Gastroesophageal Reflux Disease

Gastroesophageal Reflux Disease or GERD can be defined as a condition of mucosal damage produced by the abnormal reflux of gastric contents into the esophagus. ^[1] According to the Canadian Digestive Health Foundation, 5 million Canadians experience heartburn and/or acid regurgitation at least once each week.^[2] The term heartburn is often confused with GERD, and although the two are sometimes used interchangeably, heartburn refers to the symptom of experiencing acid reflux, while GERD is the condition of severe or chronic acid reflux that can lead to other complications such as cancer. Thus heartburn is a symptom of GERD, along with regurgitation or nausea.^[3]

Common symptoms of GERD include heartburn (particularly after a meal), regurgitation which can occasionally get into the tracheobronchial tree and cause respiratory complications such as coughing, dysphagia or the sensation of food being stuck, and wheezing, hoarseness, and non-cardiac chest-pain.^[4] The major pathophysiologic defect that is responsible for GERD has been identified as transient lower esophageal sphincter relaxations (TLESR). The lower esophageal sphincter (LES) is a ring of muscle at the entrance to the stomach that normally relaxes during swallowing. In GERD, the LES relaxes inappropriately, during the day or night, causing stomach acid to reflux.^[5] Conventional medical treatment for GERD focuses on combating stomach acid, which is seen as the primary cause of inflammation in the esophageal mucosa. Proton pump inhibitors such as Omeprazole (Prilosec) are the most commonly prescribed acid suppressants for GERD. One of the main issues of taking acid suppressants is that gastric acid is required for the proper absorption of some very important vitamins and minerals thus acid suppression can lead to deficiencies of these. The vitamins and minerals whose absorption is acid-dependent include vitamin C, vitamin B12, calcium, iron, magnesium, phosphorus, and zinc.^[1] Naturopathic approaches to treating GERD first and foremost involves identifying the root cause, whether it be stress, obesity, hiatal hernia, diet, medications, or other known factors. These factors are then addressed and eliminated using modalities such as botanical medicine, dietary and lifestyle counselling, Traditional Chinese Medicine and acupuncture to name a few. This paper will discuss the common causative factors of GERD, the evaluation and diagnosis of this condition, and naturopathic approaches to treatment.

CAUSATIVE FACTORS

The main contributing factor to GERD is diet. A number of foods have been found to cause GERD by either weakening the LES or irritating the esophagus. Foods that have been found to weaken the LES include alcohol, chocolate, coffee, fatty foods, onions, and sugar.^[4] Foods that have been found to irritate the esophagus include citrus fruits and juices, carbonated drinks, coffee, and spicy foods.^[4] GERD and obesity have been found to be associated, more so due to increased abdominal pressure than due to a defective esophogastric barrier.^[6] Psychosocial stressors have long been associated with exacerbations of symptoms in functional and inflammatory disorders of the gastrointestinal tract. As with other chronic gastrointestinal conditions such as irritable bowel syndrome (IBS), heartburn severity appears to be most responsive to major life events and not an accumulation of more minor stressors or fluctuations in mood. One study found that severe exhaustion, which may in part result from sustained stress, may represent psychophysiological symptom complex most closely associated with heartburn exacerbation.^[7] Medications that can trigger or exacerbate GERD symptoms by weakening the LES include anticholinergics, beta-blockers, bronchodilators, calcium channel blockers, narcotic analgesics, and tricyclic antidepressants.^[3] Other medications that have been found to irritate the esophagus include Aspirin, NSAIDS, potassium chloride tablets, Quinidine, and Tetracycline.^[4] Many pregnant women experience heartburn during their pregnancy due to enlargement of the uterus, which pushes the stomach and its contents up into the esophagus and tends to subsequently resolve post-partum. External factors such as smoking has been found to be associated with GERD as it causes a fall in sphincter pressure, thereby increasing the risk for reflux to occur.^[8]

IMPLICATIONS, AND EVAULATION

Prolonged heartburn can lead to damage of the mucosal lining and the gastrointestinal tract, including the esophagus. Chronic GERD is therefore accepted as the primary risk factor for the development of a condition known as Barrett’s esophagus. In this condition, the regular stratified squamous epithelium of the esophagus is replaced by columnar epithelium, which has the potential to develop into a malignant condition such as cancer.^[9] Other complications of GERD can include esophagitis or inflammation of the esophagus, esophageal stricture or narrowing of the esophagus, and esophageal ulcer or an open sore on the esophagus from chronic irritation. A patient who presents with symptoms indicative of GERD would generally be recommended a 4-week trial of specific nutritional treatments or dietary changes.^[4] If the patient continues to experience symptoms of GERD after the 4-week trial, a number of diagnostic tests would be conducted in order to determine a more definitive diagnosis. Laboratory testing for the evaluation of GERD may therefore include an Esophagogram to check for stricture and hiatal hernia, Esophagogastroduodenoscopy to rule out conditions such as esophagitis and Barret esophagus, Esophageal manometry to evaluate LES function, 24-hour pH monitoring, or the Gastro-Test which is the simplest and least invasive test for this condition.^[4] The type of evaluation can depend on either the severity of symptoms of the differential diagnoses that the Physician would want to rule out.

