Stop Acid Reflux Now!

Transcription

1 Stop Acid Reflux Now! Revised October 2007 Disclaimer: All material in this ebook is provided for information only and may not be construed as medical advice or instruction. No action or inaction should be taken based solely on the contents of this ebook. Instead readers should consult their physician or other qualified health professionals on any matter relating to their health and well-being. Readers who fail to consult with appropriate health authorities assume the risk of any injuries. The publisher is not responsible for errors or omissions.

2 Table of Contents Introduction 4 What are Acid Reflux, GERD and Heartburn? 4 What s the Difference Between GER and GERD? 7 Causes 7 Being Overweight 8 Pregnancy 9 Hiatal Hernia 9 Lower Esophageal Sphincter 9 Esophageal Contractions 10 Emptying of the Stomach 10 Genetics 10 Symptoms 10 The Impact of Acid Reflux, GERD and Heartburn 13 The Stressed 13 Pregnant Women 13 Over 50s 14 The Overweight 15 Infants and Children 15 Symptoms indicative of Reflux Disease or GERD: 17 Medication Takers 19 Medications Used to Treat Asthma and Breathing Difficulties 20 Medications Used to Treat Heart and Blood Pressure 20 Medications Used to Treat Arthritis and Inflammation 20 Medications Used to Treat Osteoporosis 20 Medications Used to Treat Anxiety, Insomnia, Depression, and Pain 21 Medications Used to Treat Parkinson's Disease and Muscle Spasms 21 Medications Used to Treat Cancer 21 Hormones 21 Complications 22 Anemia 22 Apnea 22 Asthma 22 Barrett's Esophagus 23 Bleeding and Ulcers 23 Coughing and Hoarseness 24 Eroded Dental Enamel 24 Esophageal Cancer 24 Failure to Thrive 25 Fluid in the Sinuses and Middle Ears 25 Gagging and Choking 26 Inflammation and infection of the Lungs 26 Inflammation of the Throat and Larynx 26 Painful and Difficult Swallowing 26 Sleep 27 2

3 Diagnosing Acid Reflux, GERD and Heartburn 28 Examination of the throat and larynx 29 Endoscopy 259 Biopsy 29 Esophageal ph Probe 30 X-Rays 30 Esophageal Acid Testing 30 Acid Perfusion Test 32 Esophageal Motility Testing 32 Gastric Emptying Studies 32 Medications 34 Antacids 34 Foaming Agents 35 H 2 Blockers 33 Proton pump Inhibitors 36 Prokinetics 37 Surgery 37 Fundoplication 36 Potential Complications of Fundoplication 39 Endoscopy 40 Lifestyle Changes 41 Eating Habits 41 Smoking 41 Weight loss 41 Alcohol 42 Relaxation 42 Exercise 42 Dressing Sensibly 42 Sleep 43 Dealing With Stress 43 Herbal Treatments 45 Digestive Enzymes 49 Diet 50 Food Table 53 Recipes 55 Breakfast 56 Lunch 57 Main Courses 59 Desserts 63 Pregnancy 67 Infancy 69 Common Myths 71 GERD at a Glance 74 For More Information 77 Glossary 79 3

4 Introduction What are Acid Reflux, GERD and Heartburn? GERD, or gastro-esophageal reflux disease, is an alternative name for what many people call acid reflux. It is a condition that occurs when your lower esophageal sphincter doesn t close properly and your stomach contents leak back, or reflux, into your esophagus. The lower esophageal sphincter, or LES, is a ring of muscle, which is at the bottom of your esophagus - or gullet - that acts like a valve between your esophagus and stomach. Your esophagus carries the food you eat from your mouth to your stomach. When refluxed stomach acid contacts the lining of your esophagus, it can cause a burning feeling in your chest or throat known as heartburn. When this fluid is tasted in the back of your mouth this is called acid indigestion. This may inflame and damage the lining of your esophagus. The regurgitated liquid usually contains acid and pepsin, an enzyme produced in the stomach that begins the digestion of proteins. The refluxed liquid may additionally contain bile that has backed-up into your stomach from your duodenum, which is the first part of the small intestine that attaches to your stomach. The acid is believed to be the most damaging part of the refluxed liquid. Heartburn usually feels like a burning pain in your chest, beginning behind your breastbone and moving upward to your neck and throat. It can feel like food is coming back into your mouth leaving an acidic or bitter taste. The burning, pressure can last up to two hours, or longer and is often worse after eating. Heartburn can also be caused by lying down or bending. The most common remedy is to take an antacid that can help neutralize acid in the stomach. 4

