GASTROESOPHAGEAL REFLUX DISEASE
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Some times after attending late-night superb parties offered by friends in marriage functions or company bonus parties with a variety of spicy delicious foods when we return home at bed we feel a fullness of stomach with a prickly burning sensation at the heart. Commonly known as Heartburn is nothing but acid reflux from the stomach to the esophagus by the irregular behavior of the gastroesophageal valve. Technically this condition is known as Gastro-Esophageal-Reflux-Disease or simply known as GERD
The esophagus is the food passage down from the larynx the portion down next from the oral or buccal cavity. Food, after chewed and swallowed by the mouth, is pushed down to the esophagus through the larynx then passes down through it to reach the stomach by opening the valve gate known as the Lower esophageal sphincter(LES) which should open downwards into the stomach.
Esophagus the food passage has no protection from the acid attacks. Heavy food and spicy unbearable filling of the stomach may lead to an irregular upward opening of the lower esophageal sphincter and the acidic stomach juice refluxed up rapidly into the esophagus to cause heartburn.
This may not be a disease if it happened occasionally. But the frequent and prolonged stay of the acidic stomach contents effluxed into the esophagus may cause damages to the esophageal tissues (Reflux Esophagitis) and heartburn.
Symptoms
A burning sensation or pain focused at the lower chest can slowly radiate upwards to the left side and make confusion with the pain of a heart attack.
Symptoms usually occur soon after a meal and when lying on the bed.
Severe mucosal damage may cause pain during swallowing.
Complications
Patients with severe uncontrolled GERD may suffer from bleeding due to esophageal ulcerations, and respiratory complications due to the entry of the refluxed acid materials into the lungs through the upper airways.
Patients who have pain in swallowing(Dysphagia) may have esophageal ulcers, strictures, or cancer.
Etiology
Many people with GERD have a weak LES. As a result, the high pressure in the stomach (by taking full stomach or spicy foods) produces enough force to overcome the weak squeeze of the LES and allows the content to elude upward and causes reflux.
The following other factors also may weaken LES tone, delaying gastric emptying, increasing acid secretions, or impairing the gastroesophageal pressure gradient as follows:-
1.Calcium channel blockers like Amlodipine, nifedipine, verapamil, and diltiazem
2.Nitrates like nitroglycerin, sodium nitroprusside,
3.Anticholinergics like tricyclic antidepressants(amitriptyline,imipramine,clomipramine)antihistamines
antihistamines(Diphenhydramine, chlorpheniramine)
4.Oral contraceptives and estrogen.
Treatments
A.Nonpharmacological
1. Elevate the head of the bed about 5 inches by some mechanical means.
2. Eat night meals at least 2 hours before going to sleep
3. Avoid foods that reduce LES tones such as chocolate, mint and high-fat foods
4. Avoid the following foods that irritate the esophagus like tomato preparations, coffee, citrus juice, spicy foods.
5. Take small meals
6. Avoid bed soon after the meals
7. Stop smoking
8. Avoid alcohol
9.Reduce obesity
10. Avoid tight clothing.
B.Pharmacologic
Generally, the approach should follow first the nonpharmacologic procedures.
The pharmacologic procedure contains the antacids, the OTC H-2 Receptor Antagonists, with the nonpharmacological procedures as the first step.
1.Antacids
Antacids may reduce the acidity of the stomach contents by increasing its pH, and reduce the pressure on LES.
Generally, they reduce the heartburn in 10 to 15 minutes. The duration may range from 1 to 3 hours.
Repeated doses may require the maximum 5 times per day because of the short duration of action.
40 to 80 mEq is the daily dose should be taken after each meal and at bedtime.
a)Sodium bicarbonate should be used carefully because of its sodium content (12mEq/gm).
It is not suitable in patients with edema, CHF, kidney failure, cirrhosis in the liver, and hypertension.
b)Calcium carbonate is also good for GERD but may cause constipation.
c)Aluminum hydroxide may cause constipation but avoid to be used in patients with hemorrhoids, with constipation.
d)Magnesium hydroxide may frequently cause diarrhea. To prevent this a mixture of Aluminium and Magnesium hydroxide is better.
