I have GERD! Now what?

I have GERD.Now

what?Finding your path to relief

®

YLÅ\_TK�JVT

I Have GERD! Now What? Finding your path to relief i

Copyright and Use of This Book

Copyright © RefluxMD, Inc.

All rights reserved. Except as permitted under the U.S. Copyright Act of 1976, no part

of this publication may be reproduced, distributed, or transmitted in any form or by any

means, or stored in a database or retrieval system, without the prior written permission

of RefluxMD, Inc.

This book contains information on medical topics that are for informational use only and

the authors are not providing medical advice. Information in this book should not be

used as a replacement for direct medical advice from certified and licensed medical

practioners. The information in this book should not be used for self-diagnosis or self-

treatment and you should seek the counsel of your medical professional with any

question you may have concerning your GERD symptoms or treatment. Please consult

with your physician before making any changes to your treatment plan or diet. The

authors, advisors and contributors disclaim any liability arising directly or indirectly from

any actions taken as a result of information contained this book.

Version 1.1 August 1, 2014

I Have GERD! Now What? Finding your path to relief ii

I’ve Got GERD! Now What? Finding your path to relief will….

• Provide you with the information necessary to understand your long-term, chronic condition and build a plan to manage your disease.

• Expose the problems of today’s status quo treatment model that has led to a dramatic increase in the incidence of Barrett’s esophagus, a pre-cancerous condition, and adenocarcinoma, which is refluxed induced esophageal cancer.

• Discuss all the underlying causes of reflux disease and the related symptoms. • Expose the real facts about anti-reflux medication and provide an approach for

you to determine the necessity of powerful prescription or OTC drugs. • Explore all treatment options including lifestyle changes, diet recommendations,

home remedies, medication, and surgery. • Assist you to develop a plan to gain relief and improved health. • Highlight the importance of a team to ensure success as you design your plan

and travel your path to health. If you have acid reflux symptoms, then this book is for you. If you are not satisfied with your current treatment plan, then this book is for you. If you are worried about your daily use of powerful medications to relieve your symptoms, then this book is for you. If you have a spouse, a child, a parent, a friend or a co-worker and you are worried about their struggle with GERD, then this book is for you --- and then to share. In fact, we encourage you to share this electronic book with anyone who you feel can benefit from its broad discussion about a disease affecting one of every five adults. Some of the information and concepts in this book may be difficult to understand and create additional questions. For those with access to the Internet, we encourage you to ask all of your questions at www.refluxmd.com. At the end of each article, you will find an “Ask a question” feature, which allows you to submit your questions. RefluxMD will

I Have GERD! Now What? Finding your path to relief iii

respond as promptly as possible and, if necessary and where appropriate, they will encourage you to consider scheduling an appointment with a GERD specialist. RefluxMD wants to thank its medical and scientific directors who developed and/or reviewed most of the content in this book as well as GERD specialists that collaborated on its development. Specifically we want to thank: Ronald Cornwell, MD FACS Advanced Surgery of Idaho, Caldwell, ID Peter Denk MD FACS GI Surgical Specialists, Fort Myers, FL Gopal Grandhige, MD Tampa Bay Reflux Center, Tampa, FL Casey Graybeal, MD FACS NGPG Surgical Associates, Braselton & Gainesville, GA David Johnson, MD FACS Premier Surgical Associates, Palm Springs, CA Jon King MD FACS Estrella Surgical Group, Phoenix, AZ Dan Lister, MD FACS The Surgical Clinic of Central Arkansas, Heber Springs, AK Richard Nedelman MD FACS SAS Surgery & Vein Specialists, Springfield, OH

http://www.refluxmd.com/rcornwellmd?utm_source=GERDGUIDE&utm_medium=PDF&utm_term=GERD&utm_content=ColaboratorDR&utm_campaign=GUIDE

http://www.refluxmd.com/pmdenkmd?utm_source=GERDGUIDE&utm_medium=PDF&utm_term=GERD&utm_content=ColaboratorDR&utm_campaign=GUIDE

http://www.refluxmd.com/ggrandhigemd?utm_source=GERDGUIDE&utm_medium=PDF&utm_term=GERD&utm_content=ColaboratorDR&utm_campaign=GUIDE

http://www.refluxmd.com/cjgraybealmd?utm_source=GERDGUIDE&utm_medium=PDF&utm_term=GERD&utm_content=ColaboratorDR&utm_campaign=GUIDE

http://www.refluxmd.com/dsjohnsonmd?utm_source=GERDGUIDE&utm_medium=PDF&utm_term=GERD&utm_content=ColaboratorDR&utm_campaign=GUIDE

http://www.refluxmd.com/jkingmd?utm_source=GERDGUIDE&utm_medium=PDF&utm_term=GERD&utm_content=ColaboratorDR&utm_campaign=GUIDE

http://www.refluxmd.com/dlistermd?utm_source=GERDGUIDE&utm_medium=PDF&utm_term=GERD&utm_content=ColaboratorDR&utm_campaign=GUIDE

http://www.refluxmd.com/rnedelmanmd?utm_source=GERDGUIDE&utm_medium=PDF&utm_term=GERD&utm_content=ColaboratorDR&utm_campaign=GUIDE

I Have GERD! Now What? Finding your path to relief iv

Forward By RefluxMD

We wish that medicine was like engineering, reduced to a set of equations and formulas that would allow a physician to assess your symptoms and test results, and then generate a personalized cure to end your pain and suffering. But it is not. Medicine is a combination of science, experience, and intuition that must consider the unique personal elements that make everyone different. As a result, your path to relief and good health may be different than that of your friend, your family member, or your co-worker. But one fact is true; only you can truly manage your reflux disease. Only you can make the decisions that will determine if your disease is properly managed or if it will control your life.

You are not alone. Today the Internet connects to you with information, medical experts, and other patients who have struggled to manage their reflux disease. Sometimes, though, it can be difficult to sift through the vast amount of information online to figure out what is relevant to you. That is why we established RefluxMD: to provide you a one-stop resource for the information you need to build a personalized GERD treatment plan and to connect you with a GERD expert physician when you need top-quality, professional help. We are proud to have teamed up with some of the best gastroenterologists; ear, nose and throat specialists; and surgeons, and made them available to you. While you may find many physicians in your area, these expert physicians have superior experience and knowledge about GERD and can help you explore your treatment options, so you can finally get the relief you deserve.

We hope that you find this resource valuable. If you want or need more information, please join us at RefluxMD to access hundreds of articles. We wish you the best as you develop your strategy to reduce your symptoms, while slowing or stopping the progression of your disease.

Your Path to Relief

I Have GERD! Now What? Finding your path to relief v

How to Use This Guide

This guide was designed to provide an overview of reflux disease, its causes and its

treatments, so there may be more information than you currently need. To help you

maximize your value and your time, the authors have crafted each chapter with five

elements to facilitate your review:

1. Descriptive chapter title

2. Sub-headings in each chapter

3. Key points from the chapter

4. Chapter contents

5. Links to recommended online articles

There are three ways to build your knowledge about GERD:

Cover-to-Cover Reading This is the most comprehensive approach to understanding all of the important aspects

of GERD. Take your time and schedule two or three chapters at each sitting. You may

also prefer to click on the recommended articles listed at the end of each chapter for a

more detailed review of the topic.

