Gastroesophageal reflux disease (GERD) affects approximately 20% of adults and 10% of children in the United States (1). Despite treatment guidelines advocating for short-term courses of proton pump inhibitors (PPIs) due to their potential side effects and limited efficacy over time, data shows that 25% of patients end up taking PPIs for extended periods.
This highlights the need for exploring different approaches in GERD management, focusing on strategies that may help improve symptoms and enhance the overall quality of life for those affected.
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What Is GERD?
GERD stands for gastroesophageal reflux disease. Acid reflux is the backflow of stomach acid from the stomach into the esophagus (the tube connecting the mouth to the stomach). GERD occurs when acid reflux becomes chronic, occurring at least twice a week for several weeks.
GERD Signs & Symptoms
Common symptoms related to GERD include (24):
- Heartburn: a burning sensation in the chest
- Regurgitation: the backflow of stomach contents into the throat or mouth
Other symptoms of GERD may include (24):
- Upper abdominal pain
- Increased fullness
- Burping
- Hiccups
- Bloating
- Nausea
- Difficulty swallowing
- Painful swallowing
- Lump-in-throat sensation
- Chronic cough
- Inflammation of the vocal cords
- New or worsening asthma
Symptoms of GERD are generally worse after meals and when lying down (2).
Root Causes of GERD
During normal digestion, food travels down the esophagus and is let into the stomach by the relaxation of a muscular band called the lower esophageal sphincter (LES). The LES then closes, creating a tight barrier between the esophagus and the stomach, preventing the regurgitation of stomach contents into the esophagus. If the sphincter does not close as it should, stomach acid can backflow into the esophagus, contributing to GERD. (7, 25)
GERD Risk Factors
Factors that may increase your risk for developing GERD include (10, 12):
- Connective tissue disorders, like scleroderma
- Hormonal imbalances in estrogen and progesterone
- Conditions that delay stomach emptying, like viral infections, vagal nerve damage, diabetes, and autoimmune disease
- Standard American diet
- Eating large meals late at night
- Tobacco use
- Consumption of alcohol and coffee
Use of the following medications is also associated with an increased risk of GERD (2):
- Antidepressants
- Albuterol
- Anticholinergic medications
- Benzodiazepines
- Calcium channel blockers
- Nitroglycerin
- Non-steroidal anti-inflammatory drugs (e.g., aspirin and ibuprofen)
- Proton pump inhibitors (PPIs)
LES Dysfunction
LES dysfunction, which causes transient relaxation of the sphincter, is a common element involved in the origin of GERD.
Many aspects of the Western lifestyle can contribute to this relaxation, including lack of complete chewing, lying down too soon after a meal, eating large meal portions, excessive saturated fat and alcohol intake, and smoking. (25)
Increased intra-abdominal pressure associated with obesity and pregnancy can contribute to LES laxity by exerting too much upward pressure on the sphincter (25).
A hiatal hernia occurs when the stomach travels upward from its appropriate position in the abdomen and bulges through the diaphragm (the muscle separating the chest and abdomen). This causes the LES to lose muscular support and pressure, increasing the frequency of transient LES relaxation.
Hypochlorhydria, or low stomach acid levels, is a major and often overlooked factor in acid reflux and GERD. Stomach acidity helps to control LES function. When LES sensors detect an acidic stomach environment, the muscles constrict, closing the sphincter. In states of low stomach acid, this feedback mechanism does not occur, inducing LES relaxation and allowing stomach contents to travel into the esophagus. (12)
SIBO
Small intestinal bacterial overgrowth (SIBO) is the overgrowth of bacteria in the small intestine and, in more severe cases, the stomach and esophagus. GERD and SIBO commonly coexist, and patients with SIBO are more likely to report symptoms like bloating and burping (15, 26).
