Montgomery Medicine #791

By: Dr. John Roberts

GERD Part 2

I left you hanging last week wondering about the treatment of Gastroesophageal Reflux Disease (GERD). First, a quick review: Recall that acid from the stomach (gastro) can enter the tube that connects the mouth to the stomach (esophagus) and flow backward (reflux).

When I see someone complaining of GERD symptoms, I review the patient’s history to identify any risk factors for GERD. These can include decreased tone of the lower esophageal sphincter (LES), loss of normal muscular function of the esophagus, excess production of stomach acid, delayed emptying of the stomach, and overeating. Fatty or fried foods, coffee, tea, caffeinated drinks, chocolate, and mint are common culprits that can cause or worsen GERD. Alcohol and cigarette smoking are also significant risk factors.

Many patients immediately reach for medication to control their symptoms rather than addressing the underlying causes of GERD. Direct-to-consumer advertising has been highly effective in promoting medications for this common problem. In fact, many medical insurance companies report that their largest drug expenses come from a class of medications called proton pump inhibitors (PPIs).

Simple lifestyle changes form the foundation of GERD treatment. Losing even a modest amount of weight can significantly improve symptoms. Reducing dietary fat and avoiding large, fatty meals close to bedtime are critical to managing the condition. Other strategies include avoiding tight-fitting clothing, reducing alcohol consumption, and quitting smoking. For those who wake up at night with reflux symptoms, elevating the head of the bed is often beneficial. This can be accomplished using commercial plastic bed risers, a 4×4 post cut into blocks, or two 2x4s screwed together. Using pillows to elevate the head and chest is not recommended, as this can increase abdominal pressure and worsen reflux. Elevating the head of the bed itself is the preferred approach.

For those who do not respond to lifestyle modifications, medications may be necessary. The effectiveness of reducing the frequency and intensity of heartburn, the most common GERD symptom, can vary. People often need to try different medications from various classes to find the one that works best for them. Histamine antagonists are among the oldest medications available and work by blocking the release of histamine, which stimulates stomach acid production. Over-the-counter options include Tagamet® (cimetidine) and Pepcid® (famotidine), which are effective for many people.

Proton Pump Inhibitors (PPIs) are a newer, more powerful class of medications for acid suppression. These include well-known names such as Prilosec®, Protonix®, Nexium®, Prevacid®, and others. While PPIs are highly effective and generally safe for short-term use, long-term use has been associated with a slightly increased risk of hip fractures in individuals over age 50, possibly due to reduced calcium absorption. Many people mistakenly believe they need to remain on PPIs indefinitely because their symptoms return when they stop taking the medication. This phenomenon, known as “rebound” reflux, is sometimes described as a dependency on PPIs. However, once initial GERD symptoms are controlled, preventing their recurrence can often be achieved with less potent medications. If you have been on PPIs for more than a few months, it is worth discussing with your doctor how to taper off them safely.

The “two-week warning” found on boxes of GERD medications advises users to contact their physician if symptoms persist beyond two weeks. This is an important reminder for individuals to consult with a medical provider to discuss risk factors, develop a management plan, and assess the risk of more serious GERD complications.

Surgery is considered a last resort for GERD that does not respond to lifestyle changes and medications. The most common procedure is laparoscopic Nissen fundoplication, which involves wrapping the top of the stomach around the bottom of the esophagus to create a valve that reduces reflux. Another option, EsophyX TIF, is a newer and less invasive procedure that reconstructs the lower esophageal sphincter using an endoscope passed through the mouth. It is essential to consult a gastroenterologist or surgeon experienced in these procedures to determine whether you are a suitable candidate.