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, there are anti-reflux procedures. Gold standard is the gastric fundoplication, a time-honored (50 years) procedure that has been refined to the point where it is 92-98% effective in stopping reflux in the short term. Yes, there can be side effects of the operation, especially if not done well (dysphagia, gas bloating), but these are minimized if modern methods and concepts are followed. Recurrence rates are about 6-10% depending on who is doing the procedure. The concept is wrapping (plicating) the stomach to itself around the esophagus at the level of the LES. This will splint the LES and prevent it from relaxing. It makes the LES into a more effective one-way valve.