How to Diagnose GERD
GERD is diagnosed based on a combination of clinical presentation, endoscopic evaluation, reflux monitoring, and patient response to treatment. Below is a step-by-step algorithm for diagnosing GERD based on the American College of Gastroenterology's (ACG) clinical guidelines.
Step 1: Empiric Proton Pump Inhibitor Therapy
For patients with classic GERD symptoms, the ACG recommends an 8-week trial of a PPI taken once daily before a meal to test for GERD empirically. If the patient experiences complete relief of GERD symptoms during this trial, GERD is likely. (18)
Step 2: Imaging
Endoscopy should be performed as the first test of evaluation in lieu of empiric PPI therapy for patients who present with alarm symptoms, which include:
- Difficulty swallowing
- Unintentional weight loss
- Pain with swallowing
- Early satiety
- Vomiting
- Aspiration
- Gastrointestinal bleeding
- Unexplained iron deficiency anemia (18)
Endoscopy is recommended for patients who do not respond to an 8-week empiric trial of PPIs or whose symptoms recur after discontinuing PPI therapy. Ideally, endoscopy is performed 2-4 weeks after stopping PPIs. (18)
Inflamed esophageal tissues (esophagitis) are suggestive of GERD. The severity of esophagitis is graded using the Los Angeles classification system.
For patients with normal endoscopy but for whom clinical suspicion of GERD is still high, reflux monitoring can be performed to establish the diagnosis. This test measures the amount of reflux in the esophagus over 24 hours to make a definitive GERD diagnosis. More than 80 episodes in 24 hours is considered an abnormal test. (14)
Step 3: Comprehensive Gut Testing
Gastrointestinal dysbiosis and microbial imbalance may contribute significantly to GERD symptomatology. Providers can tailor treatment approaches more precisely by integrating comprehensive stool analysis and SIBO breath testing into the diagnostic algorithm for GERD.
Comprehensive stool analysis (CSA) offers insights into the gut microbiome composition, assessing for dysbiosis, inflammation, and potential pathogens that could exacerbate GERD symptoms.
- GI-MAP by Diagnostic Solutions
- GI360 by Doctor's Data
- GI Effects Comprehensive Profile - 3 day by Genova Diagnostics
SIBO breath testing evaluates for bacterial overgrowth in the small intestine. Performed at home, this test requires patients to collect a series of breath samples over two to three hours after drinking a specialized mixture.
- SIBO - 3 Hour by Genova Diagnostics
- SIBO/IMO Lactulose Breath Test by Commonwealth Diagnostics International, Inc.
- trio-smart SIBO Breath Test by Gemelli Biotech
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Treatment Plan for GERD
Below is a step-by-step treatment plan that can be personalized for patients managing GERD.
1. Lifestyle Modifications
Here's Why This Is Important:
Certain lifestyle habits can trigger and exacerbate GERD. Modifying these habits may help address the underlying factors of GERD and support esophageal health. Foundational lifestyle habits conducive to optimal LES functioning may help alleviate symptoms and reduce the frequency of acid reflux episodes.
How Do You Do This?
Studies have indicated that the following lifestyle modifications may help reduce distal esophageal acid exposure:
- Weight loss focused on decreasing central abdominal adiposity to reduce intraabdominal pressure and pressure against the LES
- Avoid eating 2-3 hours before bedtime or lying down
- Elevate the head of the bed
- Smoking cessation
- Avoid trigger foods, such as coffee, carbonated beverages, alcohol, spicy foods, tomatoes, citrus, chocolate, peppermint, and fatty foods.
- Stress management
2. Proton Pump Inhibitors
Here's Why This Is Important:
PPI therapy may support mucosal healing and symptom reduction at about two times the rate as histamine 2-receptor antagonist (H2RA) medications (e.g., Pepcid).
How Do You Do This?
Commonly prescribed PPIs include esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), and pantoprazole (Protonix).
