The various causes of GERD and the treatment

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WJF
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Date Joined Sep 2011
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   Posted 4/28/2012 11:17 PM (GMT -6)   
I have been thinking through the causes and treatment of GERD. I realized that most doctors just treat GERD symptomatically without regard to its root cause. It's hardly surprising because there are so many causes of GERD. Each patient can have uniquely different characteristics. There are a number of mechanisms that prevent over-exposure of esophageal tissue to acid, if any fails, you get GERD. This also explains why certain patients react positively to certain natural remedies while others do not.

1. Abnormally high abdominal pressure

  • Pregnancy - last for only 10 months, treat symptomatically with lifestyle modification, OTC antacid, H2RA and PPI.
  • Obesity - lose weight
  • Bacterial overgrowth in intestine - Probiotics, low-carb low-fat diet
  • Indigestion resulting in gases or wind - Probiotics + digestive enzymes, sometimes ACV can help too, low-carb low-fat diet
  • IBS - ?


2. Abnormal gastric motility

  • Weak stomach, prolonged gastric emptying - prokinetic agents such as motilium, cisapride or metoclopramide / dieting / acupuncture
  • Low acidity - ACV (provided the patient does not have gastrisis or esophagitis symptoms) / dieting.
  • Hyperacidity - H2RA / PPI / akaline diet


3. Hiatus hernia

  • Mild form - still under debate in medical community whether it is a cause
  • Severe form, paraesophageal - nissen, TIF, LINX


4. Abnormal esophageal motility

  • Weak LES - treat symptomatically, or surgery.
  • Slow acid clearance - treat symptomatically, carafate.
  • high rate of tLESR - baclofen (new drugs are coming, which are baclofen derivatives)


5. Other causes, self-perpetuating causes (vicious cycle)

5.1. Stress & anxiety may cause GI problems leading to reflux which in turn also results in more stress & anxiety - Relaxation therapy, meditation, breathing exercise, Yoga, anti-depressant
5.2. Esophagitis, inflammation of LES can cause LES to be weakened further - H2RA / PPI
5.3. Gallbladder issue - treatment for gallbladder
5.4. Gastrisis? - treatment for gastrisis
5.5. Diabetes mellitus causes prolonged gastric emptying, resulting in increased gastric contents and gastric pressure - respective treatment for diabetes.

Comments?
WJF: Please list your reference. Thank you.

Below I give two review articles from medical sources as reference. They both provide the definition of GERD and the standard protocol of how it is managed. Because I am not satisfied with the symptomatic treatment approach to GERD, I give the breakdown of the various causes and suggest the treatment approach to each. This is something not found in the medical journals. So this post is FYI only!

References:
Gastroesophageal Reflux Disease - Medscape
Medical management of gastroesophageal reflux disease

Post Edited (WJF) : 5/5/2012 6:13:15 PM (GMT-6)


bcfromfl
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Total Posts : 417
   Posted 4/29/2012 12:01 AM (GMT -6)   
A couple of thoughts. First, you have made the same generalization that many do here on this forum -- on one hand, it's semantics, and everyone knows what you're talking about. However, you seem to want to explore the subject further, so this is a significant distinction: GERD is defined as a weak/non-functioning lower esophageal sphincter. There are several possible causes to reflux, but only one "cause" to GERD. Important, because reflux from causes other than GERD may have more to do with nausea, regurgitative reflex, or gas pressure than an actual mechanical malfunction.

Secondly, there has been no official link between a small/moderate hiatal hernia and reflux. Some people with hiatal hernias have reflux, and others without hiatal hernias also have reflux. Many folks have hiatal hernias with no symptoms. Paraesophageal hernia, definitely a cause of reflux.

You might want to include, IBS, anxiety, and perhaps gall bladder issues in your list, as it seems that there have been quite a few members correlating these conditions.

-Bruce

mudmagnetmum
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   Posted 4/29/2012 12:42 AM (GMT -6)   
What about gastritis? Quite a few of us have that - where would you slot that into your definition of GERD?

MMM
New stuff: GERD, Recurrent cystitis/Overactive bladder
Lifelong stuff: Food allergies/intolerance, eczema, asthma

WJF
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Date Joined Sep 2011
Total Posts : 273
   Posted 4/29/2012 2:19 AM (GMT -6)   
Thank you for the reply. I have edited the original post accordingly.