5 Heartburn pain is sometimes mistaken for a heart attack, but there are a number of differences. For example, a heart attack typically feels like your chest is being squeezed or crushed with the pain extending up into the jaw and back and can be accompanied by cold sweats. Exercise makes the chest pain worse, whereas with heartburn the pain often gets worse with rest, especially when lying down. However, if you suspect a heart attack it s important to seek medical attention immediately. Occasional heartburn is common, but this doesn t necessarily mean that you have GERD. If your heartburn occurs more than twice a week, a doctor will often diagnose GERD, which can possibly lead to more serious health problems. Although heartburn is the most common symptom of GERD, you can have GERD without having heartburn. Symptoms can include excessive clearing of your throat; problems swallowing; the feeling that food is stuck in your throat; a burning feeling in your mouth; or chest pain. GERD may cause coughing, and other respiratory problems as well as repeated vomiting in infants and children. Most infants grow out of GERD by the time of their first birthday. If you ve been using antacids for over two weeks, you need to see your medical practitioner. You may also need to visit a specialist - a gastroenterologist who treats diseases of the stomach and intestines. Changes in your lifestyle and diet changes can help to relieve heartburn. Some people who suffer from GERD also need medication, and surgery may be a last resort solution. No-one knows why some people who suffer from heartburn develop GERD. Several factors are likely to be involved. GERD is a chronic condition, and once it begins, it tends to last your whole life unless life style changes are made. After medical treatment, the condition returns in most patients within a 5

6 few months. Therefore, once treatment for GERD is started it usually needs to be continued indefinitely unless it is managed through life style changes. Reflux actually occurs in most individuals. The difference with GERD sufferers is that reflux is experienced more frequently and as a result damage is often caused to the esophagus. During the day acid reflux can often be counteracted by the body s natural position and process. The refluxed liquid is more likely to flow back down into your stomach. Also, while you are awake, you repeatedly swallow, whether or not you have reflux. Each time you swallow refluxed liquid is carried back into the stomach. The saliva glands in your mouth produce saliva, which contains bicarbonate. This means that the bicarbonate-containing saliva that travels down the esophagus neutralizes the small amount of acid that remains in your esophagus. Because you swallow less when sleeping your saliva is reduced, and reflux that occurs at night is more likely to cause acid to remain in the esophagus longer, potentially causing damage. Some people are more susceptible than others to GERD. For example, it can be a serious problem during pregnancy. Higher hormone levels and the growing fetus increasing pressure in the abdomen contribute towards this. About twenty-five million adults suffer from heartburn daily. Twenty-five per cent of pregnant women experience daily heartburn and more than half per cent have occasional problems. Over sixty million Americans experience heartburn at least once a month. Recent studies show that GERD in babies and children is more common than was previously recognized and may produce a variety of problems. In the following sections, we ll look at GERD in more detail, and the various options for managing this condition. 6

7 What is the Difference Between GER and GERD? The term reflux is an alternative way of referring to GER (Gastro Esophageal Reflux). When someone is referred to as having GER, it means that they have a benign condition in which they have frequent reflux episodes. This may also be called "functional GER" and it doesn t cause complications, lead to long term problems, affect growth or development in babies or always require medical attention. GER can range from reflux material in the esophagus to spitting up and sometimes frequent projectile vomiting in babies. Projectile vomiting alone is not a complication. GER is referred to as GERD when complications arise. However, the terms are often used interchangeably. In secondary GER, there is an underlying cause of the reflux episodes. Examples of secondary GER are food allergies, metabolic disorders and infections. Silent GER refers to GER or GERD without any obvious or typical symptoms. It means that someone isn't vomiting or appearing uncomfortable but is having episodes of reflux. Some children swallow refluxed material back down instead of throwing it up. This can be much more difficult to diagnose as the most common symptoms aren t present. Additionally, it can be more damaging. Whether or not a child s silent reflux needs to be treated depends on the complications that arise from it. Causes No one knows why some people suffer with GERD and others don t. However, some factors that may contribute to GERD include: Drinking alcohol Being overweight Being pregnant Smoking 7

8 Also, certain foods are associated with reflux occurrences including: Citrus fruits Chocolate Drinks with caffeine Fatty and fried foods Garlic and onions Mint flavorings Spicy foods Tomato-based foods For a more comprehensive list please refer to the food table on page 50. There are multiple causes, and different causes can be apparent in different people or in the same individual at different times. A few people with GERD produce abnormally large amounts of acid, however, this is not common. Some factors that contribute towards GERD are hiatal hernias, lower esophageal sphincter abnormalities, esophageal contractions, and slow emptying of the stomach. Alcohol and smoking relax the LES, and therefore can contribute to GERD as this allows the stomach contents to escape more easily. Being Overweight People who are obese - in other words those who have a body mass index greater than thirty - have been found to be almost three times more likely to develop esophageal cancer than those with healthy body weight. (BMI is a measure of a weight in relation to height.) Esophageal cancer can be a complication of GERD. Exactly how excess body weight increases the likelihood of GERD is unclear. A possibility is that excessive weight in your abdomen compresses your 8

9 stomach and raises the pressure inside, leading to reflux. In addition, obesity can contribute towards the release of inflammatory substances that can raise the risk of GERD. Diet plays a large role in the development of GERD and fatty foods are high risk foods that commonly trigger acid reflux. Pregnancy Higher hormone levels in pregnancy cause reflux by lowering the pressure in the LES as well as the growing fetus increases pressure in the abdomen. The combination of these factors often increases reflux. Women with diseases that weaken the esophageal muscles become more prone to develop GERD. It usually begins in the first or second trimester of pregnancy and continues until delivery. For many women, the heartburn is mild and intermittent; with others it may be severe. The symptoms often disappear after delivery. Hiatal Hernia A hiatal hernia occurs when the upper part of the stomach bulges above your diaphragm, the muscle wall that separates your stomach from your chest cavity. The diaphragm helps the LES prevent acid from coming up into your esophagus. With a hiatal hernia, it s easier for acid to reflux. A hiatal hernia can occur in people of any age, however it is more common in people over the age of fifty. Sudden physical exertion, straining, coughing, or vomiting can cause increased pressure in your abdomen resulting in hiatal hernia. Obesity and pregnancy are also contributory factors. Hiatal hernias don t always need treatment. Lower Esophageal Sphincter Studies have shown that many GERD suffers have various abnormalities of the LES. Common problems include an abnormally weak contraction of the LES that reduces its ability to prevent reflux. Another is abnormal relaxations of your LES, called transient LES relaxations. They don t tend accompany swallows, and can last for up to several minutes. These allow reflux to occur more easily. They occur most commonly after meals when your stomach is 9

