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Gastroesophageal
Reflux Disease |
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Overview |
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Definition |
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Gastroesophageal reflux disease (GERD), a disorder associated with a range of
clinical manifestations, results from the reflux of gastroduodenal contents into
the esophagus. A common and often chronic condition, GERD affects a large
percentage of healthy individuals, both male and female, many of whom have
experienced symptoms for more than a decade. Heartburn, the primary symptom, is
often exacerbated by lying down after eating. Complications are more common with
older patients. Although nearly 20% of adults use indigestion aids at least
weekly, only about one-quarter of those who experience true GERD seek medical
attention.
GERD is generally not considered to be a disease unless the symptoms are
severe and occur frequently or the esophageal mucosa is damaged. It is important
to note that individual symptoms do not always reflect the severity of
esophageal mucosal damage. |
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Etiology |
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- Lower esophageal sphincter (LES) dysfunction
- Peptic stricture
- Esophageal inflammation
- Peristaltic dysfunction
- Esophageal cancer
- Abnormal saliva
- Excessive acid production
- Delayed gastric emptying
- Reflux of bile salts
- Reflux of pancreatic enzymes
- Scleroderma
- Decreased LES pressure resulting from progestational hormones during
pregnancy
- Chalasia in infants
- Heller's myotomy for
achalasia
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Risk Factors |
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- Esophageal clearance dysfunction (possibly hiatal hernia)
- Taking medications that lower LES pressure
- Eating foods that lower LES pressure
- Exposure to substances that irritate esophageal mucosa
- Smoking
- Alcohol or coffee consumption
- Chest trauma
- Indwelling nasogastric tube
- Elimination of H. pylori infection (controversial)
- Children: cerebral palsy, Down syndrome, mental
retardation
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Signs and Symptoms |
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- Heartburn
- Regurgitation
- Dysphagia
- Odynophagia
- Water brash
- Belching
- Retrosternal burning sensation
- Chest pain (similar to angina)
- Bronchospasm (asthma)
- Laryngitis
- Chronic cough
- Recurrent aspiration
- Pulmonary fibrosis
- Wheezing
- Hoarseness
- Sore throat
- Globus sensation in the neck
- Infants: apnea syndrome, failure to thrive, recurrent
emesis
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Differential
Diagnosis |
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- Esophagitis
- Angina
- Respiratory ailments
- Ear, nose, and throat ailments
- Radiation exposure
- Crohn's disease
- Esophageal carcinoma
- Achalasia
- Ulcer disease
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Diagnosis |
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Physical Examination |
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Usually normal |
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Pathology/Pathophysiology |
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- Abnormal peristalsis
- Poor LES tone
- Actual mucosal damage (including from cell damage), ranging from
shallow, linear erosions to denudation
- Hyperplasia
- Barrett's epithelium changes
- Acute esophageal inflammation, including erosions, ulceration, and
strictures
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Imaging |
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- Barium swallow: reveals reflux, esophageal damage (not effective for
mild esophagitis), and hiatal hernia; simple and inexpensive
- Radionuclide scintigraphy: reveals
reflux
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Other Diagnostic
Procedures |
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Can be used to confirm GERD, determine if GERD resulted from acid reflux,
determine if mucosal inflammation or other damage has resulted, and ascertain
the severity of the condition.
