Treating GERD
Updated on 7/23/09
The vast majority of patients can be treated effectively by combining medication with life-style modifications. Because GERD is generally a chronic condition, some form of treatment must be continued indefinitely in most cases. For those who fail to respond to medical treatment, or who find the constraints of medical treatment unacceptable, surgical or endoscopic intervention may be necessary.
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Lifestyle modifications:
For people with GERD, gravity is a friend—it's key to keeping gastric contents in the stomach and to returning regurgitated material back to the stomach when reflux does occur. Therefore, it's best to avoid lying down after eating and to consider elevating the head of the bed by using 6-inch blocks under the headposts. Both can improve GERD symptoms.
For unknown reasons, GERD symptoms often worsen with weight gain and ease with weight loss. Therefore, weight reduction is usually recommended for patients who are overweight.
Other changes that may alleviate symptoms of GERD are:
- Avoid certain foods, such as caffeine, carbonated drinks, chocolate, mints, high fat foods and fried foods, tomato sauces.
- Avoid large meals. Eat small amounts more frequently.
- Stop smoking.
- Limit caffeine and alcohol intake.
- Eat at least three hours before bedtime.
Drugs
In some patients, simple implementation of dietary and life-style changes is sufficient to control reflux symptoms. However, most who see a physician with severe symptoms or with esophagitis require drug therapy. Current drug therapy depends on two categories of drugs: those that decrease gastric acidity and those that enhance upper gastrointestinal motility, or the movement of food and stomach contents through the gastrointestinal tract.
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Antacids
Antacids can neutralize gastric acid and are more effective than placebo. However, they leave the stomach quickly, and gastric acid neutralization tends to increase acid production as a result of neural and hormonal responses to low acidity itself. Therefore, the duration of acid neutralization by antacids tends to be limited. Antacids are best for quick relief of intermittent and relatively infrequent symptoms. There are several commonly-used types of antacids, and most are available over-the-counter. These include calcium-based antacids, such as Tums, magnesium-based antacids, such as Maalox and Mylanta, and antacids containing aluminum, such as Rolaids. The major side effect of magnesium-containing antacids (Maalox, Mylanta) is diarrhea caused by magnesium hydroxide.
H2 receptor blockers
Histamine-receptor blockers reduce gastric acid production. They work by blocking the H2 receptor on the parietal cells, or acid secreting cells, located in the lining of the stomach. These drugs fit into the H2 receptor like a key in a lock and shut off a significant amount of acid production.
The available H2 blockers, used to treat gastric and duodenal ulcers as well as GERD, include cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid), and nizatidine (Axid). This group of compounds effectively decreases acid secretion. H2-receptor blockers are generally safe, although they can cause nausea and constipation or diarrhea, and in rare cases, such problems as dizziness, sleeplessness, and heart arrythmias. They are available over-the-counter and by prescription.
Proton-pump inhibitors
PPIs block the action of the hydrogen pumps that produce stomach acid in cells of the stomach lining. As a result, the acid suppressing capability of PPIs is substantially greater than that of H2 blockers. In sufficient doses, PPIs are capable of approaching or producing a state in which the stomach produces no acid at all.
The vast majority of patients with typical esophageal symptoms of reflux can get their symptoms under control with PPIs. Further, PPIs heal erosive esophagitis in most patients, even those with severe esophageal damage. When initial treatment fails, increasing the dose is usually effective. The most common side effects of PPIs are headache, diarrhea, constipation, abdominal pain, nausea, and rash. Nevertheless, PPIs generally are well tolerated.
PPIs available by prescription include omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), pantoprazole (Protonix), esomeprazole (Nexium), and dexlansoprazole (Kapidex). One PPI is available over-the-counter (omeprazole or Prilosec OTC). They differ in how they are broken down by the liver and how they interact with other medications. The absorption of some medications is affected by the presence of acid in the stomach, and therefore they may work less well when taken with a PPI. For example, PPIs reduce the absorption and concentration in the blood of the antifungal medication ketoconazole (Nizoral), possibly reducing its effectiveness. By contrast, they increase the absorption and concentration of digoxin (Lanoxin), prescribed for heart failure.
Prokinetic agents
These drugs enhance motor activity of the smooth muscle characteristic of the gastrointestinal tract. Although potentially beneficial for improving the strength of pressure of the lower esophageal sphincter at rest, the drugs also enhance the strength of gastric contractions that move food along the GI tract-most importantly, through the stomach. In standard doses, prokinetic agents are as effective at treating GERD as H2 blockers but less effective than PPIs. In the United States, they tend to be used in combination with an acid-suppressing agent when the latter does not achieve the desired results. Studies support the effectiveness of this approach.
Cisapride, once commonly prescribed for GERD, has been withdrawn from the U.S. market because of rare but life-threatening cardiac arrhythmias. Metoclopramide, another prokinetic agent proven effective for GERD, can cause side effects such as dizziness and drowsiness, involuntary movements, and muscle spasms. There is currently a need for effective and well-tolerated prokinetic agents.
Surgery
In the past, antireflux surgery was recommended in patients who failed to respond to medical therapy. Today, using available drugs, treatment failures are sufficiently rare as to raise concerns about the accuracy of the original diagnosis. Currently, the most common indication for antireflux surgery is the personal preference of the patient seeking alternatives to chronic life-style modifications and drug treatment.
A number of surgical approaches are available, all of which attempt to bolster the strength of the antireflux barrier. The most commonly employed surgical approach is referred to as a Nissen fundoplication.
In this surgery, the upper part of the stomach is "wrapped" around the entire circumference of the lower esophagus. After this operation, the lower esophageal pressure, as recorded during esophageal manometry (see Tests), is usually increased. Elevations in pressure on the stomach, which provokes GERD, are transmitted to the lower esophagus, thereby enhancing the antireflux barrier. The Nissen fundoplication has been reported to produce permanent relief of reflux in 80 percent to 85 percent of patients.
The Nissen fundoplication can cause difficulty in swallowing (usually mild and often temporary) and sometimes results in abdominal distention, or stretching and pain, due to an inability to belch. This is sometimes called the "gas-bloat" syndrome. Although usually mild, it can be severe and debilitating. Careful selection of patients plays an important role in avoidance of these complications. In patients with impaired ability to move food contents through the esophagus, operations that do not involve a complete 360-degree wrap are often preferred. These alternative surgeries are generally associated with fewer side effects but are somewhat less reliable at preventing reflux.
Recently, laparoscopic approaches to antireflux surgery have been developed. The usual surgical technique involves creation of a Nissen fundoplication, indistinguishable from that created with the standard open approach. The advantage of the laparoscopic Nissen fundoplication is a shorter recovery time related to the less invasive approach. However, the ultimate outcome and potential complications are the same as with the standard.
Endoscopic approaches to performing antireflux surgery are also being developed. There are a variety of techniques which have been developed that include radiofrequency ablation, injection of bulking substances, and suturing. One of the most well studied of these so far is the full-thickness plicator procedure, which can be done through an endoscope. This involves suturing the top of the stomach around the lower esophageal sphincter and thus increasing the anti-reflux barrier. Long-term results have not been established and studies are still underway to determine the most effective endoscopic treatment for GERD.
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