Gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease (GERD)

Definition Gastro-oesophageal reflux disease (GERD) is a chronic condition where the stomach acid flows back up into the oesophagus, causing symptoms such as heartburn and regurgitation. This occurs when the lower oesophageal sphincter (LES) is weakened or does not function properly.

Synonyms Acid reflux, chronic heartburn, reflux oesophagitis

Causes / Etiology

1. Weakening of the lower oesophageal sphincter (LES) due to aging, obesity, or hiatal hernia.
2. Delayed gastric emptying, which allows stomach acid to flow back up into the oesophagus.
3. Increased pressure in the stomach, which can force stomach acid up into the oesophagus.
4. Certain medications, such as antihistamines, decongestants, and pain relievers, can relax the LES and worsen GERD symptoms.
5. Eating habits, such as consuming large or heavy meals, lying down after eating, or drinking beverages that can trigger GERD symptoms.

Types / Classification

1. Acute GERD: Symptoms of heartburn and regurgitation that occur suddenly and last for a short period, usually up to 2 weeks.
2. Chronic GERD: Symptoms of heartburn and regurgitation that occur frequently, lasting for more than 2 weeks.

Pathophysiology / Pathology

1. Stomach acid flows back up into the oesophagus, causing irritation and inflammation of the oesophageal lining.
2. The LES fails to function properly, allowing stomach acid to flow back up into the oesophagus.
3. The oesophagus becomes inflamed and irritated, leading to symptoms such as heartburn and regurgitation.
4. Over time, chronic inflammation can lead to scarring and narrowing of the oesophagus.

Clinical Features

1. General features: Heartburn, regurgitation, difficulty swallowing, and chest pain.
2. Specific features:
   • Acute GERD: sudden onset of symptoms, usually within 2 weeks.
   • Chronic GERD: frequent occurrence of symptoms, lasting for more than 2 weeks.
   • Complications: oesophagitis, stricture, and Barrett's oesophagus.

Complications

1. Acute complications:
   • Oesophagitis: inflammation of the oesophagus.
   • Stricture: narrowing of the oesophagus due to scarring.
2. Chronic complications:
   • Barrett's oesophagus: transformation of the oesophageal lining into a pre-cancerous state.
   • Oesophageal cancer: increased risk of developing oesophageal cancer due to chronic inflammation.

Investigations / Diagnosis

1. Routine tests: endoscopy, barium swallow, and oesophageal manometry.
2. Specific tests: 24-hour pH monitoring, ambulatory oesophageal pH monitoring.
3. Confirmatory tests: biopsy, endoscopic ultrasound.

Differential Diagnosis

1. Other causes of heartburn: gastro-oesophageal reflux, peptic ulcer disease, and oesophageal spasm.
2. Other causes of difficulty swallowing: oesophageal cancer, oesophageal stricture, and achalasia.
3. Other causes of chest pain: angina, myocardial infarction, and pneumothorax.

Management / Treatment

1. General management: lifestyle modifications, such as maintaining a healthy weight, eating smaller meals, and avoiding trigger foods.
2. Modern medicine treatment:
   • Antacids and acid reducers: to neutralize stomach acid and reduce symptoms.
   • Histamine-2 (H2) blockers: to reduce acid production in the stomach.
   • Proton pump inhibitors (PPIs): to reduce acid production in the stomach.
   • Surgery: to tighten the LES or remove the hiatus hernia.
3. Diet and lifestyle advice:
   • Eat smaller meals to reduce pressure on the LES.
   • Avoid trigger foods, such as citrus fruits, tomatoes, and chocolate.
   • Maintain a healthy weight to reduce pressure on the LES.
   • Elevate the head of the bed to reduce symptoms during sleep.

Homeopathic Therapeutics

1. Arsenicum album:

   • Causation: overeating, rich or spicy food.
   • Characteristic symptoms: burning sensation in the chest, regurgitation of food.
   • Modalities: worse from lying down, eating spicy food.
   • Mental state: anxiety, restlessness.
   • Thirst and appetite: increased thirst, decreased appetite.
   • Nature of discharges or secretions: acidic, sour.
   • Physical generals: burning sensation in the chest, regurgitation of food.
   • Suitable constitution or patient type: anxious, restless patients.
   • Helps in the disease: relieves symptoms of heartburn and regurgitation.