Review of Chapter Key Points This is particularly appropriate if your time is limited and you desire to gain a good

overall understanding of GERD. To learn most of the key facts simply read the

summaries at the beginning of each chapter. This should take between 15 and 20

minutes to complete.

Target Specific Areas of Interest For those with some understanding of acid reflux disease and who seek specific

information on one or more topics, simply visit the Table of Contents and select the

chapter of interest. Each chapter title is hyperlinked (highlighted with a blue color) so

simply click on the title and you will be taken directly to the area of interest.

I Have GERD! Now What? Finding your path to relief vi

We’d Love Your Feedback

Finally, we would love to know what you think of this guide to acid reflux, so please

email us your thoughts and comments at [email protected]. Thank you for your

time and your input – we want this to become the best resource available online.

Your RefluxMD Team

I have GERD! Now what? Finding your path to relief 1

Contents

Chapter 1 GERD: A Growing Epidemic

Chapter 2 Your Patient Bill of Rights

Chapter 3 The Underlying Causes of GERD

Chapter 4 The Symptoms That Say You Have GERD

Chapter 5 The Stages of GERD: Why You Need To Know Yours

Chapter 6 The Importance of Accurate Diagnostic Testing

Chapter 7 Lifestyle Choices to Treat GERD

Chapter 8 Using Medications to Treat GERD

Chapter 9 Surgical and Procedural Alternatives for GERD

Chapter 10 Complications If GERD is Not Treated Properly

Chapter 11 Home Remedies That May Help Manage Your Symptoms

Chapter 12 The Importance of a GERD Friendly Diet

Chapter 13 Let’s Get Started: Next Steps to Relief and Better Health

Appendix A The GERD Patient’s Bill of Rights

Appendix B Contributors


Chapter 1 GERD: A Growing Epidemic

“GERD is not just a nuisance; it is long-term chronic condition that can progress if not managed properly.”

How many people have GERD?

Do you consider a disease that affects between 20% and 33% of all adults an epidemic? Would you expect national health agencies to respond with an all-out effort to slow, and ultimately stop, the growth of a disease that impacts so many? While we have seen this response with many illnesses, such as typhoid, polio, measles, whooping cough, etc., it has not been the case with gastroesophageal reflux disease, also known as GERD or acid reflux. Let’s look at some of the facts about GERD:

• 75 million American adults, or 1 in 3, have symptoms monthly, and 50 million American adults, or 1 in 5, have symptoms weekly.

• Over the counter (OTC) and prescription medications to treat acid reflux cost Americans over $10 billion annually.

• The average annual medical costs for an individual with GERD are $3,355 higher than for an individual without GERD.

Key Points • 1 in 3 adults (75 million)

in the US have GERD symptoms monthly and 50 million adults have GERD symptoms several times weekly.

• The incidence of GERD in the US is increasing at a rate of 30% every decade.

• Over 190 million adults around the world suffer from GERD.

• Most adults view their symptoms as a “nuisance” and trivialize the disease, but there are five facts every GERD sufferer should understand:

1. GERD is a long-term chronic condition that can progress.

2. Reflux disease is directly linked to esophageal cancer.

3. Today’s status quo treatment for GERD has limitations and risks.

4. Daily use of PPIs has several potential serious side affects.

5. You can manage your disease.


• GERD costs employers an estimated $1.9 billion a week due to lost productivity and absenteeism. That’s almost $100 billion annually.

• The incidence of GERD in American adults is increasing at a rate of 30% every decade.

GERD is not just a problem in the United States. There are an estimated 190 million adults suffering from acid reflux disease when we include Canada, Europe, Japan, and Australia. These 190 million are not just experiencing minor discomfort – their experience is much worse than that. For more than half, GERD seriously impacts their quality of life. Many miss work, they cancel social plans with friends and family, they cannot go out to dinner, and some are forced to sleep in a chair since they cannot lie flat in a bed. GERD is not just a nuisance; it is long-term chronic condition that can progress if not managed properly.

Why has nothing been done? The general attitude of most adults with GERD is that acid reflux is just a nuisance. In fact, during the early stages of reflux disease, it is rare to find anyone who takes their symptoms seriously. Each year, heartburn sends over 200,000 adults rushing to an emergency room for presumed heart attacks. Most of those 200,000 will simply ignore the important message their body is sending to them, as they never view their symptoms as a disease.

Here are some of the most frequent excuses for ignoring GERD symptoms:

It’s just my food choices.

It is amazing how little most people know about reflux disease. Many still think it’s all about the pepperoni pizza or the spicy hot sauce they ate last night. In reality, GERD symptoms are caused by a structural weakness in the esophagus. The lower esophageal sphincter (LES), located at the junction of the esophagus and the stomach, performs an important function similar to a valve. When working properly, it creates a very effective barrier between the esophagus and the stomach. However, when the


LES loses its barrier function, stomach contents can freely move up into the esophagus. As a result, the stomach acids that typically remain in the stomach reach the esophagus, creating pain and often doing serious damage.

My pills cured me.

Proton pump inhibitor (PPIs) medications such as Nexium and Prilosec aren’t a cure for GERD; they only control symptoms for some people. One of the biggest problems with how GERD is currently treated is that physicians often prescribe long-term daily PPIs without explaining what they can and can’t do. Patients may take these drugs for years without ever understanding that PPIs only mask the symptoms of their disease and though the pain may subside, the reflux continues and their disease may progress.

I just love my lifestyle and I can’t give up certain things.

Another problem with simply managing the symptoms of GERD with PPIs is that they enable the exact lifestyle that, in many cases, created the disease. Without these medications, most sufferers would be forced to make dietary and lifestyle changes to avoid the painful symptoms of heartburn. Since PPIs can be so effective at controlling symptoms, however, the bad habits continue, leaving the door open to potential disease progression.

It’s just about excess acid in the stomach.

That couldn’t be further from the truth. Everyone has a significant amount of stomach acid, whether they suffer from GERD or not. Since antacids and PPIs reduce the acidity of the stomach, most people just assume that they “make” too much acid; however, the stomach was designed to have a high acid level to promote good digestion.

Five FACTS you need to know about GERD

1. Reflux is a long-term chronic condition, and if left untreated, can progress. Heartburn is just a result of what we eat, right? Wrong! As noted earlier, reflux disease is caused by a weak LES, a ring of muscle in the lower end of the esophagus. Reflux can happen for a variety of reasons – eating large portions, obesity, smoking, and


excessive consumption of alcohol are all known to damage or weaken the LES. Over time, the longer you indulge in these activities, the more you potentially weaken the LES. Because the lining of the esophagus is easily irritated by the contents of the stomach, reflux disease can lead to complications such as inflammation, erosions of the lining of the esophagus, narrowing of the esophagus, Barrett’s Esophagus (a pre-cancerous condition), and esophageal cancer.

2. Reflux disease is directly linked to esophageal cancer

No one ever died from heartburn, right? Wrong! Esophageal adenocarcinoma, a type of cancer of the esophagus, is directly linked to reflux disease. In fact, reflux disease is the only cause for this type of cancer. The number of esophageal cancer cases has grown over 600% since 1975 making this deadly disease the fastest growing type of cancer in the United States. When charted against the incidence of all other cancers, esophageal cancer is in a league of its own. Sadly, esophageal adenocarcinoma is also one of the most lethal types of cancer. The overall likelihood of surviving five years is only 15% to 17%. This year alone approximately 20,000 deaths will result from reflux-induced esophageal cancer.

3. Today’s status quo treatment for GERD has serious limitations and risks.

Over-the-counter and prescription medications stop the reflux, right? Wrong! Many times when a patient complains of the symptoms of reflux, a proton pump inhibitor, or PPI, such as Prilosec, Prevacid, or Nexium is prescribed by a physician or is simply purchased over-the-counter at a drug store. These drugs relieve the symptoms of reflux by reducing the amount of acid produced by the stomach, which helps minimize or even eliminate heartburn symptoms. But reducing heartburn doesn’t mean that the reflux is cured. Unfortunately, taking PPIs does not stop the reflux – it only stops the heartburn - and the disease continues to progress.

4. There are potential negative side effects associated with daily PPI use. Those PPIs must be safe since they are sold over-the-counter and don’t need a doctor’s prescription, right? Wrong! Consumers spend more than $20 billion worldwide each


year on PPIs (over $10 billion in the US annually), looking for relief from their reflux symptoms. While these medications have helped millions of people, there are risks that users must understand. Reflux disease is a chronic, progressive disease, so once PPIs are started, use typically continues on a daily basis indefinitely. Studies have shown that long-term daily use of these drugs is correlated to an increase in the incidence of bone fractures, clostridium difficile colitis (a potentially deadly infection of the intestines), pneumonia, and low magnesium levels. PPIs are also known to interact with other drugs; the most important of these is Plavix, a blood thinner used for prevention of heart attacks and strokes. What’s most distressing is that several studies have documented that 30% of PPI users don’t even have reflux. This means that millions of people are taking these drugs unnecessarily.

5. You can manage your reflux disease!

There must be something that can be done to stop symptoms and the progression of reflux disease, right? RIGHT! Although reflux disease cannot be reversed, the good news is that most people with reflux can effectively manage their symptoms and impact the progression of their disease. Those options change as the disease progresses, so getting an early start is important.

Get started today This actual account from a GERD sufferer might make these five facts more meaningful. We’re confident that this woman would have done things differently had she known about them earlier in her life:

"By the time the paramedics got to me I thought I was dying of a heart attack, so imagine my relief when I found out it was only heartburn. When the doctor sent me home with a prescription, I had not a care in the world, so confident was I that the prescribed medicine would cure me. And I thought it did because I felt fine and could eat just about anything I wanted for a long time. It was like a miracle until eventually after years of taking the daily PPIs, my symptoms came back with a vengeance and no amount of medicine stopped the pain. Desperate for help, I


sought the care of a specialist and was shocked to be diagnosed with Esophageal Cancer. After several weeks of chemotherapy, surgeons removed my esophagus and gave me the devastating news that the cancer had spread to my lymph nodes. While I am determined to keep fighting, the anger and frustration I feel is overwhelming. Why was I not warned that my heartburn symptoms were only being masked by the medication I was taking? Why was I not told about the possibility that my disease could be progressing like a silent killer to a deadly stage? I am 52 years old, a wife and a mother of three, and I just want to live.”

If you have reflux disease, then this resource is for you. There is a lot to do! First, educate yourself about this chronic condition and know where you are in the progression of your disease. Then, take steps to stop that progression, monitor your symptoms, design a personal reflux disease management plan, and build a team of family, friends and medical professionals who can help you on your journey to good health.

Additional Resources

What is acid reflux? Getting real about reflux disease Don’t be fooled, your heartburn could be serious Esophagus to brain: “Houston, we have an acid reflux problem” The four myths about heartburn (3-min video) “If I only knew then what I know now about heartburn” (Real life story)

!

http://www.refluxmd.com/learn/resources/2012-10-03/395/what-acid-reflux-getting-real-about-reflux-disease?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH1.1

http://www.refluxmd.com/learn/resources/2013-06-19/3430/dont-be-fooled-your-heartburn-could-be-serious?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH1.2

http://www.refluxmd.com/learn/resources/2013-06-13/3278/esophagus-brain-houston-we-have-acid-reflux-problem-part-1?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH1.3

http://www.refluxmd.com/heartburn?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH1.4

http://www.refluxmd.com/learn/resources/2013-10-18/5701/if-i-only-knew-then-what-i-know-now-about-heartburn?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH1.5


Chapter 2 The GERD Patient Bill of Rights

“The current medical approach to reflux disease is a path to massive financial costs and increased suffering.”

The status quo treatment model In January 2012 a group of top GERD physicians

spent several days together in Pasadena, CA to

discuss why the incidence of reflux disease was

growing unchecked and to determine what, if

anything, could be done about it. It was clear that

the status quo treatment plan used by most

physicians was not working; and in most respects,

the incidence of the disease continues to increase

every year. Several facts were evident:

1. Primary care physicians are not adequately

trained to diagnose or treat GERD. It is estimated

that less than 30% of all physician visits where

GERD was the primary diagnosis were with

specialists who have the equipment and training to

diagnose GERD accurately. Consequently,

diagnosis for the remaining 70% was done via

“symptom reporting”, which has resulted in

misdiagnosis and inappropriate medication therapy

of over 30% of all PPI users.

2. Most of the specialists who accurately

diagnose GERD recommend the same treatment

protocol as primary care physicians – daily PPI

Key Points • Despite billions spent

annually on long-term PPI medications, the incidence of GERD continues to grow.

• The incidence of Adenocarcinoma (reflux induced esophageal cancer) is increasing faster than any other cancer today.

• The status quo treatment model of daily PPI medications is broken.

• Almost one-third of GERD patients placed on PPIs are misdiagnosed and mistreated, primarily due to the lack of specific disease knowledge at the primary care level.

• GERD sufferers are responsible for THEIR disease and must make certain that their physicians always operate under the guidelines of the Pasadena Protocol.

!


usage. In most cases, this becomes a prescription for life. If symptoms return,

typically the recommendation is to double the medication dosage. Unfortunately,

only in limited situations did those prescribing physicians disclose important facts

to their patients about the treatment plan: 1) PPI medications only treated

symptoms and are not a cure for reflux disease, 2) the disease could still continue

to progress while using PPIs, even in the absence of symptoms, 3) long-term

daily use of PPIs have several negative side effects as documented on the FDA

mandated packaging insert, and 4) there are alternative treatments that should be

considered by all patients with GERD.

3. Medical societies and associations have demonstrated little or no interest in

challenging the status quo treatment model.

4. The big winners are the pharmaceutical manufacturers who have spend millions

in advertising dollars to promote their medications directly to GERD sufferers.

5. The American healthcare system spends $3 billion annually on anti-reflux

medications for individuals that do not have reflux disease.

6. The biggest losers are those GERD sufferers that are put on the status quo

treatment plan believing they have cured their disease, but years later develop

serious complications with a deteriorating quality of life.

The Pasadena Protocol What developed from that meeting was a response to the current status quo method of

diagnosing and treating reflux disease. The Pasadena Protocol is a set of conventions,

principles, and behaviors that have the power to dramatically impact relationships

between patients, practitioners, insurers, and employers. The Pasadena Protocol will

be a powerful tool to achieve the following objectives:

• Improved long-term medical outcomes for the treatment of reflux disease.

• Enhanced quality of life for patients suffering from reflux disease.


• Lower healthcare cost associated with the treatment of reflux disease.

Every physician should not only agree with these principals, but they should also

actively follow them. For their patients, this is their Bill of Rights. A more detailed

discussion of the Pasadena Protocol is found in Appendix A.

Elements of the Pasadena Protocol

1. Educated and empowered patients are essential to success.

2. Reflux disease sufferers deserve an assessment of their disease along with

relevant recommendations.

3. Knowledgeable GERD experts should treat those with reflux disease.

4. Powerful anti-reflux medications must be appropriately prescribed.

5. A support team is essential to successfully manage reflux disease.

6. Reflux disease is a progressive chronic condition requiring long-term monitoring.

7. The reflux community must be informed and agile as new technologies,

knowledge, and treatments become available.

Changing the future of reflux disease The status quo treatment model is failing and must change. We shouldn’t hear one

more story like this:

“I am a 68-year-old white male who has suffered from acid reflux most of my

adult life. About 15 years ago, I was placed on Prilosec by my gastro doc. After

that, I had few symptoms of reflux and heartburn. Since I had no significant

symptoms, neither my primary care doc nor my gastro doc ever recommended

an endoscopy, and I never thought about asking for one since I thought symptom

control meant reflux control and even healing. Then about two years ago when

all the scares started coming out about long-term use of PPIs and since I was

having no significant symptoms of reflux, I asked my primary care doc if I could

stop the Prilosec to see if symptoms returned. Symptoms did not change, and

that affirmed my belief that the Prilosec had allowed my esophagus to heal.


Then about a year after going off the Prilosec I was diagnosed with

adenocarcinoma stage 3. Since then, until I found RefluxMD, I have beat up on

myself and blamed myself for going off the Prilosec as the cause of the cancer.

My gastro doc clearly thought that is what caused the cancer, although my

oncologist said that being off only a year was not enough time to allow the cancer

to develop. I now think both are wrong in their reasoning. What I read at

RefluxMD indicates to me that going off the Prilosec did not cause the cancer,

nor did stopping the drug ‘cold turkey’ (which I later read could result in serious

damage to the esophagus due to "rebound reflux") since all the Prilosec was

doing was controlling the symptoms for all those years and not stopping the

progression of disease.

Although knowing the answer to this question will not change the fact of my

cancer or the probable outcome, it is important to me to feel that I did not operate

in an irresponsible way concerning my health care based on the best information

and medical guidance available to me at the time. I also want to share

information with friends and family who are taking these drugs, and I want what I

tell them to be accurate.”

Although the incidence of cancer is still relatively small with 18,000 projected deaths this

year, that number is still increasing despite billions spent on today’s “status quo”

medication therapy. The current medical approach may reduce short-term symptoms for

some, but research suggests it will result in a higher rate of disease progression leading

to an increased incidence of esophagitis, Barrett’s esophagus, and esophageal

adenocarcinoma. Additionally, improper and unnecessary treatment adds a

tremendous financial burden to the healthcare system. The Pasadena Protocol is a

response to this possible future. Comprised of the principles and concepts noted above,

this new outlook has the potential to change the behaviors of the reflux disease and

address the severe shortcomings of today’s treatment model.



The Pasadena Protocol: A New Dawn for Reflux Disease Treatment

Young heartburn sufferer finds the right doctor…and relief (Real life story)

http://www.refluxmd.com/learn/resources/2012-10-17/479/pasadena-protocol-new-dawn-reflux-disease-treatment?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH2.1

http://www.refluxmd.com/learn/resources/2013-07-26/4253/success-story-young-heartburn-sufferer-finds-right-doctor-and-relief?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH2.2


Chapter 3 The Underlying Causes of GERD “GERD occurs when the valve between the stomach and the esophagus is unable to generate adequate pressure to function as an effective barrier.”

Why do I have GERD?

GERD is a disease prevalent in economically developed countries, particularly in North America, Europe, Japan, and Australia. So you, like over 190 million adults worldwide, are probably wondering why you have GERD, or acid reflux.

It is impossible to be certain as to why you have this disease and what is driving your symptoms. GERD occurs when the valve between the stomach and the esophagus is unable to generate adequate pressure to function as an effective barrier. Once this lower esophageal Sphincter (LES) begins to deteriorate, stomach contents are able to reflux back up into the esophagus, resulting in the painful symptoms of GERD.

The real questions we should be asking are these:

1. What caused my LES to become non-functional? 2. Why is GERD so common in the western world?

Key Points • GERD occurs when the

lower esophageal sphincter (LES) loses its ability to function as a barrier between the stomach and the esophagus.

• Diet and lifestyle are major factors impacting the deterioration of the LES.

• Overeating and obesity are significant factors impacting the ability of the LES to act as a barrier.

• Alcohol and smoking can trigger GERD symptoms and weaken the LES.

• Given the growth rate of obesity and alcohol consumption, it will be difficult to slow the growth curve of reflux disease.


Our Diet is the Culprit Both questions share a common answer: the underlying reason is that we overeat! In many parts of the world most people “eat to live”. In economically developed countries, we “live to eat”. In most westernized countries the quality of food is so good we crave more and more – and we eat more and more. Most people love the typical American meal - double cheeseburgers and super-sized fries. Many adults, including many GERD sufferers, have become addicted to gaining satisfaction from a meal only if they feel full. Therein lies the problem.

What Happens When We Overeat? When we eat more than a “comfortable” or appropriate amount of food for the stomach to handle, the stomach must stretch, or distend, to accommodate this additional volume. When this stretching happens, the lower end of the esophagus, where the LES is located, distends to a shape that resembles the horn end of a trumpet. In this situation, the lower portions of the LES become exposed to stomach acid and damage to the esophagus is possible. The stomach lining can accommodate acid that it normally produces for digestion. The esophagus, however, including the LES, cannot handle contact with the highly acidic stomach contents on a regular basis.

Overeating on a limited and intermittent basis is typically not a problem. Under these circumstances, minimal irritation of the lower esophagus and LES results and the esophagus heals itself. However, repeated and significant overeating can damage the LES and cause it to lose its strength. Once the barrier is lost, acid reflux occurs initiating GERD symptoms.

How distending the stomach impacts the barrier function of the LES The LES has two properties that enable it to function as a barrier. The two properties are the length of the LES and the pressure by which it “squeezes” the lower esophagus closed. If the LES is chronically exposed to acid by stomach distension from


overeating, it becomes damaged to the point where it cannot generate pressure. So BOTH the length of the LES is lost and its ability to generate pressure declines. As the barrier is damaged, mild reflux may be intermittent. However, over time frequent reflux results in a significant reduction of both the LES’s length and its pressure. At some point, it is possible that the LES’s barrier function is not just reduced, but is essentially gone.

The obesity epidemic in the United States creates a very problematic situation. Obesity results from overeating so that the scenario described above is bound to occur. The increased pressure caused by large meals first compromises the LES function. Then, the very heavy abdominal wall “compresses” the stomach, resulting in excessive pressure on the LES. In fact, obese people are three times more likely to have frequent GERD than those that are not obese.

Your GERD symptoms are a message from your body telling you something is wrong. Unless you take control of your illness and manage your disease, the messages may become more frequent and intense, and serious complications can result.

Lifestyle choices impact the LES, too Certain lifestyle choices can also impact the effectiveness of the LES. Alcohol consumption is one such activity that has been studied and found to have a direct impact on the LES. Many heartburn sufferers report that their symptoms routinely occur after drinking alcohol. A study by Dr. Kaufman and Dr. Kay titled “Induction of gastro-esophageal reflux by alcohol” published in the GUT peer reviewed journal found a strong correlation between alcohol and GERD. In the study, healthy young adults were tested after consuming alcohol. Individuals were given either 180 ml of vodka or 180 ml of water to determine the impact of alcohol consumption on the LES. There was a significant difference between the two groups, and the researchers concluded that even small quantitates of alcohol triggered GERD symptoms even in healthy adults.


How big of an issue is this? According to a July 2012 Gallup survey, two-thirds of all adults reported they consumed alcohol occasionally. Of these, 22% indicated that they “drank too much”, representing an increase from 17% the year before. Men reported more alcohol consumption, 6.2 drinks per week compared to women at 2.2 drinks per week. Given the results of the study by Drs. Kaufman and Kay, it is clear that alcohol consumption may be a large factor accelerating the growing incidence of GERD.

Smoking has also proven to be an important factor in reducing the LES’s capabilities. Dr. Kahrilas and Dr. Gupta in another article published in GUT titled “Mechanisms of acid reflux associated with cigarette smoking” studied smokers and non-smokers. Their closing statement was; “We conclude that cigarette smoking probably exacerbates reflux disease by directly provoking acid reflux and perhaps by a long lasting reduction of the lower esophageal sphincter pressure.” Although tobacco use in the US has declined over the last 20 years, according to the CDC, 19% of all US adults still smoke cigarettes.

Given the current rates of obesity, alcohol consumption, and tobacco use, it is surprising that only one in every three adults experience GERD symptoms monthly. If we are unable to manage these trends in the future it is clear that GERD will be an epidemic, affecting more adults than any other chronic disease.


GERD Explained: The role of the LES Can GERD be cured? A heavy burden: GERD and obesity How I stopped taking PPIs once and for all (Real life story) !

http://www.refluxmd.com/learn/resources/2013-05-09/2559/gerd-explained-role-les?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH3.1

http://www.refluxmd.com/connect/physician-expert-blogs/7324/can-gerd-be-cured?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH3.2

http://www.refluxmd.com/learn/resources/2013-01-24/1207/heavy-burden-gerd-and-obesity?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH3.3

http://www.refluxmd.com/learn/resources/2014-02-27/7575/how-i-stopped-taking-ppis-once-and-all?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH3.4


Chapter 4 The Symptoms That Say You Have GERD

“People with GERD experience a variety of symptoms in addition to the classic symptom of heartburn.”

Classic symptoms of GERD GERD affects everyone differently. While only an

occasional problem for some, GERD can be a

lifestyle-limiting disease for many. It can disrupt daily

activities, disturb sleep, and decrease work

productivity. People with GERD experience a variety

of symptoms in addition to the classic symptom of

heartburn. Unfortunately, symptoms can become

more frequent and more severe over time and can

lead to serious complications if left unchecked. The

most common symptoms of GERD are:

Heartburn

Heartburn is the classic GERD symptom. It’s best

described as a burning sensation in the chest and/or

discomfort in the upper belly or abdomen

accompanied by a feeling of fullness. As the acidic

stomach contents move up past the LES and contact

the esophagus, the pain can range for mild to

extremely severe, and in some cases it can feel

similar to a heart attack.

Regurgitation

Regurgitation is hard to miss. It’s the abrupt feeling of

stomach contents rising past the esophagus and into

Key Points • GERD varies widely from

individual to individual by presenting different symptoms, initiated by different triggers, and developing at different times of the day.

• There are several traditional symptoms of GERD, including heartburn, regurgitation, difficulty swallowing, and chest pain.

• Lesson common symptoms include tooth decay, gingivitis, bad breath, earaches, shortness of breath, and bloating.

• Certain atypical symptoms indicate a condition known as “silent reflux”. These include chronic cough, hoarseness, constant throat clearing, laryngitis, and postnasal drip.

• Certain “Alarm Symptoms” should be taken very seriously, including difficulty swallowing and chest pain, which could signal a cardiac event.


the mouth. A horrible bitter taste and burning in the throat usually accompany this

unpleasant surprise. This is often a significant warning sign of advanced reflux disease

indicating that your disease is severe.

Difficulty swallowing (Dysphagia)

Although mild difficulty swallowing is a symptom of GERD, more frequent or severe

difficulty swallowing could be a symptom of esophageal cancer and should be promptly

evaluated by an expert. Pressure and/or pain in the chest area, or the sensation that

food is “stuck” in the throat are symptoms of dysphagia.

Chest pain

GERD and heart disease share this symptom, and it is very difficult to determine the

real underlying cause of chest pain. Consequently, it is important to always seek

immediate medical attention for chest pain to rule out a possible heart condition.

Symptoms you probably don’t expect There are several symptoms you probably don’t expect that most people don't realize

can be related to GERD:

• Tooth decay, gingivitis, and bad breath

• Earaches

• Asthma-like symptoms, such as shortness of breath

• Recurring pneumonia

• Abdominal bloating and belching

Atypical symptoms of GERD There are several symptoms that can indicate a condition referred to as

laryngopharyngeal reflux (LPR). These symptoms include hoarseness, chronic

cough, constant throat clearing, laryngitis, postnasal drip and a frequent feeling of

a lump in your throat, and are often the result of acid affecting the throat.

Because these symptoms can be caused by so many other conditions, LPR is


notoriously hard to diagnose, and unfortunately, there is no single test to confirm

the diagnosis. The most widely used therapy for GERD is PPI medication;

however, these powerful drugs are typically ineffective in the treatment of LPR. If

you experience these symptoms, it is important that additional diagnostic tests be

performed to confirm your GERD diagnosis.

Red Flags: Factors that Create Concern “Alarm” symptoms, such as difficulty swallowing and/or chest pain, indicate the

potential for serious complications and must be evaluated promptly. If you have

experienced symptoms for more than 5 to 10 years, you are at an increased risk

for Barrett’s esophagus, a pre-cancerous condition. In these situations you must

err on the side of caution, and see a GERD expert to rule out any serious

complications.


What is heartburn?

Difficulty swallowing? See your doctor Acid regurgitation: A sign of advancing reflux disease

Long-term GERD symptoms: A warning flag for complications

Chronic cough, throat clearing, hoarseness? Think reflux

Chronic throat clearing and the path to an acid reflux diagnosis !

http://www.refluxmd.com/learn/resources/2012-11-28/795/what-heartburn?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH4.1

http://www.refluxmd.com/learn/resources/2012-07-30/240/difficulty-swallowing-see-your-doctor?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH4.2

http://www.refluxmd.com/learn/resources/2012-11-09/690/acid-regurgitation-sign-advancing-reflux-disease?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH4.3

http://www.refluxmd.com/learn/resources/2013-07-20/4068/chronic-cough-throat-clearing-hoarseness-think-reflux?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH4.5

http://www.refluxmd.com/learn/resources/2013-07-19/4043/chronic-throat-clearing-and-path-acid-reflux-diagnosis?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH4.6

http://www.refluxmd.com/learn/resources/2012-12-18/916/long-term-gerd-symptoms-warning-flag-complications?utm_source=gerdguide&utm_medium=pdf&utm_campaign=CH4.4


Chapter 5 The Stages of GERD: Why You Need To Know Yours

“Treatment options and recommendations for each stage are also different, so it is essential to know your stage before you begin any treatment plan.”

GERD is a chronic, progressive condition

GERD is a long-term, chronic condition that varies in

severity. Like many diseases, GERD has several

stages ranging from mildly irritating to life threatening.

Your goal should be to contain your disease while

improving the quality of your life. GERD stages are

best defined by symptoms in conjunction with tests

such an endoscopy, pH testing, and biopsy.

Stage 1: Mild GERD

The majority of adults with GERD today have minor

damage to their LES and experience mild-GERD

symptoms occasionally – once or twice a month. In

most cases they use over-the-counter acid

suppressive medications such as antacids or H2

Blockers at the onset of symptoms. Because their

symptoms are controlled quickly, easily, and

inexpensively, their quality of life is unaffected. Here

is an example:

I am a 45-year-old man working as a traveling salesman for an auto car parts company. Because of my job I spend most of my time away from home and

Key Points • Reflux disease is a

chronic, long-term and progressive disease.

• Stage 1: Mild GERD can be managed with many over-the-counter acid suppressive medications.

• Stage 2: Moderate GERD is evidenced by more frequent symptoms that require daily, more powerful medications to manage symptoms.

• Stage 3: Severe GERD results in a substantially lower quality of life as the daily medications are unable to satisfactorily manage symptoms.

• Stage 4: Reflux induced pre-cancerous lesions or esophageal cancer is a result of advanced progression and can be life-threatening.

• GERD treatment options are highly dependent upon an individual’s GERD stage.


find myself eating fast food frequently. I have gained 25 pounds over the past 20 years but consider myself healthy. I started getting occasional episodes of discomfort under my breastbone about 10 years ago. These lasted a short time and occurred almost always when I ate a double cheeseburger with fries and a large soda. I used to ignore these but recently the episodes have become more severe, they last longer, and they are more frequent. I now have these problems about twice a week.

Last week, I got up at night with a similar pain in my chest and I worried that I was having a heart attack. The discomfort has increased and is now a burning pain that I think is heartburn. I carry a packet of antacids in my pocket now and take a couple of these when I start getting the pain. Fortunately, they control it very quickly and are inexpensive. Now I take Tums before I eat a cheeseburger because I’ve found that this prevents my pain. My quality of life is pretty normal except that I worry that I have a disease that may be serious. I have never experienced food regurgitation, I sleep at lying flat in my bed, and I have never been to a physician.

Stage 2: Moderate GERD

Stage 2 GERD is more difficult to control with acid suppressive drugs and the

accompanying reflux symptoms are more frequent and more intense. Damage to the

LES is more extensive compared to Stage 1. Many symptoms can be satisfactorily

managed long-term with more powerful acid suppressive medications. Since many

over-the-counter antacids and H2 blockers often provide inadequate relief, prescription

strength medications are necessary to manage the symptoms of acid reflux. Many can

benefit from being treated by a knowledgeable GERD specialist. Here is an example:

I am a 43-year-old woman working as an executive in a commercial bank managing real estate loans. My weight is in proportion to my height and I exercise several times each week to maintain my weight level. I started getting heartburn during my second pregnancy seven years ago. Although the symptoms decreased after my baby was born, they did not completely disappear. In fact, over the last three years they have increased significantly. I now get an episode almost every day, which is troubling to me.


I am afraid to eat normally and have changed my eating habits. I also wake up frequently at night with a pain in my chest that goes away quickly when I sit up. I have tried a variety of acid suppressive drugs that I purchased at the pharmacy, but even the recommended dosage of Prilosec-OTC did not fully control my symptoms. I went to my family doctor who prescribed a stronger drug that I use daily and my symptoms have improved, but not resolved. I am still afraid of eating and I sleep with two pillows to avoid the burning sensation I sometimes get at night. I would say that my life is generally all right but not perfect. I still have occasional episodes of regurgitation, but I don’t consider them to be too troublesome. My family doctor has told me that there is nothing more that can be done for me. Surgery is the only alternative to drug treatment and my family doctor had little to offer concerning that alternative. I have not seen a GERD specialist and have never had an endoscopic exam or any other testing for my problem.

Stage 3: Severe GERD

Stage 3 GERD results in a substantially lower quality of life and is considered to be a

very serious problem. Even prescription level acid suppressive drugs do not control

symptoms to the individual’s satisfaction and regurgitation is frequent. It is also likely

that one or more of the complications associated with erosive GERD may be present. It

is highly recommended that anyone with severe GERD schedule a thorough

examination by a knowledgeable GERD specialist. Here is an example:

I am a 52-year-old man and I work in a car dealership as a salesman. I am moderately overweight, but certainly not obese. I have had heartburn on and off for the past twenty years and until I was put on a prescription medication by my gastroenterologist, I experienced heartburn almost daily. I have been to numerous physicians that have performed a variety of tests, including endoscopic evaluation of my throat. Although my daily prescription acid suppressive drugs worked well for many years, over the last two years I have developed frequent regurgitation. I can no longer sleep in my bed and for the last nine months I’ve been forced to sleep in my recliner. I am afraid to eat knowing


that I will develop heartburn followed by regurgitation. Last week I awoke in the middle of the night with an episode of coughing and shortness of breath. This really scared me because I thought I was suffocating. I spoke with my gastroenterologist the next day and he told me not to worry and recommended continuation of my prescription drugs. When I asked him about surgical options, he told me that he would prefer for me to continue with my current treatment plan.

Stage 4: Pre-cancerous condition or reflux induced esophageal cancer

Stage 4 is the result of many years of severe reflux; 10-15% of long-term sufferers

progress to this very advanced condition. Due to long-term reflux, the lining of the

esophagus has been damaged, resulting in cellular changes. It should be noted that

these cellular changes could develop in some people with only minimal symptoms.

Stage 4 involves the development of a pre-cancerous condition called Barrett’s

esophagus or a more severe condition called dysplasia. These conditions are not

cancers, but raise the risk of developing reflux-induced esophageal cancer. Many

people with Stage 4 GERD have no pain or warning signs! At this stage, typical

GERD symptoms may also be accompanied by burning in the throat, chronic cough,

and hoarseness. Strictures, or a narrowing of the esophagus, can also occur which is

characterized by the sensation that food is sticking in the esophagus. This same

symptom can also be caused by esophageal cancer. Stage 4 GERD can only be

diagnosed with an endoscopic examination and a biopsy of cells taken in the lower

esophagus. RefluxMD highly recommends Stage 4 disease be cared for in an ongoing

way by a knowledgeable GERD specialist.

I am a 62-year-old male that retired two years ago. I have had heartburn for fifteen years and my symptoms have been well controlled with acid suppressive drugs until last year when I experienced regurgitation that is getting worse monthly. I also developed a troublesome and constant cough and my voice has become hoarse.

Last month, my physician referred me to a gastroenterologist who performed an endoscopic examination on my throat and told me that I had Barrett’s esophagus. He


told me that while Barrett’s esophagus indicated an increased risk of cancer, the risk was very small and that I should not worry. He increased my dosage of acid suppressive drugs and told me that I needed annual endoscopic examinations. I asked him if I had any other options and he mentioned surgery. However, he indicated that he would prefer to monitor me and, if necessary, he would suggest that alternative.

Each of these stages is unique, however transition from stage-to-stage is not clearly

defined and noticeable. Treatment options and recommendations for each stage are

also different, so it is essential to know your stage before you begin any treatment plan.


Find your GERD Stage

My GERD symptoms have increased over the last year and I’m worried. What should I do?

