Gastroesophageal Reflux Disease (GERD) Get Diagnosed - Get Treated

Spring 2010 CSANews Issue 74  |  Posted date : May 27, 2010.Back to list

By far the most common medical condition affecting the gastrointestinal tract in the senior population is GERD (gastroesophageal reflux disease). Estimated to occur in the general adult population in one in five persons, it is even more common in older adults. In the last few decades, there has been much research into the causes, presenting symptoms and treatment of this disabling medical condition. Forty years ago, the common GI problems were thought to be hiatus hernia, gallbladder disease and stomach ulcers, but these conditions are far less frequent than GERD.

Symptoms

GERD is most commonly associated with symptoms such as heartburn or acid indigestion, sub-sternal chest discomfort, regurgitation, nausea and sometimes trouble with swallowing. Most of us have experienced some of these symptoms when lying down after a large meal, eating spicy foods or ingesting excess alcohol and we usually get relief with an antacid. When these symptoms persist or become frequent, it's time to seek medical attention. Failure to treat this condition can lead to increased discomfort and to some serious complications. As well, sometimes angina caused by coronary artery disease may be the cause of such symptoms and it is important that a physician rule out heart disease as the cause.

What is GERD?

Normal anatomy of the junction between the esophagus (the tube that carries food from the mouth to the stomach) and the stomach does not allow for the acidic gastric contents to move into the esophagus. If there are changes to this normal valve-like barrier, the symptoms of GERD can occur. When this happens, the lower esophageal lining reacts adversely to the acidic juices and becomes inflamed. This can lead to chronic inflammatory changes to the esophageal mucosa. This malfunction of the junction can be caused by a number of conditions, including temporary or permanent relaxation of the sphincter or a hiatus hernia. A hiatus hernia occurs when the upper portion of the stomach tends to protrude upwards through the opening in the diaphragm, thereby often disrupting the normal valve-like action of the muscle. GERD does not occur with everyone who has a hiatus hernia.

Symptoms can be aggravated by large and spicy meals, citrus fruits, chocolate, fried and fatty foods, excess weight, excess alcohol intake, smoking or lying down just after eating a meal.

More recent research is focusing on a number of atypical symptoms that can be attributed to GERD. These symptoms often result in an initial misdiagnosis and more intensive investigation may be required to establish the cause as GERD. Such symptoms may include persistent sore throat, hoarseness, chronic cough and even asthma. The exact reason for these symptoms is uncertain. There is some evidence that the acidic reflux may be acting directly on the upper airway tissues or that there may be stimulation of the vagus nerve, which can then cause such symptoms. It is now suggested by some researchers that after post-nasal drip and asthma, GERD is the third most likely cause of chronic cough in a non-smoking person with a normal chest X-ray. Appropriate treatment for GERD is often successful if the patient suffers from the typical symptoms of GERD. Patients without those symptoms are more difficult to diagnose and invariably respond poorly to typical treatment.

Diagnosis

Your physician will take a careful history of your symptoms and, if typical, will likely initiate treatment without specific diagnostic testing. If the results of treatment are entirely successful, you will be maintained on the recommended regimen indefinitely. If you do not respond to treatment, if you have a relapse in spite of treatment or if you are over the age of 50 with new-onset heartburn, especially if associated with other symptoms such as indigestion, you will likely be referred to a gastroenterologist for consultation. The most common test to confirm the diagnosis in such cases is an endoscopic examination.

Performed by a specialist, a tube with a microscope is inserted into the esophagus of a sedated patient, allowing for the examination of the mucosal wall of the lower esophagus to determine the extent of inflammation, erosion, ulceration or other abnormalities. The stomach is examined at the same time. Swabs may be taken to identify a common bacterium (H pylori) which may cause an ulcer.

In persons over the age of 70, the correlation between degree of symptoms and the degree of inflammation is less predictable than in younger persons. In other words, mild symptoms may actually be associated with more esophagitis (inflammation of the esophagus) than would be seen in a younger patient. In addition, there is a greater risk of pre-cancerous changes or malignancies causing the symptoms that would need to be ruled out but which, if found, would require more specific treatment and careful monitoring.

Treatment

Treatment for GERD is very successful. Since there is a higher incidence of symptoms in persons who are overweight, weight reduction is advised and has been proven to lessen symptoms.

Persons who have been prescribed ASA, NSAIDS (anti-inflammatory drugs), Coxibs (anti-arthritic drugs) or multiple drugs are more likely to develop gastrointestinal side-effects and will often be given advice to follow the same treatment as patients with GERD.

Raising the head of the bed with six- to eight-inch blocks has traditionally been recommended, but there is little scientific evidence that this helps most people with the disorder. In addition, it is poorly tolerated, especially by one's spouse. Dietary restrictions have little effect unless, in trying certain restrictions, the patient finds definite relief. Cessation of smoking and alcohol reduction have been shown to be helpful. Over-the-counter antacids such as Tums, Rolaids, Mylanta and Maalox which neutralize stomach acids are effective for occasional heartburn but, if taken too often, can result in complications. Persons with kidney disease should not take them. Another drug, Zantac, is now available without prescription and may be useful for occasional heartburn.

The most effective treatment is the use of drugs which prevent the production of stomach acid. The two most common ones are omeprazole and pantoprazole. Well-tolerated and with little evidence as yet of long-term side-effects, these medications act directly on the acid-producing cells in the stomach. Although some of these medications in lower doses may be purchased without prescription, proper evaluation and followup by your physician, along with a prescription for one of these medications is advisable. Furthermore, your own doctor will be aware of potential drug interactions which could occur with other medications that you may be taking.

Conclusion

For many years, heartburn and related symptoms had few successful permanent remedies. With the discovery in recent years of these very effective and safe drugs, patients suffering from "acid indigestion" are now able to look forward to permanent control of their disorder.

Following your doctor's recommendations and taking your daily prescribed tablet to reduce acid production, your heartburn and other symptoms of regurgitation will likely disappear. Relapses may occur if the medication is stopped, at which time you will probably be advised to continue with the treatment indefinitely.

Some GERD facts:
  • The British spelling of esophagus is oesophagus, making the name of the condition in many European countries GORD. GORD and GERD are the same condition.
  • GERD is the third most-common cause for chronic cough in non-smokers, after asthma and post-nasal drip.
  • Herbal remedies to ease GERD symptoms include licorice, camomile and marshmallow.
  • Chronic acid reflux can now be completely controlled by following simple advice and taking prescribed medication.
  • Long-standing GERD can lead to ulcers or scarring of the esophagus, which can lead to painful swallowing and, in severe cases, a condition called Barrett's esophagus which is believed to be a risk factor for esophageal cancer.
The following may exacerbate GERD due to either increased gastric acid secretion or lowered esophageal sphincter competence:
  • caffeine
  • alcohol
  • foods high in fat
  • smoking
  • eating within 2-3 hours of bedtime
  • large meals
  • carbonated soft drinks
  • acidic foods such as tomatoes and citrus fruits
  • chocolate
  • peppermint
  • medications which delay the emptying of acid from the stomach
Recommendations for GERD sufferers:
  • Maintain a healthy body weight
  • Wear loose clothing
  • Avoid activities such as bending over or stooping after meals
  • Avoid lying down immediately after eating
  • Keep a diary of when symptoms occur in order to avoid an "attack"




Related links
GERD Information Resource Center
National Digestive Diseases Information Clearinghouse