- Esophageal manometry: indicates abnormal peristalsis and poor LES
tone; does not show reflux
- Prolonged esophageal pH monitoring: enables comparison of symptoms to
actual acid levels
- Acid perfusion (Bernstein) test: indicated for patients with atypical
symptoms or treatment complications
- Endoscopy with biopsy: most effective assessment of reflux-induced
mucosal damage; recommended with complications (e.g., stricture or Barrett's
epithelium)
- Gastric analysis
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Treatment Options |
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Treatment Strategy |
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The goal of GERD treatment depends on the severity of the
condition:
- Patients without esophagitis: relieve symptoms
- Patients with esophagitis: relieve symptoms, treat damage, and
prevent complications
GERD treatment is generally based on three levels of
severity:
- Patients with mild symptoms but without esophagitis: modify
lifestyle, prescribe PRN medications (H2 antagonists, antacids, alginic acid,
prokinetics), maintain with PRN medications
- Patients with moderate to severe symptoms but without significant
esophagitis: modify lifestyle, prescribe daily medications (H2 antagonists and
prokinetics), maintain with same medications
- Patients with intractable symptoms and severe esophagitis and
patients who have not responded to other drug therapy: modify lifestyle,
prescribe daily medication (proton-pump inhibitor), maintain with proton-pump
inhibitor, consider antireflux surgery
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Drug Therapies |
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- Antacids and alginic acid—appropriate for
mild and infrequent symptoms; ineffective for esophagitis. Gaviscon, 10 ml qid
(30 minutes after meals and at bedtime).
- Prokinetics—effectively relieve heartburn;
debatable effectiveness for esophagitis. Bethanechol, 10 to 15 mg qid or
metoclopramide (both 30 minutes before meals and at bedtime); frequent side
effects in young and older patients. Cisapride, 10 mg qid (30 minutes before
meals and at bedtime); increases LES pressure; minimal side effects; useful for
maintenance therapy for symptoms and mild esophagitis; should be used cautiously
with antifungal imidazole agents.
- H2 antagonists—effectively relieve symptoms
and generally heal mild-to-moderate esophagitis; can prevent relapse with mild
GERD. Cimetidine or famotidine or nizatidine or ranitidine, once or twice/day;
some interactions.
- Proton-pump inhibitors (PPIs)—potent,
long-acting acid secretion inhibitors; relieve severe symptoms and heal
esophagitis; provide effective maintenance therapy; minimal short-term side
effects, long-term side effects unknown. Omeprazole or
lansoprazole.
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Complementary and Alternative
Therapies |
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Dietary changes can be very important in decreasing the irritation of GERD.
Herbs may be very effective at healing esophagitis. The correct homeopathic
treatment may also be quite helpful. |
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Nutrition |
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- Digestive enzymes may assist in decreasing the occurrence of
heartburn.
- Avoid any known allergens. May be helpful to test for food
allergies.
- Avoid sweets, oils, fats, and
caffeine.
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Herbs |
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Herbs are generally a safe way to strengthen and tone the body's systems. As
with any therapy, it is important to ascertain a diagnosis before pursuing
treatment. Herbs may be used as dried extracts (capsules, powders, teas),
glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless
otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water.
Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for
roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as
noted.
Herbs used as carminatives often contain volatile oils that may actually
worsen relaxation of LES. Instead, digestive bitters are often astringent and
tonic to mucous membranes.
- Licorice (Glycyrrhiza
glabra)—anti-inflammatory, antispasmodic, and
analgesic specific for the gastrointestinal tract. Glycyrrhetinic acid has been
shown in studies to aid healing of gastric, peptic, and mouth ulcers. In
patients with hypertension, use deglycyrrhizinated licorice (DGL) to prevent
aggravating hypertension. Prolonged use may lead to pseudoaldosteronism, which
resolves with discontinuation of the herb. Chewable lozenges may be the best
form for treating GERD, 380 to 1,140 mg/day.
- Slippery elm (Ulmus fulva)—demulcent
(protects irritated tissues and promotes their healing), 60 to 320 mg/day; 1
tsp. powder may be mixed with water tid to qid.
In addition, a combination of four of the following herbs may be used as
either a tea (1 cup tid) or tincture (30 to 60 drops tid):
- Valerian (Valeriana
officinalis)—bitter, sedative, especially for
anxiety or depression and poor digestion
- Wild yam (Dioscorea
villosa)—antispasmodic, anti-inflammatory,
especially for fatigue from long-term stress or maldigestion
- St. John's wort (Hypericum
perforatum)—analgesic, antidepressant, historically
used to treat adhesions and strictures, especially for anxiety or
pain
- Skullcap (Scutellaria
lateriflora)—antispasmodic, sedative, nervine,
especially for disturbed sleep
- Linden flowers (Tilia
cordata)—antispasmodic, mild diuretic, gentle
bitter, especially for dyspepsia
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Homeopathy |
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An experienced homeopath should assess individual constitutional types and
severity of disease to select the correct remedy and potency. For acute
prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours
until acute symptoms resolve.
