* Gastroesophageal Reflux Disease, also known as GERD, is a common digestive disorder that occurs when the acid in the stomach flows back into the food pipe (oesophagus) that connects your mouth and stomach. This reverse flow of the acid may irritate the lining of the esophagus resulting in symptoms. This disorder may also be a sequela of weakness of the ring called the lower esophageal sphincter.
* GERD is a common experience; people may experience this acid reflux from time to time which causes discomfort but most of the time it can be managed with a few lifestyle changes and medications.
Prevalence of Gastroesophageal Reflux Disease (GERD) during Ramadan
During the holy month of Ramadan one fast from dawn to dusk for about 12- 16 hours a day. Fasting individuals consume meals before sunrise (Suhur) and at the sunset (Iftar). Many patients with long standing GERD and acidity are worried of worsening of symptoms during the time of Ramadan fasting. However, various clinical studies have shown that in patients with GERD on treatment, if they continue regular medications and healthy food habits, they experience less of symptoms during the holy month of Ramadan. Healthy individuals can experience minor gastrointestinal symptoms during Ramadan fasting. These include heart burn, bloating, dryness of mouth, sour taste in mouth, upper abdominal burning sensation, nausea and vomiting, but serious complications are not reported. During these times there is change in diurnal food intake, sleep pattern and one may experience many psychological factors which can all trigger the symptoms of acid reflux and acidity. The factors that may aggravate GERD symptoms during Ramadan include larger meal intake in each meal time, eating high fat and late night food and poor drug compliance. On the other hand, stopping unhealthy habits like smoking during Ramadan improves the symptoms of GERD.
In patients with acid reflux symptoms and acidity during Ramadan, it is advisable to take small quantity frequent meals after sunset and leave a gap of at least 2-3 hours before going to bed. Patients with GERD on treatment should take their medicines 30- 60 minutes before Suhur. To decrease post prandial reflux symptoms alginate-antacid treatment can be taken after the evening meal.
The predawn meal should consist of a healthy diet which should provide adequate energy and fluids for the day. Therefore, the carbohydrate or starch based diet –e.g. oats, cereals, rice based diet, breads, yoghurt etc. with adequate fluid intake will help to ensure good hydration and energy for the entire day. During the time of breaking the fast one should also ensure good intake of fluids, food with natural sugars and avoid consuming food rich in added sugars. It is important not to overload when eating during Ramadan. Consuming lots of deep fried, creamy, sweet and salty food is unhealthy and can trigger acidity and reflux symptoms. However, always follow a balanced diet during Ramadan as far as possible.
GERD Symptoms:
The most common symptom of gastroesophageal Reflux Disease is heart burn and irritation in throat. The other signs and symptoms of GERD include:
• Atypical chest pain
• Difficulty or pain during swallowing of food
• Unusual feeling of a lump in the throat
• Feeling of indigestion and increased burping
• Nausea
• Excessive salivation and regurgitation of sour fluid into the mouth
• Bad breath
At night GERD may cause few symptoms such as:
• Disturbed sleep and sleeping problems
• Asthma
• Chronic cough
• Laryngitis (inflammation of the voice box)
Causes
Frequent acid reflux, heartburn more than twice a week may indicate gastroesophageal Reflux Disease.
It is caused by:
• Abnormal Lower Oesophageal Sphincter (LES) Movement: The sphincter is a circular band of muscle at the bottom of the esophagus that relaxes and allows the food and liquid to flow into the stomach. The sphincter opens for the food to pass and closes again.
If the sphincter movement weakens or works abnormally the stomach acid can flow back reverse into the esophagus. Frequent acid reflux may irritate the esophagus lining and cause inflammation.
• Hiatus Hernia: GERD may also be caused by a condition called hiatus hernia. It is a condition where the upper part of the stomach lining slides into the chest cavity due to the weakness in the muscles at the lower part of the oesophagus. It increases the risk of GERD.
Risk factor
Apart from abnormal sphincter movement and relaxation, other conditions that can increase the risk of GERD include:
• Obesity
• Pregnancy
• Hiatus hernia (top of the stomach bulging into the diaphragm)
• Connective tissue disorders such as rheumatoid arthritis, SLE and scleroderma.
• Gastroparesis (stomach takes too long to empty its food contents)
Other factors that can provoke acid reflux include:
• Smoking
• Medications (such as Aspirin, Tetracycline, Doxycycline)
• Consuming large quantity of meal, or eating late at night
• Consuming unhealthy amounts of fatty or fried foods
• Drinking beverages such as alcohol coffee or aerated drinks
Diagnosis
A doctor can diagnose GERD based on signs and symptoms. To confirm the presence of GERD or to check complications the doctor may recommend:
• Esophageal Manometry: It is a test that measures the rhythmic muscle contractions, and movements of the oesophagus and the sphincter when food or liquid is swallowed. This test also measures the force exerted by muscles on the esophagus and the coordination between the muscles.