10 distended with food and allow trapped air to escape in the form of burping. A further problem is laxity of the LES. This allows easier opening of the LES and a greater backward flow of acid. Esophageal Contractions Swallowing causes a wave of contraction of the esophageal muscles, narrowing the inner cavity of the esophagus. This contraction begins in the upper part of the esophagus and travels to the lower esophagus. It pushes food and saliva down the esophagus into your stomach. When this contraction is defective, refluxed acid is not pushed back into your stomach, therefore staying in the esophagus for longer and increasing the risk of damage. Emptying of the Stomach Most reflux during the day occurs after meals. This reflux probably is due to transient LES relaxations caused by your stomach being distended with food. Some GERD sufferers have stomachs that empty abnormally slowly after a meal. This prolongs the distension of their stomach with food after meals. The slower emptying prolongs the time during which reflux is more likely to occur. Genetics It s unclear whether GERD is inherited. The fact that members of the same family often experience symptoms could be due to inherited genes, or it could be due to their shared environment. Recent studies have shown that inherited genes are likely to be an important cause of GERD, but non-genetic factors are responsible for most cases. GERD/Acid Reflux Symptoms The main symptoms are recurring heartburn and the regurgitation of acid. Some people suffer from GERD without heartburn. Instead, they feel chest pain or hoarseness in the morning, or have trouble swallowing. It can feel like 10

11 food is stuck in your throat, as if you are choking, or your throat is tight. GERD may also cause bad breath and a dry cough. Some people also suffer from nausea. In infants and children, it may cause episodes of vomiting, coughing, and respiratory problems. Most babies grow out of GERD by their first birthday. Heartburn Heartburn, also known as acid indigestion, is the most commonly experienced symptom of GERD and often feels like a burning chest pain beginning behind your breastbone and moving upwards to your neck and throat. Many sufferers say it feels like food is coming back into their mouth leaving an acid or bitter taste. Some people suffer a sharp or pressure-like pain rather than burning. It can also extend to the back. The pain of heartburn can last for two hours or more and is often more severe after eating. It also tends to be worse at night or when lying down or bending over. As acid reflux is more common after meals, heartburn is more likely to occur after meals. Heartburn commonly strikes when you lie down because acid that escapes into the esophagus returns to your stomach more slowly without the aid of gravity. Relief can be obtained by standing up, propping yourself up with pillows or by taking an antacid. Episodes of heartburn tend to happen periodically. The episodes can be frequent or severe for a several weeks or months, and then ease or disappear for several weeks or months. However, heartburn tends to be a life-long problem, and usually returns. Regurgitation Regurgitation is when refluxed liquid returns to the mouth. However, often only small quantities of liquid reach your esophagus, with the majority of the liquid remaining in your lower esophagus. 11

12 Occasionally, larger quantities of liquid, sometimes containing food reach your upper esophagus. When small amounts of refluxed liquid enter your throat, your may experience an acid taste in your mouth. With larger quantities, you may suddenly find your mouth filled with the liquid. Frequent or prolonged regurgitation can lead to dental damage. Nausea Nausea is a less common symptom. However, some people suffer from frequent or severe nausea, sometimes resulting in vomiting. In cases of unexplained vomiting or nausea, GERD is usually one of the first conditions suspected. GERD can potentially lead to complications and cause conditions as serious as cancer more about these later on. If symptoms have persisted after two weeks of using antacids, or you have unexplained nausea or vomiting, you should see your doctor. 12

13 The Impact of Acid Reflux, GERD and Heartburn Who can Suffer From Acid Reflux? The Stressed About fifty-eight per cent of those who suffer frequent heartburn say that their hectic lifestyle is a factor in their flare-ups. Over half of all heartburn sufferers say that work-related stress increases their heartburn. Although stress hasn't been directly linked to heartburn, it can lead to behavior that can triggers heartburn. During stressful times, people may not follow normal routines when it comes to meals, exercise, and medication. By alleviating stress, you can make stress-related heartburn less likely. Regular exercise helps to lower stress and helps with digestion. Sleeping seven to eight hours each night will help to keep your stress level lower as studies show that sleep-deprived people have higher stress levels. Stress can also affect digestion by slowing it down. If food lingers in the body too long it can enhance the effects of reflux. Pregnant Women Heartburn occurs in a quarter to half of all pregnant women. It tends to begin in the first or second trimester and continues throughout the pregnancy. For most women, the heartburn is usually mild and intermittent, but in some it can be severe. Complications of GERD in pregnant women are uncommon, however the usual medications may not be safe in pregnancy, so alternative solutions may need to be found. The reason why acid reflux is common in expectant mothers is because the LES can weaken during pregnancy. This is an effect of the change in levels of 13

