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Gastroesophageal Reflux Disease (GERD)

Gastroesophageal Reflux Disease (GERD; or GORD when spelling oesophageal, the BE form) is defined as chronic symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus.

Gastroesophageal reflux disease, commonly referred to as GERD, or acid reflux, is a condition in which the liquid content of the stomach regurgitates (backs up, or refluxes) into the esophagus. The liquid can inflame and damage the lining of the esophagus although this occurs in a minority of patients. The regurgitated liquid usually contains acid and pepsin that are produced by the stomach. (Pepsin is an enzyme that begins the digestion of proteins in the stomach.) The refluxed liquid also may contain bile that has backed-up into the stomach from the duodenum. (The duodenum is the first part of the small intestine that attaches to the stomach.) Acid is believed to be the most injurious component of the refluxed liquid. Pepsin and bile also may injure the esophagus, but their role in the production of esophageal inflammation and damage (esophagitis) is not as clear as the role of acid.

Actually, the reflux of the stomach's liquid contents into the esophagus occurs in most normal individuals. In fact, one study found that reflux occurs as frequently in normal individuals as in patients with GERD. In patients with GERD, however, the refluxed liquid contains acid more often, and the acid remains in the esophagus longer.

As is often the case, the body has ways (mechanisms) to protect itself from the harmful effects of reflux and acid. For example, most reflux occurs during the day when individuals are upright. In the upright position, the refluxed liquid is more likely to flow back down into the stomach due to the effect of gravity. In addition, while individuals are awake, they repeatedly swallow, whether or not there is reflux. Each swallow carries any refluxed liquid back into the stomach. Finally, the salivary glands in the mouth produce saliva, which contains bicarbonate. With each swallow, bicarbonate-containing saliva travels down the esophagus. The bicarbonate neutralizes the small amount of acid that remains in the esophagus after gravity and swallowing have removed most of the liquid.

Gravity, swallowing, and saliva are important protective mechanisms for the esophagus, but they are effective only when individuals are in the upright position. At night while sleeping, gravity is not in effect, swallowing stops, and the secretion of saliva is reduced. Therefore, reflux that occurs at night is more likely to result in acid remaining in the esophagus longer and causing greater damage to the esophagus.

This is commonly due to transient or permanent changes in the barrier between the esophagus and the stomach. This can be due to incompetence of the lower esophageal sphincter (LES), transient LES relaxation, impaired expulsion of gastric reflux from the esophagus, or association with a hiatal hernia.

Symptoms

Adults

Heartburn is the major symptom of acid in the esophagus, characterized by a burning discomfort behind the breastbone (sternum). Findings in GERD include esophagitis (reflux esophagitis) — inflammatory changes in the esophageal lining (mucosa) — strictures, difficulty swallowing (dysphagia), and chronic chest pain. Patients may have only one of those findings. Atypical symptoms of GERD include cough, hoarseness, changes of the voice, chronic ear ache, acute sharp chest pains, or sinusitis. Complicatons of GERD include stricture formation, Barrett's esophagus, esophageal ulcers and possibly even lead to esophageal cancer.

Occasional heartburn is common but does not necessarily mean one has GERD. Patients that have heartburn symptoms more than once a week are at risk of developing GERD. A hiatal hernia is usually asymptomatic, but the presence of a hiatal hernia is a risk factor for development of GERD.

Children

GERD may be difficult to detect in infants and children. Symptoms may vary from typical adult symptoms. GERD in children may cause repeated vomiting, effortless spitting up, coughing, and other respiratory problems. Inconsolable crying, failure to gain adequate weight, refusing food and bad breath are also common. Children may have one symptom or many — no single symptom is universally present in all children with GERD.

It is estimated that of the approximately 8 million babies born in the U.S. each year, upwards of 35% of them may have difficulties with reflux in the first few months of their life. A majority of those children will outgrow their reflux by their first birthday, however, a small but significant number of them will not outgrow the condition.

Babies' immature digestive systems are usually the cause, and most infants stop having acid reflux by the time they reach their first birthday. Some children do not outgrow acid reflux, however, and continue to have it into their teen years. Children that have had heartburn that does not seem to go away, or any other symptoms of GERD for a while, should talk to their parents and visit their doctor.

