
* sore throat,
* difficulty swallowing,
* unexplained lung infections, or
* anemia (due to bleeding from esophageal inflammation or ulceration).

Clues to the presence of diseases that may mimic Gastroesophageal / Acid Reflux Disease, such as gastric or duodenal ulcers and esophageal motility disorders, should be sought.

If there are no symptoms or signs of complications and no suspicion of other diseases, a therapeutic trial of acid suppression with H2 antagonists often is used. If H2 antagonists are not adequately effective, a second trial, with the more potent PPIs, can be given. Sometimes, a trial of treatment begins with a PPI and skips the H2 antagonist. If treatment relieves the symptoms completely, no further evaluation may be necessary and the effective drug, the H2 antagonist or PPI, is continued. As discussed previously, however, there are potential problems with this commonly used approach, and some physicians would recommend a further evaluation for almost all patients they see.

If at the time of evaluation, there are symptoms or signs that suggest complicated Gastroesophageal / Acid Reflux Disease or a disease other than GERD or if the relief of symptoms with H2 antagonists or PPIs is not satisfactory, a further evaluation by endoscopy (EGD) definitely should be done.

There are several possible results of endoscopy and each requires a different approach to treatment. If the esophagus is normal and no other diseases are found, the goal of treatment simply is to relieve symptoms. Therefore, prescription strength H2 antagonists or PPIs are appropriate. If damage to the esophagus (esophagitis or ulceration) is found, the goal of treatment is healing the damage. In this case, PPIs are preferred over H2 antagonists because they are more effective for healing.

If complications of Gastroesophageal / Acid Reflux Disease, such as stricture or Barrett's esophagus are found, treatment with PPIs also is more appropriate. However, the adequacy of the PPI treatment probably should be evaluated with a 24-hour pH study during treatment with the PPI. (With PPIs, although the amount of acid reflux may be reduced enough to control symptoms, it may still be abnormally high. Therefore, judging the adequacy of suppression of acid reflux by only the response of symptoms to treatment is not satisfactory.) Strictures may also need to be treated by endoscopic dilatation (widening) of the esophageal narrowing. With Barrett's esophagus, periodic endoscopic examination should be done to identify pre-malignant changes in the esophagus.

If symptoms of GERD do not respond to maximum doses of PPI, there are two options for management. The first is to perform 24-hour pH testing to determine whether the PPI is ineffective or if a disease other than Gastroesophageal / Acid Reflux Disease is likely to be present. If the PPI is ineffective, a higher dose of PPI may be tried. The second option is to go ahead without 24 hour pH testing and to increase the dose of PPI. Another alternative is to add another drug to the PPI that works in a way that is different from the PPI, for example, a pro-motility drug or a foam barrier. If necessary, all three types of drugs can be used. If there is not a satisfactory response to this maximal treatment, 24 hour pH testing should be done.

Who should consider surgery or, perhaps, an endoscopic treatment trial for GERD? (As mentioned previously, the effectiveness of the recently developed endoscopic treatments remains to be determined.) Patients should consider surgery if they have regurgitation that cannot be controlled with drugs. This recommendation is particularly important if the regurgitation results in infections in the lungs or occurs at night when aspiration into the lungs is more likely. Patients also should consider surgery if they require large doses of PPI or multiple drugs to control their reflux. Still, it is debated whether or not a desire to be free of the need to take life-long drugs to prevent symptoms of Gastroesophageal / Acid Reflux Disease is by itself a satisfactory reason for having surgery.

Tuesday, October 4, 2011

How is Gastroesophageal / Acid Reflux Disease treated?

How is Gastroesophageal / Acid Reflux Disease treated?

Life-style changes

One of the simplest treatments for Gastroesophageal / Acid Reflux Disease 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 Gastroesophageal / Acid Reflux Disease. 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.

Gastroesophageal / Acid Reflux Disease 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 Gastroesophageal / Acid Reflux Disease 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:

* chocolate,
* peppermint,
* alcohol, and
* caffeinated drinks.

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 Gastroesophageal / Acid Reflux Disease 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 Gastroesophageal / Acid Reflux Disease 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.