14 hormones (estrogen and progesterone) that forms part of pregnancy. This weakness usually resolves itself after delivery. It s unknown if the contraction of the esophagus above the sphincter is impaired in pregnancy by the baby and whether this is responsible for delaying acid clearance from the esophagus back into the stomach. The distortion of the organs in the abdomen along with increased abdominal pressure caused by the growing fetus also acts to promote the reflux of acid. Management of GERD during pregnancy involves many of the same principles as treatment for non-pregnant individuals. Lifestyle changes are particularly important. The head of the bed should be raised or six to eight inches with wedge-shaped foam rubber pads used to elevate the upper body. The wedges should extend all the way to the waist so that the entire chest is elevated. Lying on the left side at night may also decrease acid reflux as this promotes the clearance of acid from the stomach. Any specific foods that aggravate heartburn should be avoided. Over 50s Up to twenty per cent of adults aged fifty-five to seventy-four suffer from GERD. Reflux is more common in this age range because of the physiological changes that time brings. The wave-like motions of the esophagus that push down food may not be as powerful as they used to be. Aging can also weaken the LES. Mature sufferers are also almost twice as likely to develop a hiatal hernia, which can lead to acid reflux symptoms. Other factors that can impair the LES include medications prescribed to mature patients for other conditions, such as nitroglycerine (for angina), calcium channel-blockers (for high blood pressure) and beta-agonists (for asthma). Erosive esophagitis (where the esophagus becomes inflamed, damaged and bleeds) and other GERD complications occur more frequently in the over 50 s age range. They frequently have impaired motility of the esophageal muscles, 14

15 decreased saliva volume, hiatal hernias, take medications that may reduce the strength of the sphincter, and are more likely to do less physical exercise. The Overweight People who are overweight (defined by a body mass index of 25 to 30) are almost one and a half times as likely to develop GERD symptoms, while people who are obese (a body mass index of 30+) are nearly twice as likely to develop symptoms in comparison with those with a healthy body weight. Also, obese people are almost three times more likely to develop esophageal cancer than those with a healthy body weight. The risks increase with increasing weight. Popular opinion has associated heartburn with being overweight for a long time, and most medical practitioners find this to be valid. Heartburn is often caused by eating the wrong types of foods and can occur because of overeating. Even small weight changes can increase the risk of heartburn. Losing weight is a factor in managing heartburn, and as little as ten per cent decrease in weight has been shown to improve heartburn symptoms. However, weight loss does not guarantee symptoms will subside. Some studies have shown that heartburn sufferers continue to experience symptoms even after major weight loss. Therefore, weight loss alone may not be enough to resolve symptoms for everyone. Infants and Children Reflux can occur when babies cough, cry, or strain. The majority of infants with GERD are happy and healthy even if they spit up or vomit. More than half of all babies experience reflux during their first three months of life. An infant with reflux may experience: Constant or sudden crying or colic like symptoms Spitting 15

16 Vomiting Irritability Coughing Poor feeding Blood in their stools Irritability and pain Arching their necks and back during or after eating Poor sleep habits typically with frequent waking Spitting-up Wet burp or frequent hiccups Frequent ear infections or sinus congestion An infant doesn t need to exhibit all of these symptoms, in fact, only displaying one of the above could mean they have reflux. This does not necessarily mean that they need treatment. If your infant shows one or more symptoms, but otherwise is happy and healthy, then some lifestyle modifications will help until they outgrow it. GERD is common and can be overlooked in children. It can cause vomiting as well as coughing, and other respiratory problems. Children's immature digestive systems are usually the cause, and most infants grow out of GERD. Only a minority of infants suffers severe symptoms and most infants stop spitting up between the ages of twelve to eighteen months. Occasionally, babies have other symptoms that can cause concern including: Poor growth because of not holding down enough food Irritability 16

17 Refusing to feed due to pain Blood loss from acid burning the esophagus Breathing problems The above problems can be caused by a number of disorders. Your doctor needs to determine what is causing your child's symptoms. If the child is healthy, happy, and growing well, tests or treatment may be unnecessary. Any treatment depends on the infant's symptoms and age, and can include changes in eating and sleeping habits. Medication may sometimes be an option or even surgery in severe cases. Symptoms indicative of Reflux Disease or GERD: Refusing food Accepting only a few bites of food despite being hungry Requiring constant small meals or liquid Food or oral aversions Anemia Excessive drooling Running nose Sinus infections Swallowing problems Gagging Choking A chronic, hoarse voice Frequent red and sore throat without an infection being present Apnea 17

18 Chronic ear infections Respiratory problems such as pneumonia, bronchitis, wheezing, asthma, night-time cough, aspiration Gagging themselves with their fingers or fist (sign of esophagitis) Poor weight gain Weight loss Failure to thrive Dental enamel erosion Neck arching (Sandifer's syndrome) Bad breath Because infant reflux is so common, reflux is often diagnosed simply by child s symptoms alone. Some doctors prefer to have tests done before prescribing medication. Some babies appear to have been outgrowing their reflux when their symptoms return. Teething can irritate reflux as can colds, flu, and other common illnesses. At other times, reflux can get worse for a day or more with no apparent reason. Every baby is different, and it's difficult to pinpoint a single specific formula that is the best to use when they have reflux. If your baby has a milk allergy or sensitivity then giving a soy based or hypoallergenic formula may help their reflux improve. Hypoallergenic formulas are pre-digested (partially or completely) and they tend to move through the stomach faster than standard formulas. Breast milk is often the best option for reflux. Its proteins are more hypoallergenic than those of formula and it's more easily digested. 18

