Gastro-Esophageal Reflux Disease

Overview

Motility disorders of the distal esophagus (e.g. reduced peristaltic amplitude, decreased velocity and increased duration of peristaltic contractions) cause prolonged exposure of the esophagus to refluxed gastric contents.[1]

Epidemiology

The pooled prevalence of GERD in the Indian population is 15.6% (95% CI 11.046 to 20.714). (Keshari et al., 2021) [5]

Reference:

Keshari, R. P., Singh, A., Sharma, B. C., Kumar, A., & Kumar, S. (2021). Prevalence and risk factors for gastroesophageal reflux disease in the Indian population: A meta-analysis and meta-regression study. BMC Gastroenterology, 21(1).

Year of Publication: 2021

Causes of Gastro-esophageal reflux disease

Factors which facilitate reflux are i.e.

• Hernia, fatty meal
• Diabetes mellitus, sliding hiatus
• Prolonged gastric tube intubation
• Scleroderma Drugs – e.g. Anticholinergics, β-adrenergic agents, calcium channel blockers, nitrates
• Ascites, obesity, pregnancy
• Alcohol, smoking
• Pyloric obstruction, fatty foods
• Gastroparesis
• Large meals, Z-E syndrome [1]

Types of GERD 

There are two main types of GERD:

1. Non-erosive reflux disease (NERD): This is the most common type of GERD and is characterized by reflux symptoms without visible damage to the esophageal lining.

2. Erosive esophagitis (EE): This type of GERD involves inflammation and damage to the esophageal lining, which can be seen during an endoscopy. [6]

Risk factors

• Obesity: Increased abdominal pressure can push stomach contents up into the esophagus.
• Hiatal Hernia: A condition where the upper part of the stomach bulges through the diaphragm.
• Pregnancy: Hormonal changes and increased abdominal pressure can contribute to GERD.
• Smoking: Weakens the lower esophageal sphincter (LES) and increases stomach acid production.
• Certain medications: Some medications, such as calcium channel blockers, nitrates, and certain pain relievers, can relax the LES or increase stomach acid.
• Dietary factors: Fatty or fried foods, chocolate, peppermint, alcohol, and caffeine can worsen GERD symptoms. [6]

Pathogenesis of Gastro-esophageal reflux disease

The pathogenesis of Gastroesophageal Reflux Disease (GERD) is multifactorial and involves several mechanisms:

1. Transient Lower Esophageal Sphincter Relaxations (TLESRs): The lower esophageal sphincter (LES) is a muscle that acts as a barrier between the esophagus and stomach. TLESRs are brief, inappropriate relaxations of the LES that allow stomach contents to reflux into the esophagus.

2. Hypotensive LES: A weak or hypotensive LES fails to maintain adequate pressure to prevent reflux.

3. Hiatal Hernia: A hiatal hernia occurs when the upper part of the stomach protrudes through the diaphragm into the chest. This can disrupt the normal function of the LES and contribute to reflux.

4. Impaired Esophageal Clearance: Ineffective esophageal peristalsis (muscle contractions) or decreased salivary production can impair the clearance of refluxed material from the esophagus.

5. Delayed Gastric Emptying: Slow emptying of the stomach increases the volume and pressure within the stomach, promoting reflux.

6. Acid and Pepsin Exposure: The acidic gastric contents and the enzyme pepsin can damage the esophageal mucosa, leading to inflammation and erosions.

7. Other Factors: Obesity, smoking, certain medications, and dietary factors can also contribute to the development of GERD. [6]

Pathophysiology of Gastro-esophageal reflux disease

The pathophysiology is multifactorial, but dysfunction of the lower esophageal sphincter (LOS) has a primary role. [1]

Clinical Features of GERD

The clinical features of GERD can be categorized into:

Typical (Esophageal) Symptoms:

• Heartburn: A burning sensation in the chest that often radiates to the throat and may worsen after eating or lying down.
• Regurgitation: The backflow of stomach contents into the mouth, often with a sour or bitter taste.

