Focus on …
Three things you need to know:
Associated problemsInvestigations
Treatments that work
Especially, what are practical measures to help symptoms and what unhelpful dietary or drug advice should I avoid?
Why does this matter?
- Gastric reflux is common; it affects 30% of both sexes over age 50 in Europe, Australasia and USA. The medical terminology is Gastro-Oesophageal -Reflux-Disease hence GORD or GERD in the USA [esophagus].
- As it is tricky to absolutely define GORD as distinct from dyspepsia [‘indigestion’] your Dr needs to consider various possibilities. So, both GERD and dyspepsia may be associated with helicobacter pylori infection in the stomach, which increases the risk of stomach cancer and ulcers [1]. If H. pylori is diagnosed it can be treated.
- GORD is associated with Barrett’s oesophagus, a common condition which is the only known precursor to oesophageal adenocarcinoma, a highly lethal cancer [incidence increasing].
- The common treatment for GERD is prescription of a Proton Pump Inhibitor [PPI] to suppress gastric acid. However, PPIs have some side effects if used long-term. [see details below], and not everyone responds to them with up to 40% of PPI users dissatisfied. Therefore finding alternatives to long term PPI use or other ‘tweaks’ is important.
- Lifestyle advice can make a big difference but conventional dietary advice is often just generally prohibitive.
- This is NOT always acid reflux. The refluxed liquid may include the digestive enzyme pepsin, or bile contents [these are alkaline]
What does good look like?
The first step before medication, is understanding factors that make GERD worse and avoiding them:
- An overfull stomach ie large meals
- Eating late at night ie just before bedtime
- Things that relax the oesophageal sphincter [some drugs, a hiatus hernia]
- External pressure from abdominal fat
- Regular NSAID use
- Poor dietary choices [more below]
- Sleeping position
- Bad mouth microbiome – as described in a previous InfoSheet
So it follows that losing weight [yes, sorry, that issue again], eating smaller meals, and possibly moving to 3 small-plate meals instead of eating 2 full-plate main meals will help.
In respect of posture - in bed, raising the head of the bed on blocks [or books, bricks etc] by 6-8 inches and using a wedge pillow provides mechanical protection against reflux. Sleeping position also matters - sleep on your left side [because of the side the oesophagus joins the stomach]
Bad diet advice?
If you look at health information sources, worldwide, the instructions are often to avoid everything fatty, ‘acidic’, spicy, fried etc. This is ridiculous: it leaves you with nothing to eat, and likely nutritionally deficient.
There are triggers for everyone; but they are totally individual. You will know if eg alcohol or fish and chips or whatever, is your personal problem. Asking others with reflux and reflecting my own experience, spicy food is not much of an issue for many. So-called ‘acidic food’ is also mostly trouble free. But if you have followed all the other advice and a food is definitely a trigger then you can avoid it.
It is also the case that if your medical regime has relieved symptoms that you can probably eat freely and still have no symptoms.
Good dietary advice?
The data shows that GORD symptoms are much less if you follow a healthy diet of the sort I have discussed in other InfoSheets: a rainbow plate and “Mediterranean’ influences [vegetable dominant, modest meat, preference for fish, olive oil, seeds and nuts etc]. So take this positive approach rather than prohibition!
What drugs cause reflux?
Reflux due to sphincter relaxation is seen with adrenergic beta-2 receptor agonists, calcium channel blockers, nitrates, theophylline and benzodiazepines.[2]
Do you need investigation?
If you have persistent GORD symptoms or severe and non-responsive symptoms then your Dr should exclude H. pylori infection by referring you to a lab/ gastroenterological clinic for a ‘breath test’. If you are in the high risk group for Barrett’s then a gastroscopy is indicated.
What treatment options are there?
PPIs successfully resolve the pain of reflux in [only] 60+% of sufferers. The once a day dosing seems preferable to the need to take alginate preparations [brand – Gaviscon] or antacids several times, daily. However, the simpler methods have no long term risks, PPIs have some. So don’t necessarily focus on PPIs.
Your pain may be due to acid reflux, pepsin [digestive enzyme] or bile reflux [alkaline]. There is data to show that in pregnant women, acidifed water [eg a teaspoon of live cider vinegar in half a pint of water] is as effective as antacids for some [presumably those with bile reflux]. It is worth a try-out to see if it helps YOUR symptoms. Similarly alkaline water is said to help about 30% [half a teaspoon of bicarbonate of soda in a halfpint.] Interestingly, a comparison study [not an RCT] showed alkaline water and a Mediterranean diet were equally as effective as PPI treatment. [3]
Gaviscon 1-3 times daily is pretty effective [take one at bedtime if heartburn troubles you at night but do the physical things mentioned above too!]
There is some evidence to support the use of mastic gum [4]. Two capsules of Mastika twice daily. The H2 receptor agonists such as ranitidine may work if a PPI does not.
For those with Barrett’s oesophagitis, PPIs are the recommended medical element of treatment.
Actual risks of PPIs
You will find suggestions online that PPIs increase the risk of dementia, osteoporosis, B12 and Magnesium deficiency, gastric cancer, clostridium difficile infection, heart disease and chronic kidney disease. Although there are theoretical justifications for these suggestions there is not strong evidence for most of them. There are two relevant concerns.
As in all studies that investigate drug effects, the quality of study is critical and observational and epidemiological studies can never establish causation [although they often claim to do so or to imply this by describing ‘increased risk’]. A summary by Chinzon covers the evidence well [5] and establishes that there is no evidence of osteoporosis or fracture risk, nor of an increase in gastric cancer, nor of dementia.
Poor absorption of B12, magnesium deficiency and low iron absorption are common in over 60’s and PPIs do not definitively increase that. All these vitamin issues should be checked whether PPIs are used or not.
No Cardiovascular effects: In respect of cardiovascular disease, there is NO good evidence of an increase with PPI use. They may impact established heart failure badly and interfere with some antiplatelet medications in people with existing heart disease: these individuals should seek alternatives.
Negative Microbiome impact …but: there is no doubt that PPIs affect the gut microbiome. If you follow my advice on protecting your mouth and intestinal microbiome with pre and probiotics then you may overcome this difficulty. However I believe this is a good reason to use alternatives.
Negative Kidney disease impact: there is a small increase in Chronic Kidney Disease [CKD]. The 10-year estimated absolute risk of CKD among the 322 baseline PPI users was 11.8%; the expected risk had they not used PPIs was 8.5% (absolute risk difference, 3.3%). Kidney failure is a bad outcome so is a good reason to look at alternatives to regular long term PPI use.
What to do if your PPI isn’t working
In many cases the problem is poor compliance with the PPI, or too low a dose. PPI timing and adherence is an important cause for inadequate acid suppression and refractory GERD [6]. PPIs should be administered 30 to 60 minutes before breakfast for maximal inhibition of proton pumps. In one study that included 100 patients with GERD, only 46 percent of patients prescribed a PPI for GERD were taking it as advised. The NICE guidelines indicate the ‘low’ and higher dose options for all the available PPIs.
Consider that it might be alkaline or pepsin reflux. Try the other options mentioned here.
Ask your Dr for referral to exclude H. Pylori infection and to consider gastroscopy. For some the problem is simply a large hiatus hernia and surgical treatment [fundoplication] is the solution.
Where are you on this?
Check my list: Do you need to ask your Dr to be more active? If you are taking a PPI are you taking it correctly?
What do you tell me is difficult?
Mainly the lack of a comprehensive summary and good dietary advice. Hence this article! So hopefully this helps…
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