Heartburn is gastroesophageal reflux disease (GERD), in which acid stomach contents flow up the esophagus. Resultant symptoms are chest pain, belching and difficulty swallowing. Additional problems include pneumonitis, laryngitis, cough, middle ear infection, sleep disturbance, asthma and dental erosions. Up to 20% of U.S. adults have some GERD symptoms.
On the other hand, people who have non-erosive reflux disease (NERD) are symptomatic, but do not have inflammation of the esophagus. NERD patients account for as many as 85% of GERD patients, these do not respond well to PPIs. NERD does not seem to progress to erosive esophagitis over time.
People with a hiatal hernia (in which the stomach herniates up through the diaphragm) have an increased risk of GERD. The lower esophageal sphincter should be a barrier to keep stomach contents below the diaphragm, but it can fail. Obesity and the metabolic syndrome are associated with increased risk of GERD.
Esophageal reflux is more likely to be symptomatic in people with lower pH and higher amounts of acid. Reflux with a higher (more alkaline) pH were symptomatic only 15% of the time. Bile acid and pancreatic secretions can be refluxed in DGER (duodenal-gastric-esophageal reflux). The combination of acid reflux and DGER is especially symptomatic and more difficult to treat.
Endoscopy (a medical procedure looking into the esophagus) is often negative in GERD. Not all people who have GERD are symptomatic, and people who have positive esophageal endoscopy for GERD often have no symptoms. Even adenocarcinoma of the esophagus is often asymptomatic. GERD can be caused by delayed gastric emptying which results in the reflux of a larger acid volume.
People with GERD are told to avoid tobacco, alcohol, chocolate and citrus juice; studies have not proven the benefit of dietary changes or cessation of smoking or alcohol. The only lifestyle changes which benefit are weight loss and elevating the head of the bed where the patient sleeps. Antacids are beneficial to some people.
Proton pump inhibitors (PPIs) are the major therapy for GERD. They block the production of stomach acid. Erosive esophagitis is a complication of acid reflux, and esophageal adenocarcinoma is associated with erosive esophagitis. In spite of wide use of PPIs, the incidence of esophageal adenocarcinoma has rapidly increased over the past 20 years. Failure of PPIs to relieve GERD calls for more studies, such as endoscopy, biopsy and pH monitoring.
Alternative treatments include a low carbohydrate diet, acupuncture and melatonin. A combination of melatonin and nutrients which increase SAM-e production has shown a great success rate if given for more than 40 days. Other alternatives are Chinese honeysuckle, peppermint oil, Ibergast (combination of 9 herbs), alginate, pectin, D-limonene, Artemisia asiatica, curcumin, quercetin and vitamin E
CONCLUSION: PPIs are the standard treatment for GERD, but many people who do not benefit from them. There are a number of alternative treatments. Weight loss in obesity is the most likely treatment to benefit patients. There are promising alternative treatments.
NOTE: Read about melatonin and gastroesophageal reflux disease.
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