The four things your doctor will never tell you about reflux disease

Long-term GERD sufferer decides to take control of her health

!

http://www.refluxmd.com/take-action/assess-your-reflux/terms?utm_source=gerdguide&utm_medium=pdf&utm_campaign=CH5.0

http://www.refluxmd.com/connect/physician-expert-blogs/4362/my-gerd-symptoms-have-increased-over-last-year-and-i-am-worried?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH5.1

http://www.refluxmd.com/connect/physician-expert-blogs/5853/four-things-your-doctor-will-never-tell-you-about-reflux-disease?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH5.2

http://www.refluxmd.com/learn/resources/2013-08-13/4684/long-term-gerd-sufferer-decides-take-control-her-health?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH5.3


Chapter 6 The Importance of Accurate Diagnostic Testing

“GERD cannot be diagnosed based upon symptoms; accurate diagnostic tests are essential to confirm or rule out reflux disease.”

Why testing matters Seventy percent of adults with reflux disease have never seen a physician, they self-diagnose and often self-medicate. Of those that have seen a physician, approximately 70% have only seen a primary care physician who is not an expert on GERD and does not have the diagnostic tools to confirm an accurate diagnosis. GERD cannot be diagnosed based upon symptoms; accurate diagnostic tests are essential to confirm or rule out reflux disease.

When you see a GERD expert physician about your reflux symptoms, a variety of tests may be used to evaluate your condition. These procedures together provide a complete evaluation - each has a purpose and each represents a different piece of the puzzle. These procedures only provide complete clarity if they are coordinated and conducted properly. All too often, an incomplete evaluation results in a patient gaining no further insight into their condition.

Common diagnostic tests The following are the most commonly used tests

Key Points • The majority of adults

with GERD symptoms either ignore them them or self-diagnose and self-medicate.

• Family physicians and internists do not have the diagnostic tools to confirm an accurate diagnosis of GERD.

• There are several diagnostic tests used in the evaluation of GERD: o Upper endoscopy o Biopsies o Ambulatory pH

testing o Esophageal

manometry o Barium swallow

• Unfortunately, GERD is frequently misdiagnosed resulting in inappropriate use of powerful medications with the potential for serious side effects.


when evaluating a patient with GERD-like symptoms:

Upper Endoscopy

An upper endoscopy, or EGD, provides a visual examination of the esophagus and stomach. An endoscope is a thin, flexible tube with a light and tiny video camera on the end. During the procedure, the patient is sedated while the doctor advances the endoscope into the esophagus and stomach and inspects the tissue through the images on a video monitor. This study allows a doctor to see any areas of inflammation or irritation, and “rule out” many other conditions. It’s important to note, though, that EGD alone cannot definitively diagnose GERD.

Biopsies

During an upper endoscopy a doctor may take small tissue samples called biopsies from areas that appear abnormal. A pathologist will examine these tissue samples under a microscope to determine if the cells show any signs of change, or dysplasia.

Ambulatory pH Testing

Considered the gold standard of testing for GERD, ambulatory pH testing is the most accurate and objective test for diagnosing GERD because it actually measures acid levels in the esophagus. During the test, a small sensor is placed in the esophagus. Once in place, the sensor measures pH levels over a 24-48 hour period. Once completed, the test shows the effect that meals, activities, and sleep have on the pH levels in the esophagus that contribute to acid reflux.

Esophageal Manometry Esophageal manometry is a test used to gauge the ability of the esophagus and lower esophageal sphincter (LES) to effectively move food towards the stomach. The test measures the pressure in the esophagus as a patient swallows, allowing doctors to detect any abnormalities in the underlying anatomy of the esophagus. Manometry can detect a hiatal hernia and damage to the LES, as well as conditions like achalasia and nutcracker esophagus that may mimic GERD. Manometry or alternative testing to


assess the motility of the esophagus is required if surgery is being considered as a treatment option.

Barium Swallow A barium swallow is an x-ray examination of the esophagus, stomach, and upper part of the small intestines. Sometimes called an upper GI series, this procedure requires the patient to drink a contrast medium called barium, which coats the intestinal tract and makes it possible to see the anatomy on x-rays. A barium swallow helps the medical team identify hiatal hernias, tumors, or areas of inflammation of the esophagus and stomach.

What you should do if your GERD symptoms persist Too often, treatment for GERD begins and ends with a prescription for PPIs. If you continue to have symptoms even while on medication or if you are concerned about taking medications long-term, it’s time to pursue more aggressive testing to gain a complete understanding of your condition. Studies have validated that 32% of all PPI users are not refluxing and should not be using these powerful medications. In most cases, these individuals were either self-diagnosed or diagnosed by a physician based upon a discussion of symptoms. Unless definitive diagnostic tests are performed, you cannot be confident that you have GERD, and you are unable to make any appropriate treatment decisions.

Additional Resources What kind of doctor should I see for my acid reflux?

How do I know if I have acid reflux?

Let’s get angry together: The “PPI test” is not a diagnostic test Let’s change the headlines on reflux disease

The importance of accurately diagnosing acid reflux!

http://www.refluxmd.com/connect/physician-expert-blogs/4242/what-kind-doctor-should-i-see-my-acid-reflux?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH6.1

http://www.refluxmd.com/connect/physician-expert-blogs/3280/how-do-i-know-if-i-have-acid-reflux?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH6.2

http://www.refluxmd.com/connect/physician-expert-blogs/1863/lets-get-angry-together-ppi-test-not-diagnostic-test?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH6.3

http://www.refluxmd.com/learn/resources/2013-01-29/1094/lets-change-headlines-reflux-disease?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH6.4

http://www.refluxmd.com/learn/resources/2013-06-28/3622/editorial-importance-accurately-diagnosing-acid-reflux?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH6.5


Chapter 7 Lifestyle Choices to Treat GERD

“Lifestyle choices are recommended for anyone with reflux disease regardless of stage since they have proven to provide some level of symptom relief.”

Lifestyle choices can relieve symptoms In general, there are three categories of treatment for GERD: medication, procedural intervention, and lifestyle choices. Lifestyle choices are recommended for anyone with reflux disease regardless of stage since they have proven to provide some level of symptom relief. However as GERD progresses, these activities alone may not provide adequate relief. Therefore, if you think you may have GERD, it is important to start these lifestyle changes as early as possible

Manage Your Weight: Target a Healthy BMI

Weight gain increases the risk of GERD. To become obese, we consume too much food and the stomach distends frequently which damages the LES, leading to reflux. To make things worse, obese people carry excess weight in their abdominal wall, which increases pressure on the abdomen and the LES. Adjusting dietary intake with the objective of reducing weight will most likely reduce your heartburn. For some, even the loss of 5 or 10 pounds could make a substantial difference. For those that are very

Key Points • Lifestyle choices may

provide some symptom relief regardless of GERD stage.

• Over time, if GERD progresses, these lifestyle changes may lose some of their effectiveness.

• There are several lifestyle changes recommended by medical professionals: o Manage your

weight o Limit portions o Avoid trigger foods o Eat dinner earlier o Stop smoking o Reduce the use of

alcohol o Avoid carbonated

beverages o Wear loose fitting

pants and belts o Practice diaphragm

exercises o Elevate the head of

the bed


overweight (BMI greater than 35) weight loss surgery may be an option to consider. Some of these procedures, such as gastric bypass, can help control reflux and reduce GERD symptoms in addition to assisting in weight loss.