- Arsenicum album for burning pain that feels better with
warmth, especially with anxiety
- Carbo vegatabilis for bloating and indigestion that is worse
from lying down, especially with flatulence and fatigue
- Lycopodium for heartburn that feels worse with eating, and
bloating that is relieved by eructation
- Nux vomica for heartburn with cramping and constipation,
especially with irritability
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Acupuncture |
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May be helpful to normalize digestion and alleviate
stress |
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Patient Monitoring |
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Repeat endoscopy 6 to 12 weeks if symptoms not relieved. Annual
endoscopy/biopsy for Barrett's esophagus. Attentive management when
complications are present. |
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Other
Considerations |
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Prevention |
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- Reduce LES pressure: avoid fats, chocolate, coffee, and carminatives.
Avoid medications that lower LES pressure (e.g., antidepressants,
calcium-channel blockers, nitrates, progesterone, and theophylline).
- Avoid esophageal irritants: avoid spicy foods, tomato-based foods,
and citrus. Avoid medications associated with drug-induced
esophagitis.
- Improve acid clearance: change sleeping angle by elevating head of
bed or upper body. Do not lie down after meals. Avoid voluntary
eructation.
- Reduce gastric distension: avoid excessive eating. Avoid food and
liquid two to three hours before bedtime or lying down. Lose weight. Avoid
tight-fitting garments. Avoid bending and stooping.
- Maintenance drug therapy, if needed.
- Possible periodic dilation of peptic stricture.
- Surgery (primarily laparoscopic) as alternative to long-term drug
therapy.
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Complications/Sequelae |
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- Esophageal (peptic) stricture
- Esophageal ulcer
- Adenocarcinoma
- Pulmonary aspiration
- Upper GI hemorrhage
- Esophageal mucosa damage, possibly severe
- Ear, nose, and throat complications
- Loss of dental enamel
- Vocal cord granuloma
- Halitosis
- Pneumonia
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Prognosis |
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A chronic condition, GERD lapses and relapses (generally when treatment
concludes), producing symptoms with varying intensity over
time. |
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Pregnancy |
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GERD is common in pregnancy, especially in the third trimester. Chewable
papaya tablets may provide relief and are safe for pregnant
women. |
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References |
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Andreoli TE, Bennett JC, Carpenter CCJ. Cecil Essentials of Medicine.
3rd ed. Philadelphia, Pa: WB Saunders Co; 1993:285-287.
Barker LR, Burton JR, Zieve PD, eds. Principles of Ambulatory Medicine.
4th ed. Baltimore, Md: Williams & Wilkins; 1995:443-446.
Bartram T. Encyclopedia of Herbal Medicine. Dorset, England: Grace
Publishers; 1995:217.
Dambro MR, ed. Griffith's 5 Minute Clinical Consult. Baltimore, Md:
Lippincott Williams & Wilkins; 1999:422-423.
Kelley WN, ed. Essentials of Internal Medicine. Philadelphia, Pa: JB
Lippincott Company; 1994:104-106.
Morrison R. Desktop Guide to Keynotes and Confirmatory Symptoms.
Albany, Calif: Hahnemann Clinic Publishing; 1993:39-43, 102-103, 229-231,
272-275.
Stoller JK, Ahmad M, Longworth DL, eds. The Cleveland Clinic Intensive
Review of Internal Medicine. Baltimore, Md: Williams & Wilkins;
1998:595-599.
Werbach MR. Nutritional Influences on Illness. New Canaan, Conn: Keats
Publishing Inc; 1987:210. |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |