Troubled by heartburn? This is the video for you. This complete tutorial on gastroesophageal reflux disease includes lifestyle modifications and medical …
Welcome. You're watching Medicine with
Dr. Moran. I'm Dr. Keith Moran. Today I'm
going to review the treatment of gastroesophageal reflux in adults. This is a
very common disorder.
Many patients refer to it simply as acid
reflux or heartburn. In medicine
we use the term GERD. This is an acronym
for gastroesophageal reflux. Many of my
patients who take medications for this
understandably want to come off their
medications. This video will review the
lifestyle modifications that patients can
do so that they can come off their
medications. Even if they can't come off
the medications a lot of these things
will allow them to minimize their
medications. As always I recommend that
patients review their symptoms with
their healthcare providers. gastro esophageal reflux
also known as acid reflux occurs when
stomach contents reflux back up into the
esophagus or into the mouth. Reflux is a
normal process that occurs in healthy
infants, children, and adults. Most
episodes are brief and do not cause
bothersome symptoms or complications. In
contrast people with gastro esophageal
reflux disease or GERD experience
symptoms as a result of the reflux. This
is the esophageal anatomy. When we eat
food is transported from the mouth all
the way down here into the stomach and
this section here is the esophagus. It's
a tube like structure approximately
10 inches long and one inch wide. Or in
metric 25 centimeters long and 2.5
centimeters wide. It connects the back of
the throat and then subsequently
connects to the stomach as you can see
on this picture. The esophagus is made of
tissue and muscle layers that expand and
contract to move the food all the way
down into the stomach through a series
of wave-like movements which we call
peristalsis. At the lower end of the
esophagus where it
joins the stomach there is a circular
ring of muscle called the lower
esophageal sphincter or LES. After
swallowing the LES relaxes to allow
food to pass into the stomach and then
contracts to prevent the back up of food
and acid into the esophagus. However
sometimes the les can be weak or it can
become relaxed because the stomach has
distended allowing liquids in the
stomach to regurgitate back into the
esophagus. This occurs occasionally in
all individuals. Most of these episodes
occur shortly after meals. They're brief
and they do not cause symptoms. Acid
reflux occurs rarely when sleeping. Acid
reflux becomes esophageal
gastroesophageal reflux disease when it
starts to cause bothersome symptoms or
injury to the esophagus. The amount of
acid reflux required to cause gastro
esophageal reflux symptoms varies from
person to person. In general damage to
the esophagus is more likely to occur
when the reflux is very acidic. If the
reflux occurs frequently or if the
esophagus is unable to clear away the
acid quickly. Gastroesophageal reflux
symptoms. The most common symptoms
associated with acid reflux or heartburn
which is a burning feeling in the chest.
regurgitation which is when undigested
food or acid flows back into your throat
or mouth, nausea, belching, a sore throat, a
raspy voice related to acid irritating
the vocal cords, causing reflux
laryngitis unexplained cough, also
trouble swallowing, a sense of a lump in
the throat, pain in the upper abdomen or
chest pain can occur. Chest pain
obviously could represent heart disease
or other chest related diagnosis. As
always it's best to see your healthcare
professional to review your specific
symptoms. The different treatments of
GERD are designed to prevent these
symptoms from occurring
and any complications from it. At the top
of this image is an example of the
normal anatomy. You can see that the
diaphragm is a large flat muscle at the
base of the lungs and contracts and
relaxes as a person breathes in and out.
The esophagus passes through an opening
in the diaphragm called the
diaphragmatic hiatus before it joins
with the stomach. Normally the diaphragm
will contract which improves the
strength of the lower esophageal
sphincter especially during bending,
coughing, or straining. At the bottom of
the image a depiction of a hiatus hernia
is shown. This develops if there's
weakening in the connective tissue
attaching the esophagus and stomach to
the diaphragm at the hiatus and so part
of the upper portion of the stomach can
slide up through the diaphragm into the
chest forming the sliding hiatus hernia.
The presence of a hiatus hernia makes
acid reflux more likely as part of the
stomach is actually up above the
diaphragm into the chest. As we can see
here this part of the stomach is up into
the chest and it slid up. The hiatus
hernia is more common in people over the
age of 50. Obesity and pregnancy are also
contributing factors. The exact cause is
unknown but is probably mentioned a few
minutes ago. It's likely related to
loosening of the connective tissue
around the diaphragm that occurs with
advancing age. There's no way to prevent
a hiatus hernia. Reflux treatment of mild
symptoms. The initial treatment for mild
acid reflux includes lifestyle changes
and non prescription medications
including antacids. Lifestyle changes
have been recommended for many years a
literature review concluded that weight
loss and elevating the head of your bed
may be helpful but other dietary changes
were not found to be helpful in all
patients. So these recommendations may
be helpful in some people with mild
symptoms of acid reflux.