Diagnosis

Endoscopic image of peptic stricture, or narrowing of the esophagus near the junction with the stomach. This is a complication of chronic gastroesophageal reflux disease, and can be a cause of dysphagia, or difficulty swallowing

Endoscopic image of peptic stricture, or narrowing of the esophagus near the junction with the stomach. This is a complication of chronic gastroesophageal reflux disease, and can be a cause of dysphagia, or difficulty swallowing

A detailed history taking is vital to the diagnosis. Useful investigations may include barium swallow X-rays, esophageal manometry, 24 hour esophageal pH monitoring and Esophagogastroduodenoscopy (EGD). In general, an EGD is done when the patient does not respond well to treatment, or has alarm symptoms including: dysphagia, anemia, blood in the stool (detected chemically), wheezing, weight loss, or changes in the voice. Some physicians advocate once in a lifetime endoscopy for patients with longstanding GERD, to evaluate for the presence of Barrett's esophagus, a precursor lesion for esophageal adenocarcinoma.

Esophagogastroduodenoscopy (EGD) (a form of endoscopy) involves the insertion of a thin scope through the mouth and throat into the esophagus and stomach (often while the patient is sedated) in order to assess the internal surface of the esophagus, stomach and duodenum.

Biopsies can be performed during gastroscopy and these may show:

* Edema and basal hyperplasia (non-specific inflammatory changes)
* Lymphocytic inflammation (non-specific)
* Neutrophilic inflammation (usually either reflux or Helicobacter gastritis)
* Eosinophilic inflammation (usually due to reflux)
* Goblet cell intestinal metaplasia or Barretts esophagus.
* Elongation of the papillae
* Thinning of the squamous cell layer
* Dysplasia or pre-cancer.
* Carcinoma.

Pathophysiology

Having GERD indicates incompetence of the lower esophageal sphincter. Increased acidity or production of gastric acid can contribute to the problem, as can obesity, tight-fitting clothes and pregnancy. It is also thought that yeast infections of the digestive tract can cause GERD-like symptoms.

Another paradoxical cause of GERD-like symptoms is not enough stomach acid (hypochlorhydria). The valve that empties the stomach into the intestines is triggered by acidity. If there is not enough acid, this valve does not open and the stomach contents are churned up into the esophagus. There is still enough acidity to cause irritation to the esophagus.

Factors that can contribute to GERD are:

* Hiatus hernia, which increases the likelihood of GERD due to mechanical and motility factors
* Zollinger-Ellison syndrome, which can be present with increased gastric acidity due to gastrin production
* Hypercalcemia, which can increase gastrin production, leading to increased acidity
* Scleroderma and systemic sclerosis, which can feature esophageal dysmotility

Treatment

The rubric "lifestyle modifications" is the term physicians use when recommending non-pharmaceutical treatments for GERD. A 2006 review suggested that evidence for most dietary interventions is anecdotal; only weight loss and elevating the head of the bed were found to be supported by evidence.

Foods

Certain foods and lifestyle are considered to promote gastroesophageal reflux:

* Coffee, alcohol, and excessive amounts of Vitamin C supplements are stimulants of gastric acid secretion. Taking these before bedtime especially can promote evening reflux. Calcium containing antacids are in this group[3].
* Foods high in fats and smoking reduce lower esophageal sphincter competence, so avoiding these tends to help, as well. Fat also delays emptying of the stomach.
* Having more but smaller meals also reduces the risk of GERD, as it means there is less food in the stomach at any one time.
* avoid eating for 2 hours before bedtime
* avoid soft drinks
* avoid chocolate and peppermint
* avoid spicy foods
* avoid acidic foods like oranges and tomatoes (however, they are okay when fresh.)
* avoid cruciferous vegetables: onions, cabbage, cauliflower, broccoli, spinach, brussel sprouts
* milk and milk-based products contain calcium and fat, so should be avoided before bedtime.

However, following this list of foods directly is not 100% accurate for some have a more serious case of GERD than others. Thus, it is up to an individual to decide which foods bother them and which ones do not. Avoid cooking food with fat or oil, like fried or sautéed dishes. Cook by boiling, baking, grilling, broiling, poaching or steaming. Eat small portions more frequently and avoid large meals that completely fill the stomach. Drink plenty of water, do not eat very fast and chew the food properly.

Do not get into bed for at least 2 hours after eating, and try to keep a vertical torso during this time. Elevate the head 4 to 6 inches while sleeping. Try to sleep on the left side, as it improves mobility and empties the stomach quickly. Lieing on your right side, can cause back flow. Avoid stress, exercise regularly and give up smoking. Do not exercise after a meal, as this would itself cause heartburn. Tight clothes, constant bending down, certain abdominal exercises, too much fat around the abdomen, and lying face down are some things that apply pressure on the stomach, causing heartburn.

