Acid Reflux Disease Treatment
Q: I have a question re treatment of GERD.Treating the symptom (heartburn) by reducing/eliminating
the reflux of acid into the esophagus might actually do more harm than
good because the esophagus might then be exposed to more damaging bile
salts, since the actual cause of the reflux of contents from stomach to
esophagus has not been addressed when the drugs are used. The patient
has less discomfort but s/he may actually be doing himself/herself more
damage and increasing his/her risk of developing esophageal
adenocarcinoma. What treatment do you recommend for GERD? Are the
lifestyle changes of restricting food intake to at least three hours
before lying down, elevating the head of the bed on blocks, reducing the
size of meals especially the evening meal and evening snacks, and weight
loss where necessary of any benefit?
A:Acid reflux disease (GERD) is a mechanical problem. It relates to
dysfunction of the LES, whether it be baseline laxity (low resting LES
pressure) or transient inappropriate LES relaxation. Current studies
definitely tend to favor the latter as the primary cause for GERD in 60-80%
of cases. Therefore, the role of anti-secretory medications as a "cure" for
GERD doesn't make much sense in my mind. If there is no reflux-mediated
damage to the esophagus on EGD (stricture, erosion, Barrett's) then I have
no problem with using PPIs as a means of controlling the patient's symptoms,
but I think it's important to bear in mind the flip side -- we may very well
be increasing that patient's risk of esophageal cancer. We are not curing
the patient's disease, only controlling the symptoms of that disease. It's
not unlike treating a patient's painful inguinal hernia with pain
medication.
Note that (at present) I stop short of saying that everyone with acid reflux
disease should have an anti-reflux procedure. We aren't there - can't draw
that conclusion with certainty. Yet.
Since we postulate that reflux can be a significant contributer to the
development of esophageal cancer, then stopping the reflux should be our
primary goal. Just suppressing the symptoms with PPIs apparently isn't
enough, since they don't do anything to stop the reflux. They only change
the character of the refluxate. In fact, that may actually INCREASE the
incidence of esophageal cancer.
Toward that end, how do we stop the reflux? The lifestyle modifications are
an excellent place to start. Since a full stomach is a major contributing
factor to transient inappropriate LES relaxation, one should eat in a manner
such that the stomach is not overdistended (smaller meals). Since gravity
will aid reflux, one should go to bed on an empty stomach, and along those
same lines, elevating the head of the bed will also be beneficial. Since
increased intra-abdominal pressure will increase the pressure gradient
across the LES, then weight loss is also a great idea since that will
decrease the volume of the abdominal cavity. Since some foods (tomato spices
etc) will mediate transient inappropriate LES relaxation, they should be
avoided. Same for nicotine, caffiene, alcohol. All of the above are also
true if the reason for GERD is a lax LES (low baseline LES resting
pressure).
Alternatively,