19 Babies with reflux are notorious for being poor sleepers. Propping them up can be helpful, as can small frequent meals and not feeding them too close to bedtime. The treatment chosen depends on the infant's symptoms and age. Some babies may not need treatment, because the condition often resolves by itself. Healthy and happy babies may only need their food thickened with cereal and to be kept upright after being fed. Overfeeding can worsen reflux, so your doctor may suggest different ways of handling feeding. For example, smaller quantities and more frequent feeding can help to decrease the chances of regurgitation. If a food allergy is suspected, you may need to change your baby's formula, or to modify your diet if you are breastfeeding. If a child isn t growing well, food with a higher calorie content or tube feeding may be recommended. Medication Takers Heartburn can be brought on or worsened by many different medications. Let your doctor know if you suffer from heartburn or if your heartburn worsens when you begin a new medication. It s a good idea to keep a record of when you began to experience your symptoms as well as when you started taking any new medication. This applies whether it s a prescription or non-prescription medication. If the offending medication can t be stopped, alternatives could be available. You may be able to switch to another medication less likely to contribute towards heartburn. People who suffer from reflux should be aware of another pill-related problem. If a pill became lodged in the esophagus, it could cause injury to its lining. This can lead to ulcers and narrowing of the esophagus. Drugs most likely to do this are certain antibiotics (particularly tetracycline); potassium supplements; quinidine and alendronate. Anti-inflammatory agents can also have this effect. It s worth being careful with any pain medication. Always take 19

20 a full glass of water to wash pills down and don t lie down for half an hour to an hour after taking them. Medications Used to Treat Asthma and Breathing Difficulties Theophylline, and other medication used for asthma and breathing difficulties, can lead to a weakening of the LES, which makes it easier for stomach acid to reflux into your esophagus. Some people taking these medications - especially theophylline suffer from heartburn. Using an inhaler may be less problematic. Medications Used to Treat Heart Conditions and Blood Pressure Medications commonly used to treat heart conditions and high blood pressure, for example, calcium channel blockers (diltiazem, nifedipine); beta-blockers (propranolol, atenolol); alpha-blockers (prazosin); and nitrates (isosorbide dinitrate, nitroglycerin) can also relax the LES increasing your risk of reflux. Medications Used to Treat Arthritis and Inflammation All non-steroidal anti-inflammatory drugs such as aspirin, ibuprofen, naproxen, and those available without a prescription, may cause or worsen heartburn. Cyclooxygenase-II inhibitors (celecoxib) are also associated with heartburn. Low dosages of aspirin or NSAID aren t likely to produce this side effect. Medications Used to Treat Osteoporosis Bisphosphonates, for example, alendronate (Fosamax) and risedronate (Actonel), along with other medications used to treat osteoporosis, may injure the lining of your esophagus and lead to heartburn. If you take these medications, be sure to take them with a full glass of water and don t lie down for half an hour to an hour after swallowing them. Taking precautions reduces the chance of these medications causing any injury to your esophagus. 20

21 Medications Used to Treat Anxiety, Insomnia, Depression, and Pain Some medications that act on the nervous system may contribute to heartburn. Anti anxiety medications and agents used to treat insomnia, for example, diazepam or lorazepam, antidepressants including the tricyclic antidepressants such as amitriptyline, and narcotics such as morphine and merpidine used to treat pain, may all cause or worsen your heartburn by relaxing the LES. Medications Used to Treat Parkinson's Disease and Muscle Spasms Some anti-parkinson medications containing levodopa and anti-spasmodics, such as dicyclomine or glycopyrrolate, may increase reflux and heartburn by causing your LES to relax when it needs to be closed. Medications Used to Treat Cancer Some drugs used to treat cancer may cause heartburn, indigestion, and nausea. Those receiving cancer chemotherapy may require additional medication to relieve heartburn and indigestion as well as medication to treat nausea. Hormones Certain hormones, such as progesterone, a hormone contained in some birth control pills, may contribute to heartburn symptoms by decreasing LES pressure. 21

22 Possible Complications Anemia Anemia can be caused by blood loss and is defined as a drop in hemoglobin count. Reflux can lead to anemia by damaging your esophagus causing it to bleed. Apnea Apnea refers to a pause of more than ten to twenty seconds during breathing. People who have GERD are susceptible to apnea episodes. The exact cause is not known however there are a number of theories. One theory is that sleep apnea can change the pressure within the lungs and gastrointestinal systems, possibly resulting in some of the stomach contents to be drawn up into the esophagus. Another theory is that irritation of the esophagus due to reflux could cause airway spasms that lead to sleep apnea. Asthma More than seventy-five per cent of people with asthma also have GERD or reflux and asthma sufferers are twice as likely to have GERD as people without asthma do. When asthma is diagnosed, the possibility of reflux should be also be investigated. Some sufferers don t display any symptoms of reflux and are referred to as having silent reflux. The only symptom may then become asthma and the link between reflux and asthma may not be realized. This means that their asthma can be difficult to control with normal medication. One possibility as to why reflux makes asthma worse is that the acid refluxing up your esophagus can enter the airways, especially when lying down. This can cause your airways to narrow and create wheezing and shortness of 22

23 breath. Over time, your airways can become damaged from the refluxing acid, worsening asthma symptoms. Also, acid present in the lower part of your esophagus can stimulate nerve endings, causing the muscle in your airways to contract, narrowing breathing tubes and promoting asthma symptoms. Some indications that asthma may be caused by reflux are: Asthma symptoms get worse after eating, particularly after eating high fat foods Asthma like symptoms appear with any other typical or atypical symptoms of reflux A persistent cough, which is worse when you lie down Barrett's Esophagus Long-standing or acute GERD can cause changes in the cells that line your esophagus. These cells become pre-cancerous, and, may develop into cancerous cells. This condition is called Barrett's esophagus, which occurs in about ten per cent of acid reflux sufferers. Barrett's esophagus can be diagnosed through an endoscopy and confirmed by a biopsy. If you have this condition, you are advised to have occassional surveillance endoscopies, to detect any pre-cancerous changes so that cancer-preventing treatment can be started. Early treatment and prevention of GERD prevents the progression of Barrett's esophagus to cancer. Newer experimental techniques that destroy the Barrett's cells may also prevent the progression to cancer. Thankfully, only a minority of those with Barrett s esophagus go onto develop cancer. The standard treatment for early cancers in this case is surgical removal of a portion of your esophagus. Bleeding and Ulcers 23

24 Liquid refluxing from your stomach into your esophagus can damage the cells lining your esophagus. An ulcer occurs when the lining breaks down and inflammation and bleeding starts. Ulcers, and the accompanying inflammation they cause, may erode into your esophageal blood vessels and cause bleeding in your esophagus. Sometimes the bleeding is severe and requires blood transfusions and surgical treatment. You should seek immediate medical attention if you start coughing up or vomiting blood or your stools take on a black, tarry appearance. Coughing and Hoarseness GERD is a common cause of unexplained coughing. In the same way that acid refluxed from the stomach can damage your esophagus and lungs, it can also damage your throat and vocal cords. Sometimes, this might be the only symptom of GERD, which makes it more difficult to diagnose. There are a number of nerves in your lower esophagus. Some of these nerves are stimulated by refluxed acid resulting in heartburn. Other nerves don t lead to heartburn, rather they stimulate yet more nerves that provoke coughing. This means that refluxed liquid can cause coughing without ever reaching your throat. Eroded Dental Enamel Some GERD / Acid Reflux sufferers experience regurgitation. This can be just liquid or liquid and food. Occasionally this can reach the mouth and when stomach acid that enters your mouth, it can erode your teeth, just as it does your esophagus, throat and vocal cords. Esophageal Cancer 24

25 The type of cancer associated with Barrett's esophagus is increasing in frequency. Twelve to eighteen thousand new cases of Esophageal cancer are diagnosed per year in the US. One type of esophageal cancer, adenocarcinoma, accounts one-third to onehalf of esophageal cancers and is mainly found in Caucasian men. Adenocarcinoma has been increasing steadily in the US and Western Europe. It has been estimated that Barrett s esophagus might be responsible for half of all adenocarcinomas. However, adenocarcinoma can occur without the changes of Barrett's esophagus. Failure to Thrive Newborns and young babies are expected to grow at a steady and predictable rate, more rapidly than when they get older. Sometimes babies don t gain weight at an acceptable or safe rate and fall below the acceptable low end of the scale. These babies are diagnosed as having failure to thrive. Failure to thrive can have many different causes. GERD can cause failure to thrive in a few ways. Frequent or constant vomiting makes weight gain, or maintaining current weight, difficult or impossible. Even without vomiting, some babies begin to associate food with pain and unpleasantness and develop a dislike of eating. Occasionally, some children are so fearful of food that only tube feeding can provide them with nourishment. Fluid in the Sinuses and Middle Ears Refluxed liquid that enters your upper throat can inflame your adenoids causing them to swell. Swollen adenoids can block the passages from your sinuses and Eustachian tubes (middle ear). When your sinuses and middle ears are closed off from your nasal passages by your adenoids swelling, fluid accumulates in them. This accumulation can lead to discomfort in your sinuses and ears. Because the adenoids are more prominent in young children, this is usually seen in children and not adults. 25

26 Gagging and Choking Babies and children with GERD seem to have a stronger gag reflex than other children and they may frequently gag and choke on their food. They may also gag and choke for no apparent reason, probably from refluxed material coming part of the way up. Inflammation and infection of the Lungs Refluxed liquid can enter your lungs, called aspiration, which often results in coughing and choking. Aspiration, however, can occur without producing these symptoms. It can lead to infection of your lungs resulting in pneumonia. This sort of pneumonia is serious and requires immediate treatment. When aspiration is unaccompanied by symptoms, it can result in a slow, progressive scarring of your lungs, which may be observed on chest x-rays. It s more likely to occur at night, as that is when the bodily processes that protect against reflux and the coughing reflex are not active. Inflammation of the Throat and Larynx If refluxed liquid gets past your upper esophageal sphincter it can enter your throat and even your voice box. The resulting inflammation can lead to a sore throat and hoarseness. Painful and Difficult Swallowing Scars from tissue damage can narrow your esophagus and make swallowing difficult. This is called a stricture. The scar tissue is thicker than the normal lining of the esophagus causing a narrowing of the esophagus that can prevent food and even liquids from passing through. Strictures can be surgically corrected. 26