Atypical (Extraesophageal) Symptoms:

• Chest pain: Can mimic angina (chest pain related to heart disease) and may require further evaluation.
• Chronic cough: Persistent cough that is not related to any respiratory condition.
• Laryngitis/hoarseness: Inflammation of the voice box, often caused by reflux of stomach acid.
• Asthma: Worsening of asthma symptoms due to reflux.
• Dental erosions: Erosion of tooth enamel due to exposure to stomach acid.
• Dysphagia: Difficulty swallowing. [6]

Sign & Symptoms of Gastro- esophageal reflux disease (GERD)

• Typical symptoms: e.g. Heartburn, acid regurgitation.
• Atypical symptoms: Dysphasia, Globus sensation, noncardiac Chest pain, either dyspepsia or abdominal pain.
• Extraesophageal symptoms: In detail, Hoarseness or sore throat, Or both, sinusitis, otitis media, chronic cough, laryngitis or polyps on the vocal cords or both, dental erosions, non-atopic asthma, recurrent aspiration or pulmonary fibrosis, or both.
• Sleep related GERD can present with multiple awakenings. Additionally, Substernal burning and/or chest discomfort, indigestion or heartburn. Other symptoms include a sour or bitter taste in the mouth, water brash, coughing or choking.
• Malignancy: Esophageal adenocarcinoma, head also Neck cancer.
• All in all, Barrett’s esophagus is found in 10–20% of patients with Reflux esophagitis, the squamous epithelium is injured by chronic gastro-esophageal reflux also repair is effected by columnar instead of squamous cells Upper GI scopy can be diagnostic assisted by biopsy. This columnar epithelium may undergo malignant transformation.[1]

Clinical Examination of Gastro-esophageal reflux disease

• General Assessment: Assess the patient’s overall health, nutritional status, and body mass index (BMI), as obesity is a risk factor for GERD.

• Abdominal Examination: Palpate the abdomen for tenderness, masses, or organomegaly (enlarged organs). Although not specific to GERD, these findings may suggest other gastrointestinal conditions.

• Epigastric Auscultation: Listen for bowel sounds in the epigastric region (upper abdomen). This can help assess gastric emptying and rule out other causes of abdominal discomfort.

• Extraesophageal Examination: Examine the throat and larynx for signs of irritation or inflammation, which may indicate laryngopharyngeal reflux (LPR), a form of GERD where stomach acid reaches the throat and voice box. [6]

Diagnosis of Gastro-esophageal reflux disease

Your Doctor  will often be able to diagnose gastro-esophageal reflux disease (GERD) based on your symptoms.

They may prescribe medication to treat it without needing to carry out any tests.

Tests you may have i.e.:

• Endoscopy
• Either Barium swallow or barium meal test
• Manometry
• 24-hour pH monitoring
• Blood tests [1]

Differential Diagnosis of Gastro-esophageal reflux disease

• Acute gastritis
• Atrophic gastritis
• Chronic gastritis
• Crohn’s disease
• Peptic ulcer disease
• Gastrinoma
• Gastric Adenocarcinoma
• Primary gastric lymphoma [4]

Complications of Gastro-esophageal reflux disease

Long-term or untreated GERD can lead to several complications:

1. Esophagitis: Inflammation of the esophagus caused by repeated exposure to stomach acid. It can lead to pain, difficulty swallowing, and bleeding.

2. Esophageal Stricture: Narrowing of the esophagus due to scar tissue formation from chronic inflammation. This can cause difficulty swallowing and requires dilation (stretching) of the esophagus.

3. Barrett’s Esophagus: A precancerous condition where the normal lining of the esophagus changes to resemble the lining of the intestine. This increases the risk of developing esophageal cancer.

4. Esophageal Ulcer: Open sores in the lining of the esophagus that can cause pain, bleeding, and difficulty swallowing.

5. Respiratory Complications: GERD can trigger or worsen respiratory problems like asthma, chronic cough, and laryngitis due to the aspiration of stomach acid into the airways.

6. Dental Erosions: Stomach acid can erode tooth enamel, leading to tooth sensitivity and decay. [6]

Investigation of Gastro-esophageal reflux disease

1. Firstly, Radiology Barium swallow with fluoroscopy Upper esophageal sphincter disorders Defective opening of pharyngo-esophageal segment Airway aspiration.
2. Secondly, Upper esophageal endoscopy
3. Thirdly, Manometry

• Upper esophageal sphincter
• Tone of upper esophageal sphincter also relaxation

During swallowing i.e.-

• Coordination between relaxations of upper esophageal sphincter and contraction of the pharynx.
• Body motility
• Evaluation of amplitude, duration also velocity of waves.
• Lower esophageal sphincter tonic pressure and relaxation.

4. Esophageal pH testing
5. Scintigraphy. [1]

Treatment of Gastro-esophageal reflux disease

Heartburn and gastro-esophageal reflux disease (in other words; GERD) can often be treated with self-help measures and over-the-counter medicines.

If these don’t help, your GP can prescribe stronger medication or refer you to a specialist to discuss whether surgery may be an option.

