Gastroesophageal Reflux Disease (“GERD”)

This topic has received so much television marketing by the pharmaceutical companies that the word GERD has become a household term.  Indeed, many people now believe that GERD is a part of normal everyday life and that it is fine for them to stay on gastric acid inhibiting medications for the rest of their lives.  GERD is NOT normal.

The work-up for GERD is simple in traditional medicine. National Standard of Care deems that all with chronic GERD should have a barium esophagram to be sure there is no narrowing of the esophagus and that there is no overt evidence of ulcer.  If there is no contraindication, everyone then should see a gastroenterologist and have esophagogastroduodenoscopy (known as EGD).  Endoscopy consists of light sedation followed by the GI doc gently easing a small fiberoptic camera into the esophagus, stomach, and part of the duodenum (small intestine).  The procedure lasts  around an hour and is an out-patient test.

EGD, as the scope procedure is known, can reveal the presence of ulcers, which can also be biopsied through the scope to detect cancers and/or bacterial infections. In addition, EGD will show whether a potentially pre-cancerous condition known as Barrett’s esophagus might be present, which is correctable.  The scope will also allow the physician to stretch (dilate) any narrowed places in the esophagus, thus frequently relieving certain swallowing difficulties.

If ulcers or inflammation (gastritis if in the stomach, duodenitis if in the small intestine, esophagitis in the food tube) is/are present, the cause of either must be delineated.  Then, proton pump inhibitors such as omeprazole  and others will be used short-term in order to heal the mucous membrane.

In most instances the EGD does reveal “inflammation” without telling us the cause of that.  We frequently recommend food sensitivity detective work, since after all, food sensitivities cause heartburn in many folks.  We recommend elimination and provocation food allergy testing since skin prick testing and serum RAST testing may not reveal food allergies unless a person has intestinal permeability disorders. 

Much of the routine serology to detect food allergies doesn’t test IgA (immunoglobulin A), which seems to be the predominant antibody expressing true food allergies.  Saliva and fecal testing is being developed which likely will give us more reliable food allergy testing.

Frequently, instead of using the stronger drugs such as omeprazole, which turn off the stomach acid almost completely, we recommend the GI antihistamine (“H-2 blocker”) called Pepcid.  We recommend the name-brand,  Pepcid AC, which will block histamine, which will then inhibit production of stomach acid by a different mechanism than the proton pump inhibitors such as omeprazole.  Other H-2 blockers include Zantac, Axid, Tagamet. We prefer Pepcid AC due to its side effect profile.

Some folks might have a bacterial infection in the stomach called Helicobacter pylori causing GERD, ulcers, or stomach cancers. H. pylori can be present normally in small amounts.  This bacterium is extremely contagious, and in large amounts has been identified as the cause of many gastric and duodenal ulcers, as well as GERD-like stomach and abdominal pain and nausea.  More concerning, this bacterium can cause a type of stomach cancer later in life.

Although EGD with biopsy is the gold standard to detect this bacterium, we have found that blood testing and fecal testing usually will detect acute infections.  Serum H. pylori IgA, and serum H. pylori IgM detect ACUTE infections, while the serum H. pylori IgG can remain positive even after treatment.  We can monitor treatment success with the fecal H. pylori antigen test as well.  Traditional treatment consists of at least 2 antibiotics taken orally for 10-14 days, with 80-90% cure. However, this bacterium can be difficult to eradicate and may require other protocols.

EGD can also show the presence of abnormal webs and rings (such as Schatzki’s Ring), strictures, and hiatal hernias.

Interestingly, the TV doesn’t inform us that there is indeed another equally painful cause of GERD, which is ALKALINE REFLUX DISEASE. 

Alkaline reflux disease means that there is not ENOUGH stomach acid, which causes the lining of the stomach to become inflamed, and foods to be malabsorbed (malabsorption).   However, no medication exists for alkaline reflux, so not much is heard about it.  Simple non-pharmacologic treatments are successful for both types of reflux. However, we find that many folks just want to take a pill instead of getting to the CAUSE of the problem.

Lowering stomach acid production, while necessary to allow the mucous membrane to heal in cases of ulcers, etc., can have deleterious long-term effects including growth of cancers.  Therefore we do not keep our patients on the prescription medications long-term. 

Some undesired sequelae from prolonged use of antacids, proton pump inhibitors, and H-2 blockers (antihistamines for the GI tract) include bacterial overgrowth syndromes, yeast overgrowth syndromes (yes, these entities are even listed in the traditional Harrison’s Internal Medicine volumes) and malabsorption of the essential heavy metal minerals (sodium, potassium, calcium, magnesium, the list goes on and on). 

What is important in your treatment is that we be certain of the etiology and the diagnosis, and that we treat you correctly and adequately, and retest you to be certain the cause of the problem has been cured.

After we have corrected the disease, whatever it may be, it is crucial that we determine the cause of the disease, and take preventive actions so that the disease will not recur.