2. Calcarea carbonica:

   • Causation: overeating, constipation.
   • Characteristic symptoms: heartburn, regurgitation, bloating.
   • Modalities: worse from eating, lying down.
   • Mental state: anxiety, irritability.
   • Thirst and appetite: increased thirst, increased appetite.
   • Nature of discharges or secretions: sour, acidic.
   • Physical generals: bloating, gas.
   • Suitable constitution or patient type: anxious, sensitive patients.
   • Helps in the disease: relieves symptoms of heartburn and regurgitation.

3. Carbo vegetabilis:

   • Causation: overeating, poor digestion.
   • Characteristic symptoms: bloating, gas, heartburn.
   • Modalities: worse from eating, lying down.
   • Mental state: anxiety, restlessness.
   • Thirst and appetite: increased thirst, decreased appetite.
   • Nature of discharges or secretions: sour, acidic.
   • Physical generals: bloating, gas.
   • Suitable constitution or patient type: anxious, sensitive patients.
   • Helps in the disease: relieves symptoms of bloating and gas.

4. Lycopodium clavatum:

   • Causation: overeating, poor digestion.
   • Characteristic symptoms: bloating, gas, heartburn.
   • Modalities: worse from eating, lying down.
   • Mental state: anxiety, restlessness.
   • Thirst and appetite: increased thirst, decreased appetite.
   • Nature of discharges or secretions: sour, acidic.
   • Physical generals: bloating, gas.
   • Suitable constitution or patient type: anxious, sensitive patients.
   • Helps in the disease: relieves symptoms of bloating and gas.

5. Nux vomica:

   • Causation: overeating, rich or spicy food.
   • Characteristic symptoms: heartburn, regurgitation, bloating.
   • Modalities: worse from eating, lying down.
   • Mental state: anxiety, irritability.
   • Thirst and appetite: increased thirst, increased appetite.
   • Nature of discharges or secretions: sour, acidic.
   • Physical generals: bloating, gas.
   • Suitable constitution or patient type: anxious, sensitive patients.
   • Helps in the disease: relieves symptoms of heartburn and regurgitation.

6. Phosphorus:

   • Causation: overeating, poor digestion.
   • Characteristic symptoms: bloating, gas, heartburn.
   • Modalities: worse from eating, lying down.
   • Mental state: anxiety, restlessness.
   • Thirst and appetite: increased thirst, decreased appetite.
   • Nature of discharges or secretions: sour, acidic.
   • Physical generals: bloating, gas.
   • Suitable constitution or patient type: anxious, sensitive patients.
   • Helps in the disease: relieves symptoms of bloating and gas.

7. Sulfur:

   • Causation: poor digestion, constipation.
   • Characteristic symptoms: bloating, gas, heartburn.
   • Modalities: worse from eating, lying down.
   • Mental state: anxiety, irritability.
   • Thirst and appetite: increased thirst, increased appetite.
   • Nature of discharges or secretions: sour, acidic.
   • Physical generals: bloating, gas.
   • Suitable constitution or patient type: anxious, sensitive patients.
   • Helps in the disease: relieves symptoms of bloating and gas.

8. Natrum carbonicum:

   • Causation: overeating, rich or spicy food.
   • Characteristic symptoms: heartburn, regurgitation, bloating.
   • Modalities: worse from eating, lying down.
   • Mental state: anxiety, irritability.
   • Thirst and appetite: increased thirst, increased appetite.
   • Nature of discharges or secretions: sour, acidic.
   • Physical generals: bloating, gas.
   • Suitable constitution or patient type: anxious, sensitive patients.
   • Helps in the disease: relieves symptoms of heartburn and regurgitation.

Prognosis The prognosis for GERD depends on the severity of symptoms, the presence of complications, and the effectiveness of treatment. In general, GERD is a chronic condition that requires ongoing management to prevent complications.

Prevention Prevention of GERD involves lifestyle modifications, such as:

1. Maintaining a healthy weight.
2. Eating smaller meals to reduce pressure on the LES.
3. Avoiding trigger foods, such as citrus fruits, tomatoes, and chocolate.
4. Elevating the head of the bed to reduce symptoms during sleep.
5. Avoiding lying down after eating.

Diet Dietary recommendations for GERD include:

1. Eating smaller meals to reduce pressure on the LES.
2. Avoiding trigger foods, such as citrus fruits, tomatoes, and chocolate.
3. Choosing low-fat or fat-free foods.
4. Avoiding spicy or acidic foods.
5. Drinking plenty of water to stay hydrated.