Weight loss. Losing weight may help
people who are overweight to reduce acid
reflux. I see several patients a year who
will lose 20 or 30 pounds and tell me
that their reflux symptoms improved
significantly. In addition weight loss
has a number of other health benefits
including a reduced risk of type 2
diabetes and heart disease. Raise the
head of the bed 6 inches. While most
people only have heartburn for the two
to three hour period after meals some
people will wake up at night with
heartburn. People with nighttime
heartburn can elevate the head of their
bed which raises the head and shoulders
higher than the stomach and it allows
gravity to prevent acid reflux. Raising
the head of the bed can be done with
blocks of wood under the legs of the bed
or a special foam wedge under the
mattress. Several manufacturers have
developed commercial products for this
purpose.
However, it's not helpful to use
additional pillows. If you use additional
pillows this can cause an unnatural bend
in the body that increases pressure on
the stomach and this of course will
worsen acid reflux. Avoid acid reflux
inducing foods. Some foods also cause
relaxation of the lower esophageal
sphincter promoting reflux. Too much
caffeine, chocolate, alcohol, carbonated
beverages, spicy foods, peppermint, and
fatty foods may cause bothersome acid
reflux.
I recommend selective elimination of
dietary triggers in patients who find
correlation with their symptoms and an
improvement in symptoms with elimination.
Avoid large and late meals. Lying down
with a full stomach may increase the
risk of acid reflux. By eating three or
more hours before bedtime with no
evening snacking reflux can be reduced.
In addition eating smaller meals may
prevent the stomach from becoming
overdistended which can cause acid reflux.
Other measures that make sense but in
studies have not been consistently shown
to be helpful include quitting smoking.
Saliva helps to neutralize reflux acid
and smoking reduces the amount of saliva
in the mouth and throat. Smoking can also
reduce the pressure in your lower
esophageal sphincter and it can provoke
coughing which can also cause frequent
episodes of acid reflux. Quitting smoking
can in some patients reduce or eliminate
symptoms of mild reflux. Promotion of
salivation by using chewing gum or oral
lozenger to neutralize acid that's
refluxed as well as to promote acid
clearance from the esophagus when saliva
is swallowed. Avoid tight-fitting
clothing at a minimum. Tight-fitting
clothing can increase discomfort but it
may also increase pressure in the
abdomen forcing the stomach contents
back up into the esophagus. This is a
recent study demonstrating that the
intake of coffee tea or soda was
associated with an increased risk of
GERD symptoms. In contrast consumption of
water, juice, or milk was not associated
with reflux symptoms. The conclusion in
this study was that drinking water
instead of coffee, tea, or soda can reduce
the risk of gastro esophageal reflux.
Non prescription medications antacids do
not prevent GERD. Antacids are used for
intermittent when needed short-term
relief of reflux symptoms. They include
magnesium, aluminum or calcium all of
which neutralize gastric acid thereby
reducing the acidity of any acid that
would come back up into the esophagus.
They work within five minutes but have a
short duration of effect typically 30 to
60 minutes. The acid which is neutralized
very briefly so they're not very
effective after more than one hour
Typical antacids that you might buy
over-the-counter include Tums, Maalox, and
Mylanta. Histamine receptor antagonists.
These medications block the histamine
receptor in the acid producing stomach
cell. They're more effective than
antacids at relieving heartburn. Their
effects last longer. These medications
include over-the-counter Ranitidine
which is brand-name Zantac and
Famotidine brand-name Pepcid. These have
a slower onset of action with peak
concentrations occurring 2 to 3 hours
after a dose and typically last 4 to 10
hours.
Reflux treatment of moderate to severe
symptoms. In addition to the above
treatments more potent acid suppression
medication can be used if symptoms are
not well controlled. These are the Proton
Pump Inhibitors otherwise known as the
PPIs. They block the hydrogen potassium
acid pump in the stomach cell. Compared
to the histamine receptor antagonists
these provide faster symptom relief and
are much better at relieving GERD
symptoms. They also heal damage within
the esophagus much more effectively. The
proton pump inhibitors Rabeprazole also known as Pariet
Omeprazole going by brand name of Losec
or Dexlansoprazole with
brand name Dexilant.