27 Sleep Reflux commonly impacts on the quality of sleep with many sufferers experiencing their worst symptoms when lying down. Some sufferers, who have respiratory problems worsened by acid reflux, may not show heartburn symptoms. 27

28 Diagnosing Acid Reflux, GERD and Heartburn The usual way that GERD is diagnosed is by its characteristic symptom - heartburn. To confirm a diagnosis, doctors commonly treat patients with medications to suppress the stomach s acid production. If heartburn is diminished to a large extent, the diagnosis is confirmed. There are problems with this approach because it does not include diagnostic tests. Patients who have conditions that can mimic GERD for example, duodenal or gastric ulcers - may also respond to this treatment. If the doctor assumes that the problem is GERD, they won t look for the cause of the ulcer disease. An infection called Helicobacter pylori, or non-steroidal anti-inflammatory drugs (ibuprofen), can also cause ulcers. These conditions would be treated differently from GERD. There is also a placebo effect, which means that some patients will respond to any treatment. This means that those who whose symptoms are caused by something other than GERD (or ulcers) can feel a decrease in symptoms after receiving treatment for GERD. These patients then will be treated for GERD, even though they don t have GERD and the true cause of their symptoms won t be pursued any further. Typically, the first test done to diagnose reflux is not always the most reliable. Negative results are common with children who do have reflux. This is because the child needs to actually reflux during the test to produce a positive result. The test is more valuable for determining anatomic abnormalities within the digestive system. If your heartburn does not improve with changes in lifestyle or drug treatment, you may need additional tests. 28

29 Examination of the throat and larynx Sufferers with symptoms of cough, hoarseness, or sore throat, often visit an ear, nose, and throat (ENT) specialist. The specialist frequently finds signs of throat or larynx inflammation. Although diseases of your throat or larynx are usually the cause of the inflammation, sometimes it can be due to GERD. Therefore, acid-suppressing treatments are generally tried to confirm the diagnosis. Endoscopy After a spray to numb your throat, a small flexible tube with a tiny camera (called an endoscope) is inserted through your mouth and then down into your esophagus and stomach. This is used to examine the lining of your stomach, esophagus, and part of your small intestine. Most patients with symptoms of reflux have a normal looking esophagus, and therefore endoscopy won t help in the diagnosis of GERD. If the procedure reveals injury to your esophagus, no other tests are usually needed. Endoscopy will identify several of GERD s complications, including, ulcers, strictures, and Barrett's esophagus. Other problems that may be causing similar symptoms to GERD can also be diagnosed. Biopsy Biopsies can be painlessly obtained during an endoscopy. A biopsy is a small sample of tissue that is extracted and then examined with a microscope for signs of inflammation and other problems. A biopsy can reveal acid reflux damage and rule out other problems if no infecting organisms or abnormal growths are present. Biopsies are the way to diagnose the cellular changes of Barrett's esophagus. 29

30 Esophageal ph Probe This method is often used when diagnosing infants. A light, thin wire with an acid sensor at its tip is inserted through your nose and into the lower part of your esophagus. The probe is used to detect and record how much stomach acid comes back up into your esophagus. It can also tell if acid is in the esophagus when a child has symptoms such as crying, arching their back, or coughing. X-Rays Before endoscopy was introduced, an x-ray of the esophagus was the only means available of diagnosing GERD. Barium solution a white, chalky liquid - is swallowed and a series of fluoroscopic x-rays taken at intervals over about fifteen to twenty minutes. The barium highlights, or outlines, your esophagus, your throat and your upper intestines, allowing the doctor to view food as it travels down your esophagus, into your stomach and into the first part of your small intestines. A problem with this method is that it is an insensitive test. In other words, it fails to find signs of GERD in many patients because they had little or no damage to the lining of their esophagus. X-rays are only able to show some complications of GERD, such as ulcers and strictures. They are most useful when evaluating complications. Esophageal Acid Testing To show whether acid is present in the esophagus and for how long a twentyfour hour esophageal ph test. (Ph is how the amount of acidity is expressed) is carried out. A small tube (catheter) is passed through your nose and positioned in your esophagus. It has a sensor to sense acid on its tip. The other end of the catheter exits from your nose, wraps back over your ear, and travels down to your waist, where it is attached to a recorder. Whenever acid refluxes back 30