Positional therapy

Elevation to the head of the bed is the next-easiest to implement. If one implements pharmacologic therapy in combination with food avoidance before bedtime and elevation of the head of the bed over 95% of patients will have complete relief. Additional conservative measures can be considered if there is incomplete relief. Another approach is to advise all conservative measures to maximize response.

Elevating the head of the bed can be accomplished by using blocks as noted above or with other items: plastic or wooden bed risers which support bed posts or legs, a bed wedge pillow, or an inflatable mattress lifter that fits in between mattress and box spring. The height of the elevation is critical and must be at a minimum of 6 to 8 inches (15 to 20 cm) in order to be at least minimally effective in hindering the backflow of gastric fluids. It should be noted that some innerspring mattresses do not work well when inclined and tend to cause back pain thus foam based mattresses are to be preferred. Moreover, some use higher degrees of incline than provided by the commonly suggested 6 to 8 inches (15 to 20 cm) and claim greater success. Elevating the head of the bed is also known as "positional therapy".

Drug treatment

A number of drugs are registered for the treatment of GERD, and they are among the most-often-prescribed forms of medication in most Western countries. They can be used in combination with other drugs, although some antacids can impede the function of other medications:

* Antacids before meals or symptomatically after symptoms begin can reduce gastric acidity (increase the pH). Alginic acid may coat the mucosa as well as increase the pH and decrease reflux.

Antacids are prescription medications or over the counter medications that neutralize stomach acid. Antacids are used to help relieve acid indigestion, an up-set stomach, sour stomach and heartburn symptoms. There are basically two types of antacids. One type chemically neutralizes gastric acid and the other type absorbs acid. Antacids can be either in pill form or liquid form.
Following is a brief list of antacid side effects you may have experienced in the past, before learning about the natural benefits of Active Manuka Honey for acid reflux, heartburn, upset stomach, stomach ulcer, h. pylori, duodenum ulcer, diverticulitis and ibs (irritable bowel syndrome).
o drug interaction (preventing a drug from getting absorbed correctly)
o antacids can make you thirsty
o chalky taste in mouth
o discolored stool (white or speckled)
o kidney damage
o not suitable for children less that 6 years of age

o nausea
o dizziness
o vomiting
o diarrhea
o constipation
o bloating
o stomach cramps
o abdominal pain
o renal stone formation
* Gastric H2 receptor blockers such as ranitidine or famotidine can reduce gastric secretion of acid. These drugs are technically antihistamines. They relieve complaints in about 50% of all GERD patients.
* Proton pump inhibitors such as omeprazole are the most effective in reducing gastric acid secretion, as they stop the secretion of acid at the source of acid production, i.e. the proton pump. To maximize effectiveness of this medication the drug should be taken a half hour before meals.
* Prokinetics strengthen the LES and speed up gastric emptying. Cisapride, a member of this class, was withdrawn fryears of age om the market for causing Long QT syndrome.

Surgical treatment

The standard surgical treatment, sometimes preferred over longtime use of medication, is the Nissen fundoplication. The upper part of the stomach is wrapped around the LES to strengthen the sphincter and prevent acid reflux and to repair a hiatal hernia. The procedure is often done laparoscopically.

An obsolete treatment is vagotomy ("highly selective vagotomy"), the surgical removal of vagus nerve branches that innervate the stomach lining. This treatment has been largely replaced by medication.

Other treatments

In 2000, the U.S. Food and Drug Administration (FDA) approved two endoscopic devices to treat chronic heartburn. One system, Endocinch, puts stitches in the LES to create little pleats that help strengthen the muscle. Another, the Stretta Procedure, uses electrodes to apply radio frequency energy to the LES. The long term outcomes of both procedures compared to a Nissen fundoplication are still being determined.

Subsequently the NDO Surgical Plicator was FDA cleared for the endoscopic treatment of GERD. The Plicator creates a plication, or fold, of tissue near the gastroesophageal junction, and fixates the plication with a suture-based implant. The Plicator is currently marketed by NDO Surgical, Inc..

Another treatment which involved injection of a solution that is injected during endoscopy into the lower esophageal wall was available for approximately one year ending in late 2005. It was marketed under the name Enteryx. It was removed from the market due to several reports of complications from misplaced injections.

Barrett's esophagus

Barrett's esophagus, a type of dysplasia, is a precursor high-grade dysplasia, which is in turn a precursor condition for carcinoma. The risk of progression from Barrett's to dysplasia is uncertain but is estimated to include 0.1% to 0.5% of cases, and has probably been exaggerated in the past. Due to the risk of chronic heartburn progressing to Barrett's, EGD every 5 years is recommended for patients with chronic heartburn, or who take medication for GERD chronically.

GERD has been linked to laryngitis, chronic cough, pulmonary fibrosis, earache, and asthma, even when not clinically apparent, as well as to laryngopharyngeal reflux and ulcers of the vocal cords.

Natural Remedies

Active Manuka Honey

What are the benefits of using Active Manuka Honey as a natural treatment for acid reflux?

There are NO known side effects to Active Manuka Honey - unless you are allergic to honey itself. Manuka Honey can be taken alongside other medication, according to your doctors recommendations.

Active Manuka Honey is an all natural, antibacterial, medicinal honey from the wild, un-cultivated tea tree bush (leptospermum scoparium) from New Zealand. This honey is used for both internal as well as external ulcer treatment. Active Manuka Honey has natural antibiotic properties defined as UMF (Unique Manuka Factor). For more information, click on UMF Rating.

Active Manuka Honey helps to protect, coat, soothe and heal the damaged tissue of the esophagus caused by acid reflux. Expect to take Active Manuka Honey for 3-6 months. Active Manuka Honey has no know side effects (unless you are allergic to honey itself...), and can therefore be used as an all natural long term treatment for acid reflux. Active Manuka Honey also helps to coat, protect and heal the damaged lining of the esophagus and / or help to heal an esophagus ulcer all naturally.

People usually feel a difference within just 3-6 days. Improvement include less or no pain after a meal, less heartburn, less intense acid reflux symptoms, natural healing of an ulcerated esophagus. Always seek medical advice first, before trying a natural remedy.

Advantages of treating acid reflux with Active Manuka Honey?

*No known side effects - unless one is allergic to honey or the tea tree plant itself (leptospermum scoparium)

*Supported by extensive research

*Natural remedy for acid reflux, esophagus ulcer, esophagitis, GERD and other GI tract disorders such as upset stomach, stomach ulcer, h. pylori, ibs

*Soothing and natural coating to help heal the esophagus

*Can be used long-term

*Easy to use and safe

*Anti-inflammatory effect

*Antibacterial effect 4 times greater than standard Antiseptic (minimum 18% carbolic equivalent)

*Naturally seem to destroy staphaureus, streptococcus and h. pylori (helicobacter pylori)

*Cost effective

How is Active Manuka Honey taken to help sooth acid reflux symptoms?

Take 1 teaspoon of Active Manuka Honey 3-4 times per day on a small square inch size piece of bread, toast, slice or bagel, slice of banana or piece of apple, 20-30 minutes before meals, to coat out the internal tract including the esophagus.

You do not have to follow manuka honey intake with a meal - as long as you take the honey 3x per day, as described above. If you take the honey by itself - without the bread or fruit, the honey will dissolve too quickly in the blood stream and will barely reach the stomach, therefore you need to attach the honey to 'anything' one-bite size, in order to transport the honey through the entire body. Active Manuka Honey is used for the entire gastro-intestinal tract from acid reflux, heartburn, up-set stomach, stomach ulcer, h. pylori, duodenum ulcer, diverticulitis, ibs (irritable bowel syndrome).

How long will it take until I feel a difference when taking Active Manuka Honey for acid reflux symptoms?

People will typically feel a difference after just 3-6 days, when taking 3x1 teaspoon of active manuka honey attached to a small piece of bread, or toast, or slice of banana or apple (1 bite size), 20-30 minutes before meals.

How do I store Active Manuka Honey?

Store Honey at room temperature. There is no need for refrigeration. Do not leave the honey in direct sunlight. Store honey in kitchen cupboard or first aid closet.

Other remedies: Cabbage juice, apples (especially pureed), apple cidar vinegar, cola syrup, and rose water.

If your symptoms persist more than 2 weeks, consult the appropriate healthcare professional

DISCLAIMER: The information in this column, is NOT intended to diagnose and/or treat any health related issues and is provided solely for informational purposes only. Consult the appropriate healthcare professional before making any changes to your healthcare regime. Even what may seem like simple changes in the diet for example, can interact with, and alter, the efficiency of medications and/or the body's response to the medications. Many herbs and supplements exert powerful medicinal effects. Neither the author, nor the website designers, assume any responsibility for the reader's use or misuse of this information.

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