Lansoprazole, brand name Prevacid, Pantoprazole brand name Pantoloc and Tecta.and Esomeprozole brand name Nexium. One can
buy these over the counter as well as by
prescription. They are dosed typically once a
day but can be taken twice a day in
severe cases. I recommend 30 to 60
minutes before breakfast and if needed
at the same time before supper. You try
to use the lowest dose of the medication
to keep your symptoms under control.
Sometimes patients are able to
discontinue the medication and just use
it when they need. Some patients
can take PPIs for several days just
three or four times a year when reflux
is more of a problem.
Other people need to take it every
second day or even once a day. I tell
people that they can always adjust their
medication to provide the best control.
If symptoms do not improve on PPIs we
call this refractory GERD. Investigations
are clearly needed if that occurs and of
course if they've not been done at this
point options might include increasing
the dose of the PPI or switching to a
different PPI. I will often split the
dose of the PPI by giving two smaller
doses rather than one large dose daily.
Other medications can be added if
symptoms are suboptimaly controlled on
the above medications Domperidone or
Metoclopramide can be added to
further improve them both of these
medications. Domperidone and
Metoclopramide improve the muscle tone
of the lower esophageal sphincter to
reduce reflux and they also improve the
esophageal muscles contraction to
squeeze and improve acid clearance from
the esophagus. Further testing may be
required to either confirm GERD or rule
out other problems. Depending on your
symptoms surgical treatment for GERD can
be considered. Doctors consider anti
reflux procedures an equally effective
alternative to medical therapy for
chronic GERD symptoms. We do this and
offer this to patients when we have an
appropriately skilled surgeon who can do
the procedure. Typical indications are
symptoms incompletely controlled by
the medications I've just mentioned.
There are many different surgical
options. Surgery though has a failure
rate of ten to fifteen percent with
symptoms of recurrent reflux or
difficulty with swallowing. Five to ten
percent of people who have surgery will
need redo surgery down the road.
Optimal medical management compared to
standard surgical treatment provides
similar five-year remission rates for
controlling GERD symptoms.
This is an image demonstrating what the
operation looks like if the patient in
question has a hiatus hernia. The surgeon
will bring the hernia down into the
abdomen from the chest first then the
upper part of the stomach which we call
the fundus is wrapped or as we often
call it placated around the esophagus
and then it's stitched together as shown.
In the picture you can see how it's
wrapped around and placated together.
This provides a barrier against reflux.
If the barrier is too tight people have
trouble swallowing. So one needs to
measure this closely at the time of the
operation. This procedure can be done
laparoscopically through small incisions
in the upper abdomen.
The procedure is called a
laparoscopic fundoplication. This is the
most common surgical treatment for GERD.
The vast majority of patients certainly
over 99% with reflux or managed though
with current medical treatment without
surgery. PPI side effects.
PPIs are the most common medications
utilized for GERD. These medications can
be taken safely for many years and those
that need the medication we always try
to use the lowest dose possible. Safety
data has been collected 25 years out on
PPI usage. It is clear that PPIs can
cause low magnesium and low B12 due to
reduced intestinal absorption. Magnesium
and B12 levels should be followed in
patients on long-term PPIs. PPIs
are associated with a slightly increased
risk of a colon infection known as C
difficile colitis. It's known that the
PPIs can reduce the absorption of
certain types of calcium products such
as calcium carbonate. If calcium
supplementation is necessary calcium
supplement that does not require acid
for absorption such as calcium citrate
can be given. PPIs can cause acute
inflammation within the kidney called
acute interstitial nephritis. This is
uncommon but I have seen a few cases
given how many patients over the years
I've seen on PPIs.
There is conflicting data on whether PPI
usage is associated with dementia,
pneumonia, and bone fracture. I frequently
get asked about these three things and
because it's not clear from studies that
these are definitely associated I feel
that the risk if anything would be very
small.
I hope you've learned a great deal about
what you can do to manage gastroesophageal reflux disease. Thank you for
watching. If you liked the video please consider subscribing and click the bell to
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basis. Thank you for joining me on
Medicine with Dr. Moran. I'm Dr. Keith
Moran. Get healthy stay healthy.

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