... about GERD

By Julia Cyboran

He's been dependent on over the counter (OTC) antacids for years. But lately he's become suspicious that his heartburn might be something more serious than just his gut reacting to all the grease. So he booked an appointment with his GP and the diagnosis turned out to be less scary than he'd feared; no ulcer or cancer but his GP told him that he does suffer from gastroesophageal reflux disease (GERD).

GERD is the most common acid-related stomach disorder in Canada. Symptoms of GERD can often be mistaken for other gastrointestinal conditions and patients often ignore mild symptoms and reach for the chewable antacids instead of getting a checkup. "Heartburn is a symptom that is associated with GERD but not everyone with heartburn has GERD so you have to take this symptom in context with other features," explains Dr Paul Moayyedi, a professor of gastroenterology at McMaster University and one of the coauthors of the Canadian Consensus Conference on the management of gastroesophageal reflux disease in adults — Update 2004.

Given the symptom similarities, it's understandable that patients often mistake GERD for a bout of indigestion and blame the extra-hot chili peppers instead. But GERD is a serious condition that if left untreated can lead to more serious disease. Many of your patients could unknowingly suffer from GERD so here are some pointers that will help them recognize and control the symptoms.

THE WORD ON GERD
Guarantee that it's GERD In GERD, the contents of the stomach, particularly acid — rise up and enter the esophagus. It affects people of all ages and races but it's more common in folks who are overweight or obese. Also, smoking and alcohol can aggravate the disease. "Heartburn and regurgitation are the two cardinal features of GERD," explains Dr Moayyedi. You can be sure that it's GERD if the patient gets better with acid suppressing drugs, he adds.

When to scope it out "There is no gold standard testing for GERD," says Dr Moayyedi. So you can tell your patients who are under 50 that no testing is required. If acid suppressing meds relieve the symptoms mentioned above then that's enough to give you a diagnosis. However, patients over 50 might need an endoscopic examination to rule out more serious problems, like esophageal cancer. "Another test that's sometimes used to diagnose GERD is 24-hour esophageal pH," he notes. "A nasogastric tube is placed from the patient's nostril to the junction between the esophagus and stomach. This is left in place for 24 hours and measures the acid that refluxes." He is quick to point out though that the 2004 Canadian Consensus Conference on the management of GERD in adults stated that "not all patients need endoscopy and young patients can be managed in primary care." Essentially, "endoscopy doesn't add anything to the management," he says.

What not to eat — and drink According to Dr Moayyedi, lifestyle modifications do have a modest effect on GERD. So patients may see some benefit if they avoid overeating or eating too fast. You can also warn them about specific foods that can aggravate GERD like: high-fat and spicy foods, chocolate, onions, mint, citrus fruits and tomato products. Certain beverages also carry the same negative effect — alcohol, caffeinated drinks, coffee with or without caffeine and carbonated drinks all fall into this category.

Proton pump to the rescue "Over the counter [OTC] medications are fine for mild symptoms," explains Dr Moayyedi, "and it may be sufficient." Some common OTCs include antacids and histamine H2-receptor antagonists like famotidine and ranitidine. Dr David Armstrong, also a professor of gastroenterology at McMaster and the spokesperson for the Canadian Association of Gastroenterology, suggests warning patients not to use large amounts of OTCs. "In terms of safety, patients shouldn't be using antacids more than four to six times a day," he says and adds that patients with a daily need for antacids should be considering prescription treatment.

"If symptoms are severe, proton pump inhibitors [PPIs] are the best therapy," says Dr Moayyedi. The 2004 recommendations suggest PPI therapy for moderate to severe symptoms rather than trying H2-receptor antagonists, he adds.

Call in the specialist Dr Moayyedi cautions that longterm GERD can lead to esophageal cancer. But he stresses that this shouldn't worry patients as the risk is very small. However, it is important that they seek out treatment and stick with it to prevent any further damage to their esophagus. In most cases GERD can be managed by the primary care physician but in some instances a referral may be necessary. If patients are over 50 or 55 and experience a new onset of symptoms or if they exhibit alarming changes like severe weight loss, anemia or difficulty swallowing you can tell them that they need to see a specialist, advises Dr Moayyedi.