Go away, GERD

Doctors call it gastroesophageal reflux disease or GERD. Millions of people call it heartburn, and many others have coughing, wheezing, or hoarseness without realizing that GERD is to blame. By any name, GERD is common, bothersome, and sometimes serious. But once you know you have GERD, and understand its mechanics, you can control it and prevent complications.

Normal Swallowing

A complex set of 29 muscles in your mouth and tongue gets the process started. They close off your windpipe (trachea) to protect your lungs, and then move the food into your esophagus, or food pipe. The esophagus is a narrow 10- to 13-inch-long tube leading from your throat to your stomach. But food doesn’t just slide down the esophagus. Instead, muscles that encircle the food pipe contract in an orderly wave-like fashion to propel food into the stomach.

Swallowing then is normally a one-way affair. To prevent the food from returning to the esophagus, the ring-like muscles of the lower esophagus pinch the tube closed. Doctors call these muscles the lower esophageal sphincter, or LES (see illustration).

What is GERD?

Every time you swallow, the LES relaxes so food can enter your stomach. When your stomach is full, a tiny amount of food can sneak back into the esophagus when you swallow — that’s normal. But in people with GERD, substantial amounts of stomach acid with digestive juices get into the esophagus. The stomach has a tough lining that resists acid, but the food pipe doesn’t. Its sensitive tissues are injured by acid, and if the acid makes it all the way to the mouth, the other structures can be damaged.

Poor function of the LES is responsible for most cases of GERD. A variety of substances can make the LES relax when it shouldn’t, and others can irritate the esophagus, exacerbating the problem. Other conditions can simply put too much pressure on the LES.

Symptoms

Heartburns and “acid indigestion” are the most common complaints. A burning pain is typical and when it’s accompanied by burping or bloating, it points to GERD as the cause. But GERD can also sometimes cause belly pain that mimics an ulcer. And if acid in the food pipe triggers esophageal spasms, it can cause a heavy or constricting pain that may feel like a heart attack.

If the acid makes it all the way to the throat or mouth, it can cause other problems. And since these problems can occur in the absence of heartburn, they are often misdiagnosed. Here are some of the stealthy signs of GERD:

Mouth and throat symptoms:

• A sour or bitter taste in the mouth

• Regurgitation of food or fluids

• Hoarseness or laryngitis, especially in the morning

• Sore throat or need to clear the throat

• Dental erosions

• Feeling that there is a “lump in the throat”

Lung symptoms:

• Persistent coughing without apparent cause, especially after meals

• Wheezing, asthma

Diagnosis

Most people with GERD don’t need any tests at all. If your symptoms are typical and mild, you may even be able to treat yourself. Similarly, if doctors suspect you have uncomplicated GERD, they may recommend a trial of therapy as the next step; if you respond promptly, you probably won’t be asked to have additional tests.

GERD can be puzzling, however, so if the diagnosis is uncertain, tests may be in order. The old standby is the barium swallow, or upper GI series. Other tests include esophageal monitoring, such as pH monitoring which measures the level of acid in the lower esophagus over a 24-hour period, or manometry, which measures the pressure in the esophagus during swallowing. Endoscopy is the best way to detect the complications of GERD, including inflammation, ulcers, strictures, and abnormal or malignant cells.

Therapy: Lifestyle

You can control many symptoms of GERD with simple lifestyle modifications. Here are some tips:

• Don’t smoke. It’s the first rule of preventive medicine and is as important for GERD as for heart and lung disease.

• Avoid foods that trigger GERD.

• If you are taking certain painkillers, antibiotics, or other medications that can irritate the esophagus or contribute to GERD, ask your doctor about alternatives, but don’t stop treatment on your own.

• Avoid large meals and try to be up and moving around at least 30 minutes after eating. Don’t lie down for two hours after you eat, even if it means giving up that bedtime snack.

• Use gravity to keep the acid down in your stomach at night. Propping up your head with an extra pillow won’t do it. Instead, place four- to six-inch blocks under the legs at the head of your bed. A simpler (and very effective) approach is to sleep on a large, wedge-shape pillow.

• Chew gum, which will stimulate acid-neutralizing saliva.

• Lose weight.

• Avoid tight belts and waistbands.

Treatment: Medications

If you doubt that GERD is a big problem, just check out your local drug store. You’ll find out a vast array of over-the-counter (OTC) products to treat it, plus numerous prescription medications behind the pharmacist’s counter. Here is a look at the five types of medication that can help:

• Proton-pump inhibitors (PPIs). PPIs are the most effective medications for GERD. That’s because they are the best at shutting down the stomach’s acid production. They act rapidly, but even after you feel better, it may take four to eight weeks to heal an inflamed food pipe. Because GERD tends to recur, patients usually need prolonged therapy, and those with severe esophagitis may need high-dose, lifelong treatment. Fortunately, side effects are uncommon. PPIs, which are available as prescription medications, include the following: omeprazole (Losec), lanzoprazole (Prevacid), rabeprazole (Pariet), pantoprazole (Ulcepraz), and esomeprazole (Nexium).

• H2-receptor blockers. These popular drugs were the first to reduce the production of stomach acid. They can provide temporary relief for mild GERD, but are less effective than PPIs. Examples include cimetidine (Tagamet), ranitidine (Zantac), famotidine (H2BLOC), and nizatidine (Axid).

• Antacids. Antacids do not reduce the amount of acid produced by the stomach, but they do neutralize some of it. Many are available over-the-counter. They reduce acid faster than acid-suppressing medications but provide only temporary relief for heartburn.

• Coating agent. Sucralfate (Iselpin) is a prescription drug that protects the esophagus and stomach by forming a protective film on the surface. It is very safe, but long-term benefits are unclear.

• Motility agent. Metoclopramide (Plasil), another prescription drug, promotes normal contractions of the esophagus and helps the stomach to empty faster. Side effects such as drowsiness, agitation, and tremors limit its usefulness, but it can help some patients with GERD.

Getting The Better Of GERD

GERD is a problem of modern life. Smoking, poor eating habits, obesity, alcohol abuse, and stress all fuel the fire of heartburn. A little heartburn from time to time is no big deal – but persistent GERD can lead to serious complications. Fortunately, this modern problem can usually be solved with old-fashioned lifestyle changes and modern drug therapy with PPIs or other agents. –Tyrone M. Reyes, M.D. (The Philippine Star)