Self-help to GERD

You may find the following measures can help reduce heartburn and other symptoms of GERD:

• Eat smaller and more frequent meals, rather than 3 large meals a day – don’t eat or drink alcohol within 3 or 4 hours before going to bed, and avoid having your largest meal of the day in the evening.
• Avoid anything you think triggers your symptoms – common triggers e.g. coffee, chocolate, tomatoes, alcohol, and fatty or spicy food.
• Don’t wear tight clothing – clothes that are tight around your tummy may make your symptoms worse.
• Raise the head of your bed by up to 20cm (8 inches) – placing a either piece of wood or blocks underneath one end of your bed may reduce symptoms at night; don’t just use extra pillows, as this can put a strain on your tummy.

• Try to relax – stress can make heartburn also GERD worse, so learning relaxation techniques may help if you’re often feeling stressed.
• Maintain a healthy weight – if you’re higher-weighter, losing weight may help reduce your symptoms.
• Stop smoking – smoke can irritate your digestive system and may make your symptoms worse.

If you’re taking medication for other health conditions, check with your GP to find out whether they could be contributing to your symptoms.

Different medicines may be available, but don’t stop taking any prescribed medication without consulting your doctor first.[1]

Medication for GERD

A number of different medications can be used to treat symptoms of GERD.

Over-the-counter medicines for GERD

Over-the-counter heartburn and GERD medicines are available from pharmacies without a prescription. The main types are:

• Antacids – these neutralize the effects of stomach acid
• Alginates – these produce a coating that protects the stomach and esophagus (gullet) from stomach acid
• Low-dose proton-pump inhibitors and H2-receptor antagonists

Surgery may be an option if:

• The above treatments don’t help, aren’t suitable for you, or cause troublesome side effects.
• You don’t want to take medication on a long-term basis.

The main procedure used is called a laparoscopic Nissen fundoplication (in other words; LNF). Alternative techniques have been developed more recently, although these aren’t yet widely available. [1] 

Prevention of GERD

Lifestyle Modifications:

• Weight loss: Maintain a healthy weight as excess weight increases abdominal pressure, promoting reflux.
• Smoking cessation: Smoking weakens the lower esophageal sphincter (LES), making reflux more likely.
• Elevated head of bed: Raise the head of your bed by 6-8 inches to use gravity to keep stomach acid down.
• Avoid lying down after meals: Wait at least 2-3 hours after eating before lying down or going to bed.
• Loose-fitting clothing: Avoid tight clothes around the waist as they can increase abdominal pressure.

Dietary Changes:

• Smaller, frequent meals: Avoid large meals that can distend the stomach and increase pressure.
• Identify trigger foods: Common triggers include fatty or fried foods, chocolate, peppermint, coffee, alcohol, acidic foods (citrus fruits, tomatoes), and spicy foods.
• Limit or avoid trigger foods: Reduce or eliminate these foods from your diet to minimize symptoms. [7]

Homeopathic Treatment of Gastro-esophageal reflux disease

Homeopathy treats the person as a whole. It means that homeopathic treatment focuses on the patient as a person, as well as his pathological condition. The homeopathic medicines selected after a full individualizing examination and case-analysis.

which includes

• The medical history of the patient,
• Physical and mental constitution,
• Family history,
• Presenting symptoms,
• Underlying pathology,
• Possible causative factors etc.

A miasmatic tendency (predisposition/susceptibility) also often taken into account for the treatment of chronic conditions.

What Homoeopathic doctors do?

A homeopathy doctor tries to treat more than just the presenting symptoms. The focus is usually on what caused the disease condition? Why ‘this patient’ is sick ‘this way’?.

The disease diagnosis is important but in homeopathy, the cause of disease not just probed to the level of bacteria and viruses. Other factors like mental, emotional and physical stress that could predispose a person to illness also looked for. No a days, even modern medicine also considers a large number of diseases as psychosomatic. The correct homeopathy remedy tries to correct this disease predisposition.

The focus is not on curing the disease but to cure the person who is sick, to restore the health. If a disease pathology not very advanced, homeopathy remedies do give a hope for cure but even in incurable cases, the quality of life can greatly improved with homeopathic medicines.

Homeopathic Medicines for Gastro- esophageal reflux disease (GERD) :

The homeopathic remedies (medicines) given below indicate the therapeutic affinity but this is not a complete and definite guide to the homeopathy treatment of this condition. The symptoms listed against each homeopathic remedy may not be directly related to this disease because in homeopathy general symptoms and constitutional indications also taken into account for selecting a remedy.

