ACID REFLUX or GERD: what is it and how to avoid taking meds!

Lifestyle changes. I’m sure you’ve heard your doctor suggest lifestyle changes if you’ve spoken to them about acid reflux. But what exactly does that mean?? Everyone may know not to lay down right after eating as you could just imagine the acid and partially digested food forcing its way past your lower esophageal sphincter (LES), irritating your esophagus, and sometimes even ending up in your mouth! No the best feeling. So many people medicate with anti-acid medications like Nexium. But now we’re learning that staying on these medications long term is not good and associated with increased risk of infections like C. difficile diarrhea, malabsorption of key nutrients and minerals like magnesium, possible increased risk of fractures and even dementia and kidney disease. So lets try to avoid them!

Lets start with the basics:

What is GERD?

Gastroesophageal reflux disease (GERD) is movement of gastric juice from the stomach up into the esophagus. There is an antireflux barrier which is made up of the LES and diaghragm at the gastro-esophageal junction to prevent this from happening but it can be compromised in the following ways:

  1. Occasional relaxation of the LES
  2. Anatomic disruption like a hiatal hernia
  3. Obesity
  4. Pregnancy hormone changes
  5. Low pressure of the LES       
  • This includes strain-induced reflux when the LES is overcome and "blown open" by an abrupt increase of intra-abdominal pressure, i.e. lying down after eating
  • Tobacco, chocolate, carbonated beverages, and right lateral decubitus position directly lower LES pressure 

What are the symptoms?

10-20% of the Western world have GERD so know what to look out for! Heartburn, regurgitation, chest pain, trouble swallowing, chronic cough, asthma, laryngitis, sometimes abdominal pain, nausea, vomiting, bloating and belching…even waking up during the night gasping for air and having a choking sensation!

How do I get diagnosed?

See your doctor to make sure it actually IS GERD!  Be sure to bring a food/drink diary to see how your symptoms correlate with mealtimes and certain foods. Your doc may recommend lifestyle changes and/or try you on an acid suppressant and see how you respond and if you respond well, its clear. If not- you may need an endoscopy, esophageal pH monitoring or other testing.

Now to those LIFESTYLE CHANGES!

1.     WEIGHT LOSS! WEIGHT LOSS! WEIGHT LOSS! Probably your MOST EFFECTIVE option. Extra weight increases intraabdominal pressure so that gastric contents break past the LES and into the esophagus. Bariatric treatment like surgical gastric bypass has been demonstrated to be effective in reducing GERD. Losing ~ 10–15lbs decreases the occurrence of frequent heartburn by approximately 40%.

2.     STOP TOBACCO AND ALCOHOL. They loosen tension of the upper esophageal sphincter and cause hoarseness, postnasal drip and shortness of breath by irritating the mouth, larynx and trachea

3.     ELEVATE THE HEAD OF THE BED 6-8in- especially if you have nocturnal or laryngeal symptoms (cough, hoarseness, throat clearing). Use blocks or foam wedges under your mattress.

4.     FOOD RULES:

  • DO NOT LAY DOWN OR EXERCISE UNTIL 3 HOURS AFTER A MEAL
  • NO LATE NIGHT MEALS: Eat at least 3 hours before you go to bed
  • NO SUPERSIZED MEALS: Try eating 5-6 small meals a day instead of 3 big ones!
  • NO FAKE FOOD! Many commercially produced foods and drinks are treated with acid-containing substances to enhance flavor and shelf life (see the #feedyourgut tab!!!)
  • AVOID TRIGGER FOODS! The usual culprits are: caffeine, coffee, chocolate, spicy foods, carbonated drinks, raw onion, garlic highly acidic foods such as citrus/oranges and tomatoes, peppermint, and fatty foods (they take the longest to digest).
  •   EAT HIGH FIBER FOOD- Fiber enhances digestion, reducing pressure on the LES and can aid in weight loss. (see the #feedyourgut tab!!!)

If you DO need a Rx don’t forget there are plenty to chose from!

1.     Antacid (Tums)

  •  For on-demand symptom relief
  • Onset of action: 5 minutes
  • How do they work? Neutralize gastric pH, decreasing exposure of esophageal mucosa to gastric acid during reflux.

2.     Surface agent (sucralfate/Carafate)

  • Onset of action: 1-2hrs
  • How do they work? Adheres to mucosal surface, promotes healing, and protects from peptic injury
  • Short duration of action & limited efficacy
  • Safe to use so usually used in pregnancy
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3.     Alginate (Gaviscon)

  • Onset of action: 3-4min
  •  How do they work? It’s a polysaccharide derived from seaweed that forms a viscous gum that floats within the stomach and reduces the aftereating acid pocket in proximal stomach. Good for mild reflux.

4.     Histamine 2 receptor blockers (famotidine /Pepcid)

  • Onset of action: 2.5hrs
  • Usually only work up to 6 weeks
  • How do they work? Block acid secretion by blocking H2 receptors on the parietal cell

5.     Proton pump inhibitors (esomeprazole/Nexium)

  • Onset of action: 1-2 hrs
  • How does it work? Blocks gastric acid secretion by inhibition of the H+/K+-ATPase in the parietal cell
  • Its the STRONGEST anti acid medication but with the most side effects.
  • Usually only used when the above options fail. Take it at the lowest dose available for the shortest time available and make sure to take it correctly—on an empty stomach 30min before breakfast!

Why are we talking about this? Because chronic acid reflux leads to Barrett’s esophagus which puts you at higher risk for esophageal cancer. So manage your GERD early to prevent cancer later!

The resources referenced above:

ACG GERD guidelines

AGA GERD guidelines

NYTimes

Uptodate.com

Gastroenterology & Hepatology: Advances in GERD