Conventional treatment recommendations for GERD suggest dosing a PPI once daily for eight weeks. Patients who experience GERD with extraesophageal symptoms (e.g., hoarseness, chronic cough, laryngitis, asthma exacerbation) may benefit from an 8-12 week trial of twice daily dosing. (18)
If patients respond to empiric therapy, attempt to discontinue the PPI and switch patients to on-demand dosing or an H2RA medication (18).
Patients who require PPI maintenance therapy should be given the lowest dose to help manage GERD symptoms and support mucosal health (18).
3. Support Gut Health
Here's Why This Is Important:
Implementing strategies to support gut health during PPI therapy can help address underlying dysbiosis and support mucosal health. These strategies may increase the likelihood of patients being able to discontinue PPI therapy once the trial has ended.
How Do You Do This?
Gut health strategies should be tailored to the individual. Not every protocol is going to be identical. However, here are some starting points to consider:
Address Dysbiosis
Dysbiosis, or an imbalance in gut bacteria, can lead to excessive intestinal gas production, which increases intraabdominal pressure and can slow stomach emptying. Addressing small or large intestinal bacterial overgrowth can be done with antibiotics or antimicrobial herbs, depending on patient preference. Antibiotics should be chosen based on susceptibility testing, commonly included in comprehensive stool analyses. These are common herbal antimicrobials used to support gut health:
- Berberine 500-1,000 mg three times
- Oregano 50 mg three times daily
- Neem leaf 600 mg three times
Replace Digestive Enzymes
Betaine hydrochloride (HCl) is available in supplemental form and commonly used to support stomach acid levels at mealtimes in patients with hypochlorhydria.
A betaine challenge helps determine the appropriate dose that should be taken with each meal:
- Begin by taking one capsule (350-750 mg) of betaine HCl with a meal.
- If no discomfort or burning sensation is noted at this dose after two days, the patient should increase their dose by one capsule with each meal.
- Continue increasing the number of capsules every two days until you reach a maximum of 3,000 mg of betaine HCl with each meal or until a dose results in tingling, burning, or any other discomfort.
- If discomfort is noted after a dose, the patient can neutralize the acid with 1 tsp of baking soda mixed in water. At future meals, reduce the dose of betaine HCl to the previously tolerated dose.
- Once a dose is established, continue this dose at subsequent meals. A reduced meal may be taken with smaller meals.
Soothe Inflamed Tissues
Various herbs and dietary supplements possess properties that may help protect esophageal mucosa from acid, reduce mucosal inflammation, and support the healing of inflamed tissues. These are examples of commonly recommended supplements:
- Zinc carnosine 50 mg three times daily
- Lactobacillus and Bifidobacterium probiotic species, up to 46 billion CFU daily
- Melatonin 6 mg at bedtime
- Deglycyrrhizinated licorice (DGL) 760 mg three times daily before meals
The Risks of Untreated GERD
Untreated GERD can lead to complications that may significantly impact a person's health and quality of life.
Chronic exposure of the esophagus to stomach acid can result in inflammation, erosions, and ulcers, potentially leading to a condition known as Barrett's esophagus, which increases the risk of esophageal cancer. Persistent acid reflux and chronic inflammation can also cause narrowing of the esophagus (strictures), making swallowing difficult and painful. (2)
Extraesophageal complications of untreated GERD include (2):
- Dental erosion and decay
- Chronic respiratory issues, including asthma and cough
- Sleep disturbances
- Anxiety and depression (16)
GERD Case Study
You can read a case study about GERD here:
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Key Takeaways:
- GERD affects a substantial portion of the American population and is associated with poorer quality of life and health outcomes when it goes unmanaged.
- Proton pump inhibitors are a common intervention for managing GERD; however, healthcare providers should encourage patients to consider these medications as a tool for symptom management, not a long-term solution.
- By working with patients to address the underlying factors of GERD and support optimal gastrointestinal health and function, an integrative GERD management protocol can help manage digestive patterns contributing to GERD and reduce the reliance on pharmaceutical medications.
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