Homoeopathic Approach:

Homeopathy treats the person as a whole. It means that homeopathic treatment focuses on the patient as a person, as well as his pathological condition. The homeopathic medicines are selected after a full individualizing examination and case-analysis, which includes the medical history of the patient, physical and mental constitution, family history, presenting symptoms, underlying pathology, possible causative factors etc.

A miasmatic tendency (predisposition/susceptibility) is also often taken into account for the treatment of chronic conditions. A homeopathy doctor tries to treat more than just the presenting symptoms. The focus is usually on what caused the disease condition? Why ‘this patient’ is sick ‘this way’. The disease diagnosis is important but in homeopathy, the cause of disease is not just probed to the level of bacteria and viruses. Other factors like mental, emotional and physical stress that could predispose a person to illness are also looked for.

No a days, even modern medicine also considers a large number of diseases as psychosomatic. The correct homeopathy remedy tries to correct this disease predisposition. The focus is not on curing the disease but to cure the person who is sick, to restore the health. If a disease pathology is not very advanced, homeopathy remedies do give a hope for cure but even in incurable cases, the quality of life can be greatly improved with homeopathic medicines.

The homeopathic remedies (medicines) given below indicate the therapeutic affinity but this is not a complete and definite guide to the homeopathy treatment of this condition. The symptoms listed against each homeopathic remedy may not be directly related to this disease because in homeopathy general symptoms and constitutional indications are also taken into account for selecting a remedy.

Medicines:

1. Podophyllum:

• Nausea, with acidity. Vomiting of the contents of the stomach and of bile, at time mixed with blood, or of hot frothy mucus.

2. Arsenic:

• Craving for acids and brandy. Constant desire to drink, but takes very little at a time.
• Eructations, Hiccough, Nausea, Vomiting of food also drink as soon as they reach the stomach.
• The distress in the stomach is not relieved by vomiting, but the extreme irritability, burning and indescribable distress continue.
• Inflammation and ulceration, with terrible distress. In the pit of stomach, anxiety, soreness, burning or internal chilliness.

3. Argentum nitricum:

• Craving for sugar.
• Nausea, Retching; vomiting; ejecta become black.
• Furthermore, Flatulent distention of stomach, extreme.
• Pit of stomach painfully swollen Bursting sensation in pit, ameliorated by eructations.
• Besides this, Eructations difficult, as if esophagus were spasmodically closed.
• Vomiting of glairy mucus. Lastly, Pain in pit, extends around sides or into the chest.

4. Anacardium:

• Feeble digestion; melancholy especially after eating.
• All in all, a shattering sensation in the pit of the stomach on every step after eating.

5. Ipecac:

• General loss of appetite as from weakness of the stomach.
• Furthermore, Aversion to all food; or dislike for sweets and dainty things. No thirst.
• Nausea, which seems to come from the stomach, with empty eructations also salivation.
• Besides this, Retching and vomiting of food; of bile; of green, bilious mucus; of blood; renewed after taking cold drinks or smoking tobacco.

6. Baptisia:

• The whole throat becomes red, frequent inclination to swallow, with pain at the root of the tongue.
• General sore throat with a constrictive sensation; additionally, frequent efforts to swallow.

7. Hepar sulph:

• Basically, Speech very weak, voice lost. Hoarseness, painless.
• Cough hoarse, paroxysmal,  aggravation from the slightest cold, caused by tickling in the upper part of the throat, left side, talking and stooping.
• Cough rough, scraping, suffocative, in the evening on going to sleep. Dyspnoea.[3]

Diet & Regimen of Gastro-esophageal reflux disease

GERD Diet and Regimen 

Dietary Tips:

• Limit/Avoid:

  • Fatty foods (fried foods, high-fat meats)
  • Spicy foods
  • Acidic foods (tomatoes, citrus fruits)
  • Chocolate, peppermint
  • Coffee, caffeinated beverages
  • Carbonated drinks, alcohol

• Enjoy:

  • Lean protein (grilled chicken, fish)
  • Non-citrus fruits (bananas, melons)
  • Vegetables (easy on tomato-based sauces)
  • Whole grains (oatmeal, brown rice)
  • Low-fat dairy

Regimen :

• Smaller, more frequent meals
• Avoid eating close to bedtime
• Elevate head of your bed
• Maintain a healthy weight
• Quit smoking
• Manage stress

The Do’s & Don’ts 

Do’s:

• Eat smaller, frequent meals: Instead of three large meals, try eating four to five smaller meals throughout the day to reduce pressure on the stomach.
• Maintain a healthy weight: Excess weight puts pressure on the stomach and can worsen GERD symptoms.
• Elevate the head of your bed: Raise the head of your bed by 6-8 inches to help prevent stomach acid from flowing back into the esophagus while you sleep.
• Choose healthy fats: Opt for lean meats, fish, avocados, nuts, and olive oil.
• Eat non-citrus fruits and vegetables: Apples, bananas, broccoli, carrots, and green beans are good options.
• Drink plenty of water: Water helps dilute stomach acid and can ease symptoms.
• Wear loose-fitting clothes: Tight clothing can put pressure on your stomach and worsen GERD.
• Manage stress: Stress can worsen GERD symptoms. Try relaxation techniques like yoga or meditation.

Don’ts:

• Don’t smoke: Smoking weakens the lower esophageal sphincter and increases stomach acid production.
• Not consume alcohol or caffeine: Both can irritate the esophageal lining and worsen GERD.
• Don’t eat trigger foods: Common triggers include fatty or fried foods, chocolate, peppermint, garlic, onions, spicy foods, citrus fruits, and tomatoes.
• Don’t eat late at night: Avoid eating 2-3 hours before bedtime to allow your stomach to empty.
• Not lie down immediately after eating: Wait at least 2-3 hours after a meal before lying down.
• Don’t wear tight-fitting clothes: Tight clothes around your waist can put pressure on your stomach.

Terminology 

References use for Article Gastro-esophageal reflux disease

1. Medicine Golwala
2. https://www.nhsinform.scot/illnesses-and-conditions/stomach-liver-and-gastrointestinal-tract/gastro-oesophageal-reflux-disease-gord#:~:text=in%20the%20oesophagus.-,24%2Dhour%20pH%20monitoring,nose%20and%20down%20your%20oesophagus.
3. https://www.pritikin.com/acid-reflux diet#:~:text=Eat%20plenty%20of%20whole%20foods,or%20no%20alcohol%20and%20caffeine.
4. https://www.wikidoc.org/index.php/Gastroesophageal_reflux_disease_differential_diagnosis
5. Keshari, R. P., Singh, A., Sharma, B. C., Kumar, A., & Kumar, S. (2021). Prevalence and risk factors for gastroesophageal reflux disease in the Indian population: A meta-analysis and meta-regression study. BMC Gastroenterology, 21(1), 58. (2021)
6. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease Review and Assessment (11th Edition), by Anthony Fauci, Dan Longo, Dennis Kasper, Stephen Hauser, J. Larry Jameson, Joseph Loscalzo (2021), Elsevier

Also Search As

1. Search Engines:

• Use specific keywords: "homeopathic treatment for GERD," "homeopathy for acid reflux," or "GERD homeopathic remedies."
• Include relevant terms: "natural remedies for GERD," "alternative treatment for GERD," or "holistic approach to GERD."

2. Homeopathic Websites and Journals:

• Visit reputable homeopathic organizations’ websites: National Center for Homeopathy (NCH), American Institute of Homeopathy (AIH), or The North American Society of Homeopaths (NASH).
• Search online homeopathic journals: The American Journal of Homeopathic Medicine, Homeopathy, or The International Journal of High Dilution Research.

3. Online Databases and Libraries:

• Explore academic databases: PubMed, Google Scholar, or ResearchGate.
• Search library catalogs for books and articles on homeopathy and GERD.

4. Social Media:

• Follow homeopathic organizations and practitioners on social media platforms like Facebook, Twitter, or Instagram.
• Join online forums and groups dedicated to homeopathy for discussions and information sharing.

5. Homeopathic Practitioners:

• Consult a qualified homeopath for personalized recommendations and access to relevant articles.

Other ways 

1. Search Engines:

• Use general keywords: "GERD," "heartburn," "acid reflux," "reflux disease."
• Use specific keywords: "GERD symptoms," "GERD causes," "GERD treatment," "GERD complications."
• Use long-tail keywords: "natural remedies for GERD," "best foods for GERD," "GERD in pregnancy," "GERD surgery."

2. Reputable Medical Websites

3. Medical Journals and Databases:

• PubMed: Search for scientific articles and research studies on GERD.
• Google Scholar: Find scholarly literature on GERD, including articles, theses, and books.

4. Online Forums and Communities:

• GERD forums and support groups can provide insights and personal experiences from individuals living with the condition.

5. Healthcare Professionals:

• Consult your doctor or gastroenterologist for personalized information and guidance on managing GERD.