Gastric Reflux - Treatment Options, Risks and Strategies

Digestion | May 8, 2014 | Author: The Super Pharmacist

reflux, Digestion

Gastric Reflux - Treatment Options, Risks and Strategies

Gastric reflux is characterized by the reflux of abnormal amounts gastric juice into the oesophagus resulting in signs and symptoms. Over time the gastric reflux is also associated with injury of the oesophageal mucosa (oesophagitis). Treatment or management of gastric reflux is done using a stepwise approach. The goals of a successful treatment plan are:

  • To control the symptoms of the disease
  • To help in the healing of oesophagitis
  • And to help in the prevention of recurrent oesophagitis and/or other complications associated with gastric reflux.

The treatment is done either by:

  • Modifying lifestyle habits and
  • Controlling secretion of gastric acid either by medical therapy (antacids or PPIs) or corrective antireflux surgery

In about 80% of the patients suffering from recurrent gastric reflux the disease is non-progressive and can be controlled with medicines alone. It is important to identify the remaining 20% of the patients who have progressive gastric reflux as these patients are often associated with development of complications such as Barrett oesophagus or oesophageal strictures. Surgical treatment is recommended at the earliest for patients developing complications of gastric reflux so as to prevent the associated conditions of the disease that can have serious consequences. Patient management tools play an important role in stratifying patients and help in improving the management of gastric reflux patients. An example of such a tool is self-administered gastric reflux questionnaire (GerdQ).

Treating gastric reflux with lifestyle modifications

Lifestyle modifications play an important role in controlling the symptoms of gastric reflux. The following lifestyle modifications are recommended:

  • Loss of weight in overweight and obese patients.
  • Avoid certain foods such as chocolate, products made from tomato and citrus juice. It is also advised to avoid alcohol. The American College of Gastroenterology (ACG) guidelines (2005) recommend avoiding coffee, peppermint and vegetables from the onion family.
  • It is recommended to avoid eating large meals.
  • Avoiding lying down within 3 hours after eating a meal
  • Elevating the head while lying down by at least 8 inches
  • Quitting smoking in patients who smoke
  • Avoiding wearing tight clothes or belts
  • Also check with your doctor about any medicine (that you may be taking for other disease) that may be causing symptoms of gastric reflux.

According to the 2005 guidelines mentioned by the ACG, studies have demonstrated improvements by limiting the exposure of acid to the distal part of the oesophagus after these lifestyle modifications are made; however, limited data is available to confirm these findings. In pregnant females, the first line of treatment for gastric reflux is lifestyle modifications. The patients are advised to elevate the head while lying down, avoid bending or stooping, eating small meals at frequent intervals and avoid lying down within 3 hours after having a meal.

Treating gastric reflux using pharmacologic therapy

Stomach acidAntacids: One of the standard treatment therapies in the 1970s for gastric reflux, antacids are still recommended to control mild symptoms of gastric reflux. Antacids are recommended to be ingested after every meal and before going to bed. Antacids, as the name implies work by neutralizing the acid from your stomach. These products tend to work quickly for shorter periods of time. H2 blocker and H2 receptor antagonist therapy: The first line of treatment for patients who have mild to moderately severe gastric reflux disease or grade I-II oesophagitis is H2 receptor antagonist therapy. The various agents are cimetidine (Tagamet), ranitidine (Zantac) and nizatidine (Nizac). These agents are helpful in healing only mild cases of oesophagitis in 70-80% of patients suffering from reflux disease. They also help as maintenance agents to prevent the occurrence of relapse. The long-term efficiency of these drugs is reduced due to pharmacologic tolerance.  These agents work by reducing the production of acid. Additional therapy using H2 blocker agents is found useful in patients who have severe disease, especially those who have Barrett oesophagus and those patients who suffer from nocturnal symptoms. PPIs or Proton pump inhibitors:One of the most potent drugs available to treat the symptoms of gastric reflux is the PPI. PPIs are recommended only in patients in whom the disease has been documented objectively. There are few side effects of these agents and they can be used long-term. The PPIs available to treat the symptoms of gastric reflux are omeprazole (Losec), rabeprazole (Pariet), lansoprazole (Zoton) and esomeprazole (Nexium). These agents also work by reducing the production of acid by the stomach. Reflux inhibitors and Prokinetic medicines: These medicines are effective only in patients who have mild disease. These agents include metoclopramide. Long-term use of these medicines is discouraged due to the associated serious side effects. These agents work by emptying your stomach at a faster rate and reducing gastric reflux.

Treating gastric reflux using surgery

Nowadays the surgical treatment of choice for gastric reflux is Laparoscopic Nissen fundoplication. The following are the indications for undergoing a surgery for treating symptoms of gastric reflux:

  • Surgery is the recommended treatment of choice in patients whose symptoms are not completely controlled by PPIs alone. However, surgery can also be considered for patients whose symptoms are otherwise controlled, but they require one time definitive therapy.
  • Surgery is indicated for the presence of Barrett oesophagus.
  • Surgery is also recommended in patients who present with extra-oesophageal manifestations of gastric reflux. These manifestations include the following: respiratory symptoms of cough, aspiration, wheezing etc; ENT symptoms of sore throat, hoarseness, otitis media etc; and dental symptoms of erosion etc.
  • In young patients suffering from gastric reflux.
  • In patients who show poor compliance to medicines.
  • Postmenopausal females who have developed osteoporosis.
  • Patients who have defects of the cardiac conduction system.
  • Patients who cannot afford the cost of medical therapy.

According to various studies, long-term results of fundoplication surgery are that after 10 years duration, 90% of the patients have no symptoms with a minority of them still taking PPIs.

Laparoscopic Nissen Fundoplication

General endotracheal anesthesia is used in patients who have to undergo the surgical procedure. Five small incisions of the length of 5 mm to 10 mm are made on the abdomen. During the procedure the upper portion of the stomach (fundus) is wrapped around the lower portion of the oesophagus and a new valve is created at the level where the oesophagus enters the stomach. The surgery takes 2-2.5 hours to complete. The patient is required to stay in the hospital for around 2 days. Regular activities are resumed within 2-3 weeks time. Symptoms of about 90% of the patients who undergo laparoscopic fundoplication are resolved after the procedure. Complications may develop in about 10-20% of the patients who have undergone surgical treatment. The surgical procedure is generally considered only as a last resort to treatment when all other treatment options have failed.

References:

  1. http://www.nhs.uk/Conditions/Gastroesophageal-reflux-disease/Pages/Treatment.aspx
  2. http://www.webmd.com/heartburn-gerd/guide/what-is-acid-reflux-disease?page=2
  3. http://emedicine.medscape.com/article/176595-treatment
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