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Heartburn & Gastrointestinal Reflux Disease (GERD)

Humans have suffered from heartburn for ages but gastrointestinal reflux disease or GERD has only been recently recognized as a disease. GERD is defined as chronic symptoms or mucosal (lining of the wall of the esophagus) damage resulting from abnormal reflux of gastric or duodenal (small intestine) contents into the esophagus. The disease and its treatment have been the target of aggressive pharmaceutical marketing to professionals and consumers alike. The third best selling class of pharmaceutical drugs in the world are proton pump inhibitors (PPI). In 2010 this class of drugs accounted for 24 billion dollars in sales!

Symptoms related to GERD are some of the most common complaints to the primary care physician. GERD affects 30% of the population in Western countries and is now recognized as an increased risk for erosive esophagitis, strictures and Barrett’s esophagitis, which is a change in the structure of the lower esophageal cells that can lead to adenocarcinoma. Mounting evidence documents harm from long term use of drugs that suppress acid including osteoporosis, depression, vitamin B12 and mineral deficiencies, small intestinal bacterial overgrowth, irritable bowel syndrome and pneumonia.

It is clear that a new approach is needed to address the underlying causes of GERD, ideally limiting the use of pharmacologic agents and relying more on dietary, nutritional and other lifestyle therapies targeted toward removing the underlying causes and restoring normal intestinal function. Conventional approaches to GERD include limiting dietary triggers, elevating the horsed of the bed and pharmacologic treatments such as antacids, H2 blockers, PPIs, and motility agents. These are effective immediately upon use but their cessation an lead to rebound symptoms resulting in reliance and long term use.

One in ten Americans has daily episodes of heartburn. And of these, 10-20% have weekly symptoms and 44% have occasional symptoms. The functional and structural abnormalities associated with GERD are caused by exposure of the esophagus to recurrent episodes of acidic and non-acidic gastric refluxate. Gastric contents may contain intestinal proteases as well as bile, acid and gastric pepsin (an enzyme class needed in digestion). Studies have shown that a combination of acid and pepsin causes more esophageal mucosal damage. GERD for the most part can be considered a common, annoying but mostly benign condition that limits quality life for millions of people around the world. As we shall see, even though acid suppressive therapies, prescription and OTC remedies may be effective in reducing symptoms, these therapies may lead to unnecessary and potentially life threatening complications.

In the past, heartburn was traditionally treated with sodium bicarbonate and antacids such as calcium carbonate. H2 blockers followed by PPIs are now the main treatment modalities. H2 blockers include cimetidine, famotidine, nizatidine and ranitidine. PPIs include esomeprazole, omeprazole and pantoprezole. These medications, including antacids, were never meant to be used chronically, but rebound effects afters cessation has caused the general public to continue their use over time and this is where complications ensue. Besides, medication results in permissive behavior, and instead of losing weight, eating less, eating fewer fatty rich foods or attempting to isolate food triggers, people use and depend upon a pill.

We will continue this important discussion next time. Thanks for taking the time to read this…

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