Treatment of GERD

The goals of treatment are:

• To bring the symptoms under control so that the individual feels better;
• heal the esophagus of inflammation or injury;
• manage or prevent complications such as Barrett's esophagus or stricture;
• and maintain the symptoms of GERD in remission so that daily life is unaffected or minimally affected by reflux.

A diagnosis of GERD should be made by a physician. The disease can usually be diagnosed based on the presentation of symptoms alone. GERD can occur, however, with no apparent symptoms. Diagnostic tests may be used to confirm or exclude a diagnosis or to look for complications such as inflammation, stricture, or Barrett's esophagus.

GERD is a recurrent and chronic disease for which long-term medical therapy is usually effective. It is important to recognize that chronic reflux does not resolve itself. There is not yet a cure for GERD. Long-term and appropriate treatment is necessary.

Treatment options include lifestyle modifications, medications, surgery, or a combination of methods. Over-the-counter preparations provide only temporary symptom relief. They do not prevent recurrence of symptoms or allow an injured esophagus to heal. They should not be taken regularly as a substitute for prescription medicines – they may be hiding a more serious condition. If needed regularly, for more than two weeks, consult a physician for a diagnosis and appropriate treatment.

Lifestyle Modifications[1,2]

Lifestyle modifications mean changing things we have control over. It involves avoidance of factors that may bring on symptoms or make them worse, such as dietary changes or changes in daily routine. While diet does not cause GERD, reflux and its most frequent complaint of heartburn can be aggravated by foods. Certain medications can aggravate symptoms. Disclose the use of any medications to your physician.

Heartburn is the burning sensation in the chest behind the breastbone that we feel when stomach acid refluxes back into the esophagus (food tube). If you have this symptom, there are a number of things that you may be doing that brings it on and some things you can do to help prevent it.

Position

Gravity plays an important role in controlling reflux. Those of us who have a less than perfect lower esophageal sphincter (LES) find that if we lie down after a large meal, food comes back into the esophagus and heartburn occurs. If you experience heartburn, think whether it occurs after meals, when you lie in bed at night, or if you take a nap after a meal. Maintaining an upright posture until the meal is digested may prevent the heartburn. If heartburn occurs regularly at night, consider raising the head of the bed or inserting a triangular wedge to keep your esophagus above the stomach. Avoid exertion after a meal. It contracts the abdominal muscles and forces food through a weakened sphincter. This is especially true of tasks that require bending such as lifting or cleaning the floor.

Tip: Don't lie down within 3 hours of eating. That's when acid production is at its peak, so plan early dinners and avoid bedtime snacks.

How you eat

How is perhaps more important than what you eat. A large meal will empty slowly from the stomach and exert pressure on the LES. A snack at bedtime is well positioned to reflux when you lie down. It is best to eat early in the evening so that the meal is digested at bedtime. You might try having the main meal at noon and a lighter one at dinnertime. All meals should be eaten in relaxed stress-free surroundings. Trips to the kitchen to fetch food or the performance of other tasks such as minding children should be suspended during, and for a time after, eating. Smaller meals and an upright, relaxed posture should help minimize reflux.

Tip: Avoid large meals, especially late in the day. Try to make your main meal the mid-day meal.

What you eat

Certain foods compromise the sphincter's ability to prevent reflux, and are best avoided before lying down or exertion. These differ from person to person. Many person find that fats, onions, and chocolate as particularly troublesome. Alcohol often provokes heartburn, by compromising the LES, irritating the esophagus, and by stimulating stomach acid production. Common beverages such as coffee (both caffeinated and decaffeinated), tea, cola, tomato juice, and citrus juice may aggravate symptoms by irritating the esophagus or stimulating stomach acid production.[3] Certain other foods may bother some people; upon their discovery a period of avoidance or reduction may be of benefit.

Tip: Experiment to find what does and does not work best for you. Start by reducing fatty foods, onions, and chocolate.

Some oral medications such as potassium supplements or the antibiotic tetracycline will burn if allowed to rest in the esophagus. To be safe, one should always swallow medication in the upright position and wash it down with lots of water.

Other factors

Being overweight can promote reflux. Excess abdominal fat puts pressure on the stomach and the loss of even a moderate amount of weight makes many people feel better. Pregnancy is often troubled by heartburn, particularly in the first three months. Certain hormones appear to weaken the LES, and the increasingly crowded abdomen encourages reflux. Generally, if there has not been too much weight gain, a woman's heartburn improves after delivery. Stress or strong emotion can also influence heartburn.

Antacids may temporarily relieve heartburn by neutralizing stomach acid. Other over-the-counter drugs that reduce acid production are available for short term and occaisional relief of heartburn.

If heartburn occurs on two or more days per week despite the measures discussed above, you should consult your family doctor.

Prescription Medications[1]

The classes of medications prescribed to treat GERD are promotility agents, H2 blockers, and proton pump inhibitors.

Promotility drugs

Promotility drugs can be helpful in some people (after careful screening for known risk factors) with non-erosive GERD or mild esophagitis. Significantly, there are reported adverse effects of the drug cisapride (Propulsid) in people with certain preexisting conditions and some known drug interactions that can be associated with dangerous cardiac arrhythmias.

The FDA announced on March 23, 2000 that Janssen Pharmaceutica has decided to stop marketing Propulsid in the U.S. as of July 14, 2000. The drug will continue to be available to patients who meet specific clinical eligibility criteria for a limited-access protocol. The action by Janssen is voluntary and the effective date is intended to provide time for patients and physicians to make treatment decisions. Individuals who are currently prescribed cisapride are urged to promptly contact their health care providers to discuss use or alternatives. Be sure to discuss this with your physician.

H2 blockers

H2 blockers reduce the amount of acid produced in the stomach. In prescription doses, they eliminate symptoms and allow esophageal healing in about 50% of patients. However, remission is maintained in only about 25% of people using H2 blockers.

Proton pump inhibitors (PPIs)

Proton pump inhibitors (PPIs) limit acid secretion in the stomach. They allow rapid resolution of symptoms and healing of the esophagus in 80-90% of patients. The drug is also useful in managing stricture, one of the more serious complications of GERD.

Even after symptoms are brought under control, the underlying disease remains present. It is possible that a person may need to take a medication for the rest of their life to manage GERD. Long-term use of medication – whether prescription or nonprescription – should be under the direction and supervision of a physician. Side effects are rare; nonetheless, any drug can potentially have adverse effects.

Surgery[1]

Surgery is an alternative that is generally applied when long-term medical treatment is either ineffective or undesirable, or when certain complications of GERD are present. When considering surgery as a treatment for GERD a thorough review of all aspects of the procedure with a gastroenterologist (a physician who specializes in these disorders) and a surgeon is advised.

Side-effects or complications associated with the surgery occur in 5-20% of patients. The most common are difficulty swallowing or impairment of the ability to belch or vomit. Side-effects are usually temporary, but they sometimes persist.

Antireflux surgery can break down, similar to hernia repairs in other parts of the body. The recurrence rate is not well defined but may be in the range of 10-30% over 20 years. A number of factors can contribute to this breakdown. In some individuals, even after surgery, reflux symptoms may persist and the use of medication may need to continue.