• Upper GI Endoscopy: Upper GI Endoscopy is a procedure where the doctor inserts a thin, flexible tube with light and camera attached to one end into your throat ,into the oesophagus and stomach to examine the inside of the esophagus and stomach. The flexible tube is called an endoscope.
• Ambulatory pH Test: In this pH test, a monitor is put in the esophagus to identify the duration of the stomach acid reflux. The monitor can be a thin flexible tube inserted through the nose into the lower esophagus to measure and assess the acid reflux and symptomatic co-relation
Treatment
The most common treatment methods for GERD are lifestyle changes or modifications, and medications. The different treatment methods for GERD include: • Over-the-counter medications Over-the-counter medications include:
i. Antacids: Antacids neutralize stomach acid. Antacids can provide quick relief, but don’t heal the inflamed esophagus. Overuse of a few antacids can result in side effects such as kidney problems or diarrhea.
ii. H-2 receptor blockers: These medications are used to reduce acid production. H-2 receptor blockers such as famotidine, cimetidine, and nizatidine don’t work as fast as antacids but provide much longer relief and sometimes decrease stomach acid production for up to 12 hours.
iii. Proton pump inhibitors: This medication blocks acid production in the stomach and are stronger than H-2 receptor blockers which allow damaged esophageal tissue to heal.
iv. Prokinetic Agents: These drugs help to empty the stomach faster, to ensure not much acid is left behind. The medication also helps with symptoms like nausea, bloating and vomiting.
• Surgery and Endoscopic Treatments
GERD is usually controlled with medications but in case when it fails, the doctor might recommend surgical management or endoscopic therapy.
i. Fundoplication: This is a surgical procedure in which the top of the stomach is wrapped around the lower part of the esophageal sphincter, to prevent reflux. This treatment is usually done using a laparoscopic procedure. This minimally invasive procedure helps in preventing acid reflux into the oesophagus and can provide long lasting symptomatic relief.
ii. Endoscopic Antireflux Devices & Techniques
The endoscopic anti reflux devices currently available include Radiofrequency Ablation Devices (RFA) - Stretta and several endoscopic fundoplication devices like Esophyx, the GERDx device and the Medigus Ultrasonic Surgical Endostapler. These are available in few selected centres across the world and the long term efficacy is evolving.
Prevention:
Gastroesophageal Reflux Disease can be prevented by changing lifestyle and dietary modifications. Try to:
1. Stop smoking: Frequent smoking reduces esophageal sphincter ability to function properly.
2. Maintain a healthy weight: Being obese can put pressure on the abdomen, can push your stomach upwards which might cause acid reflux in the esophagus.
3. Don’t sleep after a meal: Food digestion takes time, to wait at least 3 hours before lying down or going to sleep.
4. Eat food slowly: Eat your food slowly and chew it thoroughly.
5. Avoid trigger food and drinks: avoid fatty foods and alcohol or aerated drinks that are common triggers for acid reflux.
Complication of GERD
With time gastroesophageal Reflux Disease may cause chronic inflammation that can result in complications such as:
• Esophageal Stricture: Stomach acid can damage the lower esophagus and may cause scar tissue to form. This scar tissue narrows the esophagus, the food pathway that can create problems of food swallowing.
• Barrett ’s Esophagus: It can damage the tissue lining of the lower esophagus. Such changes in tissue lining increase the risk of esophageal cancer.
• Esophageal Ulcer: Stomach acid can damage the tissue in the esophagus that can result in esophageal ulcer, the open sore can bleed, make swallowing difficulties, and cause severe pain.
Prognosis or Outlook for Patients
GERD is treatable and curable. It can influence patient’s health-related quality of life and is associated with a mild increased risk of Esophagitis, Esophageal Strictures, Barrett’s Esophagus, and Esophageal Adenocarcinoma if left untreated. It poses a substantial burden to the health care and societal resources. Most cases can be managed with lifestyle changes and medications and in some cases, surgical treatment or endoscopic therapy may be needed. Now, new endoscopic and less invasive surgical procedures are evolving but the long term efficacy and safety need to be scientifically established.
The author is Specialist – Department of Gastroenterology
at Aster Hospital,
Old Airport Road, Doha (Qatar)