NATUROPATHIC TREATMENT
Melatonin

Melatonin is a hormone released by the pineal gland of the hypothalamus and is interestingly enough, more commonly found in the gut.^[1]Melatonin has been found to be capable of protecting the esophagus and mitigating the effects of inflammatory mediators in a number of ways. These include increasing esophageal mucosal blood flow, increasing the mucosal content of prostaglandin E2 which in turn improves esophageal blood flow and mucosal defences, and promoting the nitric oxide synthase/nitric oxide system which is linked to the proper functioning of the LES.^[4] Lower than normal nocturnal levels of melatonin have been found in patients with GERD versus those without GERD, which suggests the role of melatonin in maintaining proper LES function.^[4]

Phosphatidylcholine

Phosphatidylcholine(PC) are a class of phospholipids that can be found in abundance in cell membranes.^[4] Although PC phospholipids are found in almost all cells in the body, the highest concentrations can be found in the brain, heart, liver, and kidney. PC has been found to reduce biliary reflux, which is a mechanism that is believed to contribute to esophageal damage and in the genesis of GERD.^[4] In addition, PC has been found to play a key role in mucosal defence in the gastrointestinal system. ^[10]

Marshmallow

Marshamallow or Althea officinalis is a herb found in salt marshes, damp meadows, the sides of ditches, by the sea, and on the banks of tidal rivers. This plant contains mucilage polysaccharides, which is a gelatinous substance that has demulcent or soothing properties by forming a protective coating over mucosal lining.^[11] Marshmallow leaf and root are commonly used for respiratory tract mucous membrane inflammation, dry cough, diarrhea, constipation, peptic ulcers, and gastric mucosa inflammation that as seen in GERD.^[12]

Slippery Elm

Slippery Elm or Ulmus Rubra is a plant that is indigenous to eastern Canada and the eastern and central United States. Its name refers to its slippery consistency of the inner bark when chewed or mixed with water. Like the marshmallow plant, Slippery elm has a high content of mucilage. Due to its demulcent properties, which act as a soothing agent to irritated mucous membranes, Slippery Elm is often used for coughs or sore throats, and can be used in instances of GERD.^[13]

Sodium Alginate

Sodium alginate is a compound derived from seaweed. It can be used in patients with GERD as it interact with gastric acid within a few minutes by forming a viscous gel that floats on top of the gastric contents like a raft, thereby physically inhibiting the reflux of gastric contents into the esophagus.^[3] One study of patients with symptomatic GERD observed these effects by randomly assigning the patients to receive either sodium alginate orally or an antacid of the same dose each day. Complete symptom relief occurred within approximately 30 minutes in the patients who received sodium alginate than those who received the antacid.^[14]

Dietary and Lifestyle Modifications

Aside from the aforementioned functional or mechanical problems of the LES, diet is the main cause of GERD. A number of foods and medications have been identified as major triggers of GERD by weakening the LES and/or irritating the esophagus. Therefore dietary changes that include eliminating known triggers such as alcohol, coffee, spicy or fatty foods, carbonated drink etc. are necessary to reduce the occurrence, provide relief, and prevent further complications of GERD. These dietary changes can extend further to include adopting better mastication or chewing habits. Most patients may experience symptomatic improvement after they begin to chew their food more thoroughly, owing to the fact that breaking down food into smaller particle sizes stimulates saliva production and leads to better digestion[GABY]. Better digested food is less likely to reflux. Patients on certain medications that are known to cause GERD should also consult with their primary healthcare provider to seek alternative treatment options.

CONCLUSION

GERD is a common lifestyle condition that can be managed with the appropriate dietary and lifestyle changes. If left untreated, GERD can not only affect one’s quality of life, but also lead to more severe complications such as esophageal cancer. Therefore, educating patients about the common triggers and how the importance of removing these triggers outweigh the cons of giving up on their favourite foods can help them achieve a substantial improvement in their overall general health and well-being. The aforementioned natural interventions are not comprehensive in the treatment of GERD. Always consult with a Naturopathic Doctor to determine what treatment is appropriate for you.