In general Kidney, patients should avoid all antacids
Cardiac patients can use under doctors' advice magnesium and potassium hydroxide mixtures.
The maximum daily dose is 500 mEq ANC (Acid Neutralizing Capacity) of antacids.
Antacids may interfere with the absorption of many drugs such as
Tetracyclines
Quinolones such as ciprofloxacin, ofloxacin
Iron preparations
Digoxin
2.Alginic acid
This is a safe medication for GERD as unlike antacids it works differently as follows. Alginic acid reacts with sodium bicarbonate of saliva to form viscous sodium alginate which when going into the stomach float above the stomach content so that the content cannot efflux upward beyond this viscous float and the effluxed sodium alginate will not irritate the esophagus.
Alginic acid tablets must be chewed before swallowing along with one or two glasses of water
It works well in patients with an upright position.
These products should not be taken at bedtime or just before lying into the bed.
3.OTC H-2 Receptor Antagonists
These products minimize the acid secretions by completely blocking the H-2 receptors of the histamine in the parietal cells of the stomach. The onset of the action is 1 to 2 hours.
These agents are giving effects >90%.
Very useful in healing gastric and duodenal ulcers.
All these medicines are equally effective but differ in their other untoward effects.
a)Cimetidine The adult dose is 200 mg.twice daily.
Side effects are liver problems, by interfering with the liver metabolisms of warfarin, phenytoin, and theophylline and thereby increase the plasma concentrations of these drugs dangerously.
b)Famotidine The adult dose is10 mg twice daily To be taken 1 hour before food. A 10 mg dose has an effect of 8 hours.
Fortunately, famotidine does not interfere with hepatic metabolisms of other drugs.
c)Ranitidine The adult dose is 75 mg up to twice daily.
Compared with cimetidine, ranitidine impairs hepatic metabolism of other drugs 10 times lesser.
d)Nizatidine The adult dose is 75 mg up to twice daily.
Fortunately, it does not impair the hepatic metabolism of other drugs.
The dosages of the OTC medications mentioned above should be increased only by a doctor's supervision
Side effects of H-2 RAs
1.Nausea
2.Headaches
3.Reversible gynecomastia(Male increased breast size)
4.Elevated serum prolactin results in galactorrhea
5.Altered estrogen metabolism in male
6.Inhibition of hepatic p-450 enzyme metabolism(Cimetidine and Ranitidine)
4.Proton Pump Inhibitors
These are prescription-only powerful medicines to treat GERD. Their duration of action is up to 3 days. The act by inhibiting the hydrogen-potassium ATPase pump on the surface of the parietal cells of the stomach.
1.Omeprazole
2.Lansoprazole
These medicines can be used in the following conditions:-
a)GERD with duodenal or gastric ulcers
b)Multiple Endocrine Neoplasia(MEN)
c)Systemic mastocytosis
d)Zollinger-Ellison syndrome(Hyper gastric acid secretion)
Side effects
Nausea and diarrhea
Otherwise in general these drugs are well tolerated.
5.Mucosal Protecting Agents
1)Misoprostol
This is prostaglandin E-1 analog and stimulating gastric secretions of mucus and other protective factors
Used in peptic and duodenal ulcers.
Problems due to longtime uses of NSAIDs
Side effects are diarrhea and unwanted ulcerative contractions
2)Sucralfate
It is a sulfated disaccharide sugar.
Acting by polymerization with necrotic ulcer tissues
Also, adsorb bile salts and stimulate endogenous prostaglandin synthesis. their safety is yet to be established.
Sucralfate needs an acid medium to be activated and hence it should not be taken with antacids, H-2 RAs or PPIs.
3.Bismuth
Bismuth compounds also similar to sucralfate bind to the necrotic tissues of the ulcers.
Additionally, they have anti-H-pylori effects.
Special Patients'Care
1.Pediatric
Antacids and alginic acid can be used in children and infants but their safety is yet to be established
H-2RAs can be used in children above 12 years.
2.Pregnant
Antacids are safe.
3.Geriatric
Antacids and nonprescription OTC H-2 RAs are safe
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