I think the medical definition of GERD which is shorthand for gastro-esophageal reflux disease, is an abnormal number of reflux counts per week. That is to say, if you have one count of reflux per week, you are probably normal. If you have several counts, that amounts to GERD. Weak LES is just one causal factor, I don't see how useful it is to be equated to GERD.

I think gastrisis is a comorbidity where it sometimes comes together with GERD. It isn't really causal.

bcfromfl
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Date Joined Nov 2011
Total Posts : 417
   Posted 4/29/2012 9:36 AM (GMT -6)   
I definitely think that gastritis can be a cause for reflux. (Don't you think an irritated stomach can cause a regurgitative reflex?) This is why I think it's important to separate GERD, a chronic condition, from other forms of reflux, that are symptoms of other conditions. If your ultimate goal is to identify treatments, you need to know what's causing the symptom(s) first.

I don't know where you found your definition of GERD, but it's too open-ended and vague. Many patients have 50-100 reflux episodes daily. Doctors use the DeMeester Score and time % values of pH<4.0 in the esophagus to quantify reflux.

-Bruce

mudmagnetmum
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   Posted 4/29/2012 10:15 AM (GMT -6)   
I have always wondered about the gastritis and the reflux in a chicken and egg type way (which comes first?). If the gastritis can come first, then how do you target therapy at that? I don't drink alcohol, don't have auto immune disease and don't have Helicobacter, which exhausts causes of gastritis, unless I've left any out.

I've tried to iron out the gastritis point more than once because I thought that maybe it had come first, but hard to tell as reflux can also cause nausea. Very interesting to hear your take on it Bruce - got me thinking again!

MMM
New stuff: GERD, Recurrent cystitis/Overactive bladder
Lifelong stuff: Food allergies/intolerance, eczema, asthma

mudmagnetmum
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Date Joined Apr 2011
Total Posts : 1604
   Posted 4/29/2012 10:19 AM (GMT -6)   
PS: I would debate the pregnancy point by the way - many women have reflux a long time before the baby is big enough to start pushing up on the stomach and diaphragm! The high progesterone relaxes the LES I think. Good post though WJF!

MMM
New stuff: GERD, Recurrent cystitis/Overactive bladder
Lifelong stuff: Food allergies/intolerance, eczema, asthma

mudmagnetmum
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Date Joined Apr 2011
Total Posts : 1604
   Posted 4/29/2012 10:24 AM (GMT -6)   
Other causes of gastritis:

Ibuprofen or NSAIDs inc Aspirin
Pathogens other than Helicobacter
New stuff: GERD, Recurrent cystitis/Overactive bladder
Lifelong stuff: Food allergies/intolerance, eczema, asthma

stkitt
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Date Joined Apr 2007
Total Posts : 32602
   Posted 4/29/2012 12:21 PM (GMT -6)   
This list could go on forever -
 
Diabetes mellitus causes prolonged gastric emptying, resulting in increased gastric contents and gastric pressure.
 
Whatever treatment is offered should be tailored to the individual, and this will vary according to the severity of their GERD  and the patient's individual problems and needs. 
 
Kindly,
Kitt
~~Kitt~~
Moderator: Anxiety, Osteoarthritis,
GERD/Heartburn and Heart/Cardiovascular Disease.

www.healingwell.com

"Life is not about waiting for the storms to pass...
It's about learning how to dance in the rain."~ Vivian Greene

mudmagnetmum
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Date Joined Apr 2011
Total Posts : 1604
   Posted 4/29/2012 3:31 PM (GMT -6)   
Hi Kitt,

I'm sure there are more causes as you say. What is interesting to me is the idea that the gastritis could actually be causing the reflux - I was told by a medic that they were unrelated! And I've never had any interest shown in finding the cause - I think a lot of people just get "pigeon holed" and given standardised treatment even if they don't quite fit. I had to push to get tested for Helicobacter and then ask again to have auto immune disease ruled out. I'm not diabetic either, but I had taken a lot of Ibuprofen just before it started. You'd think 2 years later the effects would have worn off!! I guess for a lot of us we feel if we could pin point the cause then we could nail the cure!

Glad to see you "out and about" Kitt,

Best wishes,

MMM
New stuff: GERD, Recurrent cystitis/Overactive bladder
Lifelong stuff: Food allergies/intolerance, eczema, asthma

WJF
Regular Member


Date Joined Sep 2011
Total Posts : 273
   Posted 4/29/2012 6:50 PM (GMT -6)   
hi Bruce,

I got the definition from Medscape
Medscape said...
Gastroesophageal reflux disease (GERD) occurs when the amount of gastric juice that refluxes into the esophagus exceeds the normal limit, causing symptoms with or without associated esophageal mucosal injury (ie, esophagitis).


What constitutes "normal limit" very much depends on individuals!

stkitt said...

Whatever treatment is offered should be tailored to the individual, and this will vary according to the severity of their GERD and the patient's individual problems and needs.

Kindly,
Kitt


I concur!!

drtinsac
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Date Joined Apr 2012
Total Posts : 458
   Posted 5/2/2012 11:35 AM (GMT -6)   
bcfromfl said...


Secondly, there has been no official link between a small/moderate hiatal hernia and reflux.


I don't think that's true, especially if you are lumping together small and moderate sized hiatal hernias. When looking at people with GERD vs people without, those with GERD are much more likely to have a HH.

mudmagnetmum
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Date Joined Apr 2011
Total Posts : 1604
   Posted 5/2/2012 11:45 AM (GMT -6)   
I think the classic description is that you don't usually find GERD without a hernia, but you can find a hernia without GERD!!

MMM
New stuff: GERD, Recurrent cystitis/Overactive bladder
Lifelong stuff: Food allergies/intolerance, eczema, asthma

Cylon101
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Date Joined Mar 2012
Total Posts : 68
   Posted 5/2/2012 1:54 PM (GMT -6)   
My barium scan found a small sliding hernia with "possible slight reflux" which I'm guessing means that there was a hernia detected, but no conclusive evidence of relfux during the barium swallow

which likely means inconclusive until more tests might be performed.

stkitt
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Date Joined Apr 2007
Total Posts : 32602
   Posted 5/2/2012 2:02 PM (GMT -6)   
Cylon,
 
Sounds like you understood that report correctly. ! Is your Dr. going to do any follow up tests ?
 
Kindly,
Kitt
~~Kitt~~
Moderator: Anxiety, Osteoarthritis,
GERD/Heartburn and Heart/Cardiovascular Disease.

www.healingwell.com

"Life is not about waiting for the storms to pass...
It's about learning how to dance in the rain."~ Vivian Greene

Cylon101
Regular Member


Date Joined Mar 2012
Total Posts : 68
   Posted 5/2/2012 2:35 PM (GMT -6)   
@kitt
 
I have a followup with ENT later this month. I got the results from the receptionist who told me to keep on PPI's until my appointment.

It's all very confusing - I don't have any active feelings of reflux, no pain, nausea etc.   Just the constant globus when I swallow and on and off mucus/throat clearing. 

Three months into this and I am still no closer to really knowing what I have or how to fix it :(
 

bcfromfl
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Date Joined Nov 2011
Total Posts : 417
   Posted 5/2/2012 2:56 PM (GMT -6)   
"When looking at people with GERD vs people without, those with GERD are much more likely to have a HH."
 
When I say, small to moderate HH, that means < 2.5cm.  An official link to GERD means that there have been peer-reviewed studies published in recognized journals.  Yes, it appears that there is a significant percentage of HH in patients who also have symptoms of GERD, but are you prepared to say that, as a result of this appearance, that it's the HH that causes GERD?  Or is it perhaps another pathology (or undiscovered/unrecognized link) that produces both conditions?  Do you see the reluctance from the medical community to make the commitment here?
 
To illustrate this, let's say that, in some patients, HH is an aging phenomenon as the hiatus relaxes and stretches.  Let's also say that the LES loses strength as part of the same aging phenomenon, causing reflux.  Do you say that the HH causes the GERD, or is it a coincidental pathology as part of an aging factor?  Certainly there are other reasons for reflux, so it's difficult to say that something like a HH is the causal factor in *all* instances of the disease. 
 
Given that HH can be produced/observed in poorly-done EGDs (the inflation problem), or misinterpreted by novice GIs, there isn't always clear evidence of a significant HH in patients.  So, to draw conclusions based upon sometimes questionable diagnoses is perhaps premature.
 
I've been to eight doctors in four years, in one university hospital and three major medical centers across the southeastern U.S., as well as audited medical videos of GERD procedures performed by highly-skilled surgeons.  I have understood the same comments of HH from all these sources.  As much as we'd like to believe to the contrary, the standard of scientific understanding of reflux is not as advanced as we'd always like to think.
 
It may be true that HH can sometimes cause GERD, but given the hit-or-miss correlations between GERD patients and those with HH < 2.5cm., the jury is still out.
 
-Bruce

WJF
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Date Joined Sep 2011
Total Posts : 273
   Posted 5/3/2012 6:39 AM (GMT -6)   
bcfromfl said...
Given that HH can be produced/observed in poorly-done EGDs (the inflation problem)


I do have a diagnosis of HH from EGD. I hope it was because of gas inflation. Is a proper diagnosis of HH done on Barium swallow?

Cylon101
Regular Member


Date Joined Mar 2012
Total Posts : 68
   Posted 5/3/2012 7:56 AM (GMT -6)   
My Small HH was detected by the radiologist who did the barium swallow scan.  I am not sure how small yet, but my guess is under 2 cm?   I am not sure how 'accurate' the test is on it's own to confirm a HH, however, I would think it would highlight a 'real time' hernia occuring as it slides up past the hiatus during a swallow.
 
My understanding is on it's own, a barium scan will not confirm GERD however, you would need the litany of tests, but again, I'm all very new at this...

bcfromfl
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Date Joined Nov 2011
Total Posts : 417
   Posted 5/3/2012 8:15 AM (GMT -6)   
WJF -- the method usually relied upon to diagnose/measure a HH is through an EGD. I don't know all the steps involved while inserting the endoscope, but I would guess that the measurement should be done before the stomach is inflated (or perhaps at the same time, carefully), not after. The barium swallow is a good test to confirm findings from the EGD, and will also record the HH "in motion".

If your GI is running a "colonoscopy mill" -- overscheduling many patients to do lower and upper GIs -- chances are greater that he will rush the EGD to get to his next patient. If he rushes the EGD, he probably won't take the time to do it right.

-Bruce

Marcello
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Date Joined Feb 2012
Total Posts : 75
   Posted 5/5/2012 11:28 AM (GMT -6)   
Hi WJF, just stopping by to say this is one of the best posts I've seen on the forum and may yield more potential information than the average GI consultation.

I would love to see this stickied and for all of us to continue to build/amend the list. Many with this walk around with reflux without much information that they may find useful in understanding their condition, even after seeing multiple GI docs and surgeons. There most definitely is a '1-size fits all' approach prevalent in this field (with exceptions eg Dr Kaufman).

Motion to sticky this!

stkitt
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Date Joined Apr 2007
Total Posts : 32602
   Posted 5/5/2012 4:44 PM (GMT -6)   
Marcello,
 
As this is a discussion with many opinions that are being debated it is not a post we would sticky.  Thank you for your input, however.   
 
HealingWell.com features a thriving support community, blog, videos, a popular newsletter, articles and resources to help you actively manage the challenges of living with chronic illness. The goal is simple....to help you take control of your illness and start "healing well".
 
Kindly,
Kitt
~~Kitt~~
Moderator: Anxiety, Osteoarthritis,
GERD/Heartburn and Heart/Cardiovascular Disease.

www.healingwell.com

"Life is not about waiting for the storms to pass...
It's about learning how to dance in the rain."~ Vivian Greene

WJF
Regular Member


Date Joined Sep 2011
Total Posts : 273
   Posted 5/5/2012 7:21 PM (GMT -6)   
hi Marcello, I am glad you find it helpful. Yes I believe after a specialist consultation we should not stop thinking and just hope the treatment plan put forth by specialist will work. We can work out new ideas, explore other options that augment the "standard therapy". We need to actively seek and continuously improve a personalized treatment to cure ourselves. The cure of every illness is there at your reach - if only you are enlightened enough to grasp it.
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