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Heartburn and GERD – GastroEsophageal Reflux Disease

By Dr. Shafiq Qaadri, MD

What is GERD?
Gastroesphageal Reflux Disease…Patients will describe classic GERD as heartburn, which is acid regurgitation, even pain on swallowing.

How common is GERD?
Probably 75% of the population has experienced GERD at some time…According to the American Gastroenterology Association, GERD was present in about 7% of individuals daily, 14% weekly. Interestingly, it occurred especially frequently in pregnant women.

Does GERD often remain undiagnosed?
It’s something that’s typically diagnosed by the patient, and most of the time primary care physicians play the critical role in managing this condition.

But many patients do not present for management clinically, and specialists may just be seeing the tip of the iceberg. For example, in the United States, there’s probably at least 61 million people who have heartburn at least monthly; and 18 million people use indigestion aids two times or more weekly.

How common are the complications and does anyone actually get Barrett’s esophagitis?
That’s a hot question. The evidence shows that there is a risk of Barrett’s with reflux, but the risk of subsequently developing adenocarcinoma is not known.

A study of Barrett’s in asymptomatic American veterans—which is a skewed population, tending to be elderly, white, and poor—showed that the incidence is about 10%. That data is not transposable to the general population, but we know that if you have reflux at least weekly, you have 7-fold increase in the risk of adenocarcinoma. If you have reflux over a 20-year period, your risk is increased by 43 times.
We’re seeing longterm GERD as a risk factor for developing Barrett’s.

For patients who experience GERD daily, what is the lifestyle impact?
GERD on a daily basis can have a significant impact, depending on the severity. Some patients experience frequent interruptions in sleep and social events.

Using a Heartburn Quality of Life Index, which measures GI symptoms, general well-being, general health, vitality and depression, patients with significant GERD felt worse than patients with diabetes and hypertension.

In a recent study of 533 patients, their quality of life improved rapidly after successful treatment of the GERD.

There’s two other important aspects when you’re diagnosing GERD: documenting the reflux and establishing GERD as the cause of symptoms.

You can diagnose reflux by a barium esophagram, but that doesn’t necessarily establish GERD as the cause of symptoms.

Hiatus hernias are quite common. There’s no doubt that patients with GERD can have hiatus hernias. It may be a marker, but the hernia is likely not the etiology of the reflux.

Are peptic ulcers a thing of the past?
No, they’re still around. Like the old quotation, “The rumour of its demise has been much exaggerated.” The moment I say I haven’t seen one for a while, I’ll see five.

There’s a combination of reasons for peptic ulcer disease. We still have Helicobacter pylori, and even though anti-inflammatory drugs for arthritis have improved, and that the COX-2 specific ones are associated with GI upset.

A recent study also re-emphasized that steroids can potentially cause ulceration and bleeding complications, and a number of medications that we use can increase the risk of peptic ulcer disease.

Is there a role for Helicobacter pylori in GERD?
It’s controversial: Helicobacter pylori is a pathogen, implicated in the cause of peptic ulcer disease. It probably isn’t associated with GI tract bleeding.

What are lifestyle modification options for GERD management?
Standard things, like dietary changes such as reducing carbonated beverages, caffeinated beverages, spicy foods. We tell patients to cut down on fried, fatty foods, because they tend to prolong gastric retention.
Weight reduction is important. We tell them to elevate the head of the bed on blocks at night, but that’s a tough one. Above all, we try to get patients to have a diet of frequent, small meals with low fat, high fibre, with a lot of protein.

For Canadian physicians to prescribe PPIs (Proton Pump Inhibitors), we must go through a course of H2 blockers, declare failure, and only then will governments pay for them. Is this the same in the USA?
In Alberta, doctors did not have to use an H2 blocker first, and then switch to a PPI, though a lot of the patients had been on H2 blockers.

In the United States, there’s evidence that H2 blockers work in reflux disease. Over-the counter antacids do not. But patients treated with PPIs have substantially better improvement.

What is the Canadian data about physicians having to double the dosage of PPIs?
We found data, for example, that showed omeprazole 20 mg is doubled more frequently, due to the fact that it contains a smaller amount of medication than pantoprazole, a 40 mg dosage.

Probably it means that all the PPIs should be used in the 40 – 60 mg dosing range when you’re treating GERD, to achieve optimal control.

For example, Canadian data shows that compared to pantoprazole, almost three times the number of omeprazole claims, and 1.5 times the number of lansoprazole claims, are for double doses. These numbers are consistent when different time periods were evaluated.

What’s the importance of achieving an acid level pH > 4, and is there any difference in the PPIs?
A pH above 4 is what we’re trying to achieve, for GERD and even GI bleeding. That’s been shown in peptic ulcer disease to aid healing.

There are a lot of variations. If you’re using a low dose of a PPI, then you’re less likely to achieve that pH. If you’re using a high dose of a PPI, any PPI, you’re more likely to achieve effects in that range.

Is GERD curable, or is it a life sentence?
GERD is a chronic condition, recurring often. For example, in the United States, it is difficult to manage chronic obesity, which is a risk factor for GERD.

Should arthritis patients who are to be treated with NSAIDs receive PPIs from day one for prophylaxis?
That would be standard in a patient at risk--an older patient, say, with a history of previous GI bleeding, with multiple medical problems, on multiple medications. But it would not be cost-effective for a younger, otherwise healthy patient, with no history of GI bleed.

What do future research directions for the management of GERD offer?
Other caregivers will get more involved, such as pharmacists…Whether we screen populations for Barrett’s esophagitis will be an issue…and the area of GERD causing pulmonary symptoms such as nocturnal asthma will be further elucidated…and determining the optimal dosages of PPIs.

What is your final message for family physicians?
Like all complex clinical problems for which we don’t have a cure, the management involves recognizing patients of differing severities, and treating different groups appropriately, to give patients maximal resolution of their symptoms and reduce the risk of longterm complications.

Dr. Shafiq Qaadri is a Toronto family physician and Continuing Medical Education lecturer. www.doctorQ.ca

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