31 into your esophagus from your stomach, it stimulates the sensor. The recorder then records the episode of reflux. After twenty to twenty-four hours, the catheter is removed and the record analyzed. While the testing is being done, you record each time you experience symptoms. It can then be worked out whether acid reflux occurred at the same time that the symptoms were present. There are problems with this method. It is not enough alone to confirm the presence of GERD. Ph testing is useful in managing GERD. The test can help determine why symptoms do not respond to treatment. If testing reveals substantial reflux while medication continues, then the treatment is ineffective and needs to be changed. If testing reveals good acid suppression with minimal reflux of acid, a diagnosis of GERD may be incorrect and other causes for the symptoms can be considered. If reflux occurs at the same time as the symptoms, then it is likely to be the cause of those symptoms. A relatively new method for prolonged measurement - over forty-eight hours - of acid exposure in your esophagus uses a small, wireless capsule attached to your esophagus just above your LES. The capsule is passed to your lower esophagus by a tube inserted through either your mouth or nose. After the capsule is attached to your esophagus, the tube is removed. The capsule measures acid refluxing into your esophagus and transmits its information to a receiver worn at your waist. The capsule falls off the esophagus after three to five days and is passed in a stool. The advantage of this is that there is no discomfort or unsightliness from a catheter passing through your throat and nose. However, sometimes the capsule does not attach, or falls off prematurely. There may be periods when the receiver doesn t receive signals, and some information may be lost. Sometimes, there is pain swallowing after the capsule has been placed. 31

32 Acid Perfusion Test The acid perfusion Bernstein - test is used to see if chest pain is caused by acid reflux. A catheter is passed through one nostril, down the back of your throat, and into the middle of your esophagus. A diluted acid solution and a salt solution are alternately poured through the catheter into your esophagus. If the acid provokes the pain and the salt solution produces no pain, it s likely that your pain is caused by acid reflux. This test is only used rarely. Esophageal Motility Testing This determines how well the muscles of your esophagus are working. A catheter is passed through one of your nostrils, down the back of your throat, and into your esophagus. The catheter has sensors that detect pressure. When the muscle of your esophagus contract pressure is generated in your esophagus and detected by the catheter. The end of the catheter is attached to a recorder. During the test, the pressure at rest and the relaxation of your lower esophageal sphincter are evaluated. Sips of water are swallowed to evaluate the contractions of your esophagus. How well the LES is working can determine whether it is contributing to your acid reflux symptoms. Gastric Emptying Studies Gastric emptying studies determine how well food empties from your stomach. About twenty per cent of patients with GERD have a slow emptying stomach. In this test, you eat a meal containing a radioactive substance. A sensor similar to a Geiger counter is placed over your stomach and measures how quickly the radioactive substance in the meal empties from your stomach. If you continue to have symptoms despite treatment, your doctor might prescribe medication that speeds up stomach emptying. Alternatively, they might do a surgical procedure to promote a more rapid emptying of your stomach. 32

33 Treating Acid Reflux and GERD With Medication and Surgery There are several ways to manage GERD with medication. The best approach to take depends on the frequency and severity of your symptoms, your response to treatment, and any complications present. For infrequent heartburn, life-style changes and an occasional antacid may be all that s needed. If heartburn is frequent, daily non-prescription strength H 2 antagonists may be necessary. Also, a foam barrier can be used with the antacid or H 2 antagonist. If these don t work, you may need to consider prescription drugs. Your doctor can assess you for possible complications based on the presence of symptoms like a cough, asthma, hoarseness, sore throat, difficulty swallowing, unexplained lung infections, or anemia. Your doctor will also look for diseases with similar symptoms to GERD, such as gastric or duodenal ulcers. If there are no symptoms or signs of complications and no likelihood of other diseases, a trial of acid suppression using H 2 antagonists often is a possibility. If these aren t effective, a second trial, with the more potent PPIs is often offered. However, dependent upon severity, sometimes treatment begins with a PPI and skips the H 2 antagonist. If treatment offers complete relief, no further evaluation is needed and the effective drug is often continued. If there are symptoms or signs suggesting complicated GERD, or a different condition is diagnosed, or if the medications don t work, an endoscopy will usually be carried out for further evaluation. There are several possible results of endoscopy, each requiring different treatment. If your esophagus is normal there are no traces of other diseases, the focus is on relieving your symptoms. Therefore, prescription strength H 2 antagonists or PPIs are given. If the esophagus is damaged, then the treatment s goal is to heal the damage. In this case, PPIs are preferred to H 2 antagonists because they allow for better healing. 33

34 If complications are found, treatment with PPIs also is appropriate. However, the adequacy of treatment often needs to be evaluated with a ph study during treatment with the PPI. Strictures may need to be treated by widening your esophageal narrowing. With Barrett's esophagus, endoscopic examinations are necessary to identify pre-malignant changes. Also if symptoms don t respond to the maximum doses of PPI, there are two options. The first is to perform ph testing to find out whether the PPI is ineffective or if another condition is present. A higher dose of PPI may be tried. An alternative is to add another drug that works in a different way, for example, a pro-motility drug or a foam barrier. All three types of drugs can be used. Medications There are a number of antacids, which you can buy over the counter, or medications that neutralize or inhibit acid production, or help muscles to empty your stomach. Antacids Antacids are usually the first drugs recommended to relieve heartburn symptoms and other GERD symptoms as they work to neutralize stomach acid. The problem with antacids is that they empty from your stomach quickly and acid can then re-accumulate. The best time to take antacids is about an hour after your meals, or just before your reflux symptoms begin. An antacid taken after a meal stays in your stomach for longer. A second dose of antacids, about two hours after a meal, replenishes the acid-neutralizing capacity within the stomach although be careful with the dosages as neutralizing acid can lead to reduced digestive effectiveness. 34