Limit the size of your meal portions

Portion control is on the top of every GERD expert’s list. Overeating is another activity that can put excess pressure on the LES. One way to manage your portions is to eat small meals more frequently to satisfy your appetite.

Avoid your trigger foods There are many common foods that trigger heartburn and other GERD symptoms; however, everyone is different and you should identify those foods and beverages that drive your symptoms. Once you recognize that certain foods or beverages create symptoms (coffee, chocolate, citrus, etc.), plan your meals accordingly.

Eat dinner earlier

Since it takes several hours for a meal to digest in your stomach, eating earlier allows that meal to breakdown and move out of the stomach before you recline for sleep. Avoid those late night snacks, as well, since they can restart the digestive process for a few hours.

If you smoke – stop immediately

Smoking contributes to the weakening of the LES that encourages reflux. Smoking has been proven to be a risk factor for multiple cancers, including esophageal cancer and lung cancer. Stopping smoking is not easy. Be sure to see your primary care physician for strategies to help you succeed.

Reduce or eliminate alcohol consumption Research has proven that alcohol reduces the barrier function of the LES and it can cause GERD symptoms. This research has also validated that consuming larger volumes of alcohol has an increasing impact on GERD symptoms.


Give up or limit those carbonated beverages Carbonation is another factor that can distend the stomach and put pressure on the LES. If you can’t give up carbonated drinks, then avoid drinking them during meals and in the evening.

Avoid tight fitting clothes Tight clothes or tight belts put pressure on the abdomen. This mimics the same issue that exists with an obese or overweight individual as noted above.

Diaphragm exercises As stated earlier, the LES is the barrier between the stomach and the esophagus that prevents reflux. The LES is augmented and surrounded by the diaphragm. Unlike the LES, an involuntary muscle that cannot be strengthened by exercise, the diaphragm is a voluntary muscle that can be made stronger by exercise. Although clinical research has yet to prove that exercising the diaphragm will improve the LES’s barrier capabilities, the following exercise can do no harm, and may provide some symptom improvement.

Diaphragm exercise is a conscious technique of breathing using the diaphragm, rather than using the lungs and the chest, to create each breath. This means expanding the abdomen to inhale and then contracting the abdomen without exhaling. Do this abdominal exercise 5 - 10 times, and then exhale. Repeat this process 10 times. It may help to place your hands on your abdomen to maintain the focus on the expansion and contraction of your stomach. This exercise can be done sitting, standing, or lying down. However, caution should be taken initially since excessive and deep breathing can induce hyperventilation. Hyperventilation may occur, so if you feel light-headed at any time, stop the exercise and attempt it again the next day.

Sleep and GERD symptoms

If your GERD is impacting your sleep, here are several recommendations that you should consider:

• Try sleeping on your left side rather than the right side or on your back or stomach.


• Raise the head of the bed by placing books or a brick under the headboard. The upper part of the bed only needs to be elevated 5 to 7 inches to be effective. Extra pillows or commercially available foam wedges tend to work poorly since they only bend the neck rather than elevating the entire chest.

• Stay in an upright position, sitting or standing, for at least 90 minutes after dinner. • Do not go to bed for at least 3 hours after dinner. Although this may be a difficult

recommendation to follow, it has proven to be very effective in reducing heartburn symptoms.

• Keep a bottle or glass of alkaline water (water with pH of 9 – this will be similar to using an antacid and can break up any acid pools below the LES) near your bed to sip if you awaken with symptoms or if you simply desire a drink. For some, this has deterred or stopped GERD symptoms at night.


Reducing GERD symptoms: Smoking and alcohol cessation

Elevation therapy for the treatment of reflux disease

Seven lifestyle changes to keep heartburn at bay

Young father breaks bad habits to control reflux symptoms

http://www.refluxmd.com/learn/resources/2014-02-01/7167/reducing-gerd-symptoms-smoking-and-alcohol-cessation?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH7.2

http://www.refluxmd.com/learn/resources/2013-04-03/1896/elevation-therapy-treatment-reflux-disease?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH7.3

http://www.refluxmd.com/learn/resources/2013-03-27/1798/young-father-breaks-bad-habits-control-reflux-symptoms?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH7.4

http://www.refluxmd.com/slideshow-seven-lifestyle-changes-keep-heartburn-bay?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH7.1


Chapter 8 Using Medications to Treat GERD

“When considering medication as a treatment option for reflux disease, remember that no drug can provide permanent relief.”

Make an informed decision

The use of prescription medications and over-the-counter (OTC) medications in the US is at an all time high. According to a Mayo Clinic study, nearly 70% of Americans take at least one prescription drug daily and more than half take two or more. It is safe to say that American society is overmedicated today. Many medications help people live longer and happier lives. Insulin for diabetics and antibiotics for infections are excellent examples. However, the use of medications for many chronic conditions may not be appropriate, and in many cases, patients are unaware of the potential harmful aspects of these pharmaceutical drugs. For some, the underlying conditions and/or the diseases themselves can be prevented and often treated with diet, exercise, and lifestyle modifications more effectively than by using pharmaceuticals. If you are considering using maintenance (daily-use) medications, it is essential to know as much as possible about the risks and the benefits of these drugs to make an informed decision with your physician.

Key Points • Acid reducing

medications cannot repair the damaged LES.

• Medications can only reduce or eliminate symptoms of GERD; they are not a cure for GERD.

• GERD can still progress while using medications, regardless of presence or absence of GERD symptoms.

• There are several medication options, both prescription and (OTC). The major categories of anti-reflux medications are acid neutralizers, H2 Blockers, and Proton Pump Inhibitors (PPIs).

• Each category of medication has benefits and risks. It is highly recommended that anyone considering medication treatment for GERD consult a qualified physician.

• Aim to take the lowest dosage of the least powerful medication that adequately controls GERD your symptoms.


About anti-reflux medications A brief search online can lead you to believe that permanent relief from GERD is just a quick pill or chewable tablet away. While numerous medications are available for relieving symptoms of reflux disease, be aware that these drugs are incapable of directly treating its root cause – a defective lower-esophageal sphincter (LES). Unable to prevent the back-flow of stomach contents into your LES, these medications function instead by neutralizing or reducing the amount of acid produced by the stomach. Because this treatment approach aims to control symptoms rather than address the cause of the disease, the long-term management of reflux disease through medications alone often fails. However, it is important to note that medications may also play an important role in improving patient wellness when used correctly.

Types of reflux medications

Acid Neutralizers Examples: Tums, Rolaids, Maalox, Mylanta, Alka-Seltzer

Acid neutralizers represent one of the most common types of drugs used to treat reflux disease. These over the counter medications are basic compounds (i.e. alkaline or high pH), like calcium carbonate, that provide temporary relief from symptoms by neutralizing stomach acid. They are used during reflux episodes or before eating a meal that is likely to cause heartburn. They reduce the acid level in the stomach immediately (be it for a short time period), and if used in sufficient dosage, improve the acid pH level to where GERD symptoms are reduced when reflux occurs.

Your stomach is constantly monitoring and adjusting its pH level for optimal digestion. Therefore, it responds to the change in pH level caused by acid neutralizers by quickly ramping up acid secretion to bring the pH to the body’s normal level. As a result, acid neutralizers only relieve symptoms for a short period of time. The fact that these drugs have had a large market for over five decades suggests that they are effective in controlling reflux symptoms with intermittent use.


Benefits of Acid Reducