Resolving symptoms and maintaining remission are primary goals of therapy (Table 3). Other therapeutic goals include esophageal healing in esophagitis, and preventing complications. To achieve these results, educating the patient is fundamentally important. The pharmacist and the primary healthcare provider should instruct the patient about gastroesophageal reflux disease (GERD) and the factors that precipitate reflux.
|Table 3. Treatment Goals|
|• Eliminate symptoms• Heal esophageal mucosa
• Prevent complications
• Maintain remission
The management of GERD can be divided into three phases — lifestyle modifications, medications, and surgery. Which option is best depends in part on the age of the patient, severity of the patient’s condition, whether esophagitis exists and its severity, and the outcome of initial therapy.
All patients with gastroesophageal reflux disease should be counseled on lifestyle modifications (Table 4) that may improve their symptoms. Some patients find that these changes reduce or eliminate symptoms of reflux. Mild symptomatic GERD can usually be managed initially with lifestyle changes such as modifying the diet, eliminating drugs that impair or lower esophageal sphincter pressure or gastric emptying time, reducing weight reduction in obese patients, and smoking cessation.
|Table 4. Lifestyle Changes|
|• Diet modifications:
a. Avoid foods that aggravate symptoms
b. Avoid eating 2–3 hours prior to bedtime
c. Avoid large meals and quantities of liquids• Avoid medications that lower LES tone or decrease motility• Elevate head of bed
• Curtail smoking and alcohol intake
• Avoid stooping and bending
• Do not exercise immediately after eating
• Avoid tight-fitting clothing
• Reduce weight, if overweight
Patients should avoid eating 2–3 hours before bedtime to reduce the amount of acid in the stomach available to reflux, and they should not lie down soon after eating. To reduce gastric volume, they should avoid eating large meals. Certain foods may provoke heartburn by directly triggering reflux while others irritate the gastric mucosa. Fatty foods or chocolate can lower esophageal sphincter (LES) tone, allowing for reflux to occur. Other foods that may produce reflux symptoms include coffee, peppermint and spearmint, onions, citrus fruits and juices, tomato-based products, and greasy or spicy foods. Alcohol also adversely affects the LES and esophageal peristalsis and therefore should be avoided. Chewing gum or sucking on lozenges can increase salivary flow and may be useful in GERD patients with reduced salivary flow. In general, each patient should be treated individually. Pharmacists can advise patients to avoid the foods that provoke their individual symptoms.
Esophageal clearance may be delayed when the body is supine, and during sleep when salivation and swallowing are minimal. Raising the head of the bed by using a 4-inch by 4-inch piece of wood or foam wedge under the mattress to elevate the head about 6–10 inches results in subjective and objective improvement in nocturnal reflux symptoms similar to that seen with an H2 receptor antagonist. Pillows are not generally effective and may exacerbate existing symptoms. Because tight clothing can lower the lower esophageal sphincter tone, wearing loose clothing is recommended.
Medications associated with lowering the LES tone include nitrates, theophylline, anticholinergics, opioids, oral contraceptives, and calcium channel blockers; these agents should be avoided.
Hiatal Hernia and Heartburn
Heartburn is no longer thought to be caused by hiatal hernia, although some patients who suffer heartburn also have a hiatal hernia. Hiatal hernia is the protrusion of a portion of the stomach through a teardrop-shaped hole in the diaphragm where the esophagus meets the stomach. It is most often caused by increased pressure in the abdominal cavity due to coughing, vomiting, straining at stool or sudden physical exertion.
Most people over age 60 have hiatal hernias, which are usually harmless. Although hiatal hernias do not cause heartburn, patients who have long-term gastroesophageal reflux disease tend to develop larger hiatal hernias; the hernial sac may act as a reservoir for acid.