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Questions to ask you doctor about GERD
The exact incidence of heartburn is hard to quantify. It is such a common occurrence that many people do not think to report it. It affects somewhere between 7-15% of the population on a daily basis.
Heartburn is a symptom, but it does not mean that one has a disease. Gastroesophageal reflux disease (GERD) is when heartburn becomes pathologic. This typically occurs after heartburn has been present for an extended period of time and there is a reduction in the quality of life.
GERD is much more common in the older population and patients often do not seek medical attention until symptoms have persisted.
GERD occurs for a variety of reasons. One major reason is when a valve between the stomach and the tube, called the esophagus, which carries food from the mouth to the stomach, does not remain closed. Typically, the opening to the stomach closes as soon as food enters. If it does not remain closed then the acid in the stomach can regurgitate into the esophagus. The valve, which is known as the lower esophageal sphincter, is a ring of muscle at the bottom of the esophagus whose job is to prevent food from going from the stomach to the esophagus.
Occasional heartburn is not serious but if it persists it can be potentially life threatening. If the esophagus remains in contact with acid from the stomach for an extended period of time inflammation can ensue leading to a condition called esophagitis. This can eventually lead to a condition called Barrett’s esophagus and potentially cancer of the esophagus.
The exact cause of GERD remains elusive but many conditions contribute. A hiatal hernia – when the upper part of the stomach is above the diaphragm (the muscle that separates the stomach from the chest) – contributes to GERD. The diaphragm helps the valve between the stomach and the esophagus keep acid from coming up into the esophagus.
Other factors that contribute to GERD include: excessive alcohol use, pregnancy, being overweight, smoking and certain foods. Signs and Symptom
Heartburn is characterized by a burning feeling in the lower chest, along with a sour or bitter taste in the throat and mouth. It usually occurs after eating a big meal or while lying down. It lasts for a few minutes to a few hours. When stomach contents – which contain acid – touch the lining of the esophagus a burning sensation occurs.
Sometimes the fluid is regurgitated all the way back into the mouth leading to a sour taste in the mouth. Occasional heartburn does not mean one has GERD, but heartburn that occurs more than twice a week is considered GERD, and it can eventually lead to more serious health problems.
Although the main symptoms of GERD are persistent heartburn and acid regurgitation, some people have GERD without heartburn. Unusual symptoms of GERD include pain in the chest, difficulty swallowing, cough, hoarseness or sore throat. Warning signs
Warning signs are situations that, if present, may represent severe underlying disease. If any of these signs or symptoms are present more aggressive workup is needed. The following is a list of conditions that indicate more serious underlying disease. If any of them are present it is important that you contact your doctor immediately.
When one of the above conditions is present your doctor should evaluate you and perform some laboratory tests and possibly an endoscopy. Laboratory tests evaluate for any blood loss or possibly for ulcers in the stomach. Endoscopy is a test where a small flexible tube is inserted down your throat into your stomach where a camera can evaluate for any disease such as ulcers and/or cancer. If you are afflicted with GERD, fill out the GERD tracking tool to document any alarm symptoms. If present – TELL YOUR DOCTOR!
Diagnosis The doctor will come to the diagnosis in three different ways: History and physical examination by your doctor is the first step to diagnosing this condition. Certain factors will alarm a doctor and more tests may be run. Specifically, if there is any indication that you are bleeding or having weight loss, the doctor may treat or evaluate you more aggressively. An evaluation of the blood counts through blood testing will indicate if there is any bleeding occurring in the stomach. Blood, stool or breath tests are available to test for bacteria in the stomach that commonly leads to ulcers that can lead to symptoms that mimic GERD. When the doctor is suspicious of the diagnosis but is not sure, a trail of medication is sometimes used to help confirm the diagnosis. As long as no alarm symptoms are present, many doctors are comfortable treating for GERD even if they are not 100% sure it is the right diagnosis. The typical scenario involves a patient coming to the office with symptoms suggestive of GERD. The doctor prescribes a medication to treat GERD and schedules a follow up appointment in a few weeks. At the follow up appointment if the symptoms are improved than the doctor has confirmed his diagnosis. If the symptoms are no better or only minimally better than the doctor will search for a different diagnosis or run one of the diagnostic tests listed below to help label the symptoms. A battery of diagnostic tests are available to aid in the diagnosis of GERD. Diagnostic tests are not always done but when the doctor is unsure of the diagnosis or when alarm symptoms are present testing can be helpful. Testing is available to help confirm the diagnosis. Certain diagnostic tests are available to monitor for life threatening conditions associated with GERD. The diagnostic tests include: pH testing, barium swallow and endoscopy. Testing for the acid level in the esophagus, with pH monitors, can be used to more specifically diagnosis the disease. Monitoring for acid is accomplished by putting a tiny probe into the esophagus for 24 hours. It can tell if there is acid coming up into the esophagus when there is no damage seen on endoscopy. A barium swallow uses an x-ray to look for a cause of difficult or painful swallowing, for the presence of a hiatal hernia, ulcers, tumors or severe inflammation. Endoscopy, which involves putting a tube with a camera down into the stomach will check for erosion to the esophagus, damage to the cells in the esophagus, ulcers or other conditions. During endoscopy the doctor can biopsy damaged areas to rule out bacteria and cancers. Treatment Treatment of GERD is typically done in a stepwise fashion – after any severe underlying disease is ruled out. Treatment starts with lifestyle interventions. If lifestyle modifications are unable to control symptoms then medications are added in a step-wise fashion. Lifestyle The first step to treatment of GERD is lifestyle changes. This means things that each individual does themselves to try to treat the disease process without medication. Dietary modification is a common treatment modality for controlling GERD but individuals vary in how certain foods affect his or her disease. The two-day food diary helps define how certain foods affect you. Filling out this form and reporting symptoms increases understand how certain foods and lifestyle modifications affect you personally. Here are some other interventions that are helpful in GERD:
MedicationsWhen lifestyle modifications do not control signs and symptoms of disease, medications are added. This does not mean that lifestyle interventions are terminated when medication is added. First-line treatment for GERD is antacids, which are bought over the counter. Common brands include: Alka-Seltzer, Maalox, Mylanta, Pepto-Bismol and Rolaids. Antacids neutralize the acid in the stomach and provide fast, short-term relief. The main side effects of antacids are diarrhea or constipation. Magnesium based antacids – such as Maalox and Mylanta – cause diarrhea while aluminum or calcium-containing antacids – such as Rolaids and Tums - lead to constipation. If lifestyle changes and antacids do not help your symptoms, talk with your doctor. Your doctor may want you to take other medicines or schedule some tests. The next drug to treat GERD, controls the acid production in the stomach. The drugs cimetidine (Tagamet), famotidine (Pepcid), nizatidine (Axid), and ranitidine (Zantac) are in a class of drugs called histamine 2 receptor (H2) blockers. They can be bought over the counter and are prescription strength. These drugs work by decreasing the amount of acid that the stomach produces. Proton pump inhibitors (PPI) are the most powerful acid inhibitors and are considered by many to be the gold standard for GERD treatment. One PPI, Prilosec, is available over the counter while the rest of the PPIs are prescription drugs. Other PPIs include lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex), and esomeprazole (Nexium), which are prescription only. Less commonly a drug named metoclopramide (Reglan) is used to treat GERD. Metoclopramide improves speed at which food goes through the digestive tract, but this drug has many side effects that limit its usefulness. Because drugs work in different ways, combinations of drugs may help control symptoms. People who get heartburn after eating may take both antacids and H2 blockers. The antacids work first to neutralize the acid in the stomach, while the H2 blockers act on acid production. By the time the antacid stops working, the H2 blocker will have stopped acid production. Your doctor is the best source of information on how to use medications for GERD. But your doctor cannot do it alone. GERD is a disease that is about controlling symptoms, you need to report symptoms and their severity to your doctor. The GERD tracking sheet will aid you in reporting symptoms to your doctor so the effectiveness of treatment can be determined.
SurgeryWhen lifestyle changes and medications do not adequately treat the disease then surgical intervention is considered. Fundoplication involves wrapping the upper part of the stomach around the lower esophageal sphincter to prevent reflux and repair a hiatal hernia. This procedure can be done by laparoscope. It is safe and effective when performed by experienced doctors. Two endoscopic treatments are FDA approved in the management of GERD: radiofrequency ablation and endoscopic plication. Radiofrequency ablation – although infrequently used - to the sphincter at the junction of the upper stomach and the esophagus is meant to increase the reflux barrier. It is mildly beneficial. Endoscopic plication is the most popular endoscopic procedure. The junction between the stomach and esophagus is stiched up to improve symptoms. Endoscopic therapies are considered in those whose symptoms cannot be controlled with lifestyle changes and medication; unable to endure medications; or do not desire or could not tolerate surgery. Complications Sometimes GERD can cause serious complications. Inflammation of the esophagus from acid causes bleeding or ulcers. In addition, scars from tissue damage can narrow the esophagus and make swallowing difficult. Some people develop Barrett’s esophagus, where cells in the esophageal lining take on an abnormal shape and color, which over time can lead to cancer. GERD may aggravate or even cause asthma, chronic cough, and pulmonary fibrosis. Health care responsibility Questions to ask your doctor Do I have any indication of a more serious underlying disease? GERD can be a simple disease or it can be complicated by severe underlying disease such as an ulcer or cancer. It is important that your doctor evaluate you for any serious underlying disease and you report any new symptoms to your doctor. How did you diagnose my disease? GERD can be diagnosed in a variety of ways, it is helpful to have an understanding how sure your doctor is that the correct diagnosis was made. May I have an ulcer that is causing my symptoms? Ulcers sometimes mimic symptoms of GERD. Simple tests are available to test for bacteria that cause ulcers. It is important to have this ruled out as a cause of disease. If on medicines: Do I take the medicines everyday or only when needed? Some medicines need to be taken everyday, but some are only used on an as needed basis. If on any medications, Will I need to be on this medicine permanently or can I stop taking it at some point? Many patients stay on medicines for GERD their whole life but many can come off after they have made some lifestyle interventions.
