About 10 to 20 per cent of the population has heartburn (gastroesophageal reflux disease – GERD).
Excessive reflux of acidic, often with alkaline bile salt and duodenal contents, results in a multitude of symptoms for the patient including heartburn, regurgitation, cough, and dysphagia.
There are also associated complications of reflux including erosive esophagitis, Barrett’s esophagus (a pre-malignant condition), stricture and cancer of the esophagus.
Your risk of heartburn and inflammation of the esophagus (esophagitis) increase if you have hiatal hernia, if you smoke, if you are pregnant, if you have scleroderma, or drink excessive alcohol. You should avoid food that’s acidic or high in fat – like citrus fruits, tomatoes, onions, chocolate, coffee, cheese, and peppermint. Spicy foods or large meals can also cause heartburn.
You shouldn’t worry about occasional heartburn. It is quite common. But frequent heartburn which does not respond to increased medications should be investigated. It is called refractory gastroesophageal reflux disease. Weight loss and difficulty swallowing are other red flags. Investigations should be carried out to see if you have complications like Barrett’s esophagus (a pre-malignant condition), strictures, esophageal ulcer, or bleeding.
Diagnostic tests required are as follows:
- Upper endoscopy with biopsies – also known as gastroscopy (scope test) to check for infection, inflammation, ulcers or cancer. This is the first step in the diagnostic and therapeutic process.
- Ambulatory acid (pH) probe test. A monitor is placed in your esophagus to identify when, and for how long, stomach acid regurgitates.
- Esophageal manometry. This test measures the rhythmic muscle contractions in your esophagus when you swallow. Esophageal manometry also measures the coordination and force exerted by the muscles of your esophagus.
- Barium x-ray of your upper digestive system.
Management of GERD
Common questions that arise regarding management of GERD include which medications are most effective with no side effects, when surgery may be indicated, which patients should be screened for Barrett’s esophagus and helicobacter pylori infection.
There are four primary treatment goals: 1. relief of symptoms, 2. prevention of relapse, 3. healing of inflamed esophagus, and 4. prevention of complications of esophagitis.
To start with, we should attempt to suppress gastric acid production and reflux into the esophagus. This is done by the use of lifestyle modifications (e.g., elevating the head of the bed, modifying the size and composition of meals) and use of appropriate medications.
Uncomplicated reflux can be managed with antacids that neutralize stomach acid. It may provide some relief but will not heal inflamed esophagus. Overuse of some antacids can cause side effects, such as diarrhea or sometimes kidney problems. In the absence of alarm symptoms, endoscopy is not necessary to make an initial diagnosis of GERD.
Persistent heartburn will require medications to reduce acid production. These medications (H-2-receptor blockers) include cimetidine (Tagamet HB), famotidine (Pepcid AC) and nizatidine (Axid AR).
Next line of management will be to use medications that block acid production and heal the esophagus. These medications – known as proton pump inhibitors (PPI) – are stronger acid blockers than H-2-receptor blockers and allow time for damaged esophageal tissue to heal. Examples include lansoprazole (Prevacid 24 HR) and omeprazole. PPI should be taken 30 to 60 minutes before the first meal. PPIs are the most effective medical therapy, and all PPIs provide similar relief of GERD symptoms.
It should be remembered that two common types of GERD medicines (H-2 receptor blockers and PPI) have been associated with B-12 deficiency to varying degrees. Also, there is a risk of hip fractures. With either type of medication, the risk of B-12 deficiency was significantly increased when taken daily for two years or more.
If medical treatment fails then, one should consider surgical options. Anti-reflux operations are aimed at creating an effective barrier to reflux at the gastroesophageal junction There are various types of anti-reflux operations that are successful. Laparoscopic fundoplication is the gold standard for surgical treatment of severe GERD and results in approximately 95 per cent patient satisfaction (World J Gastrointest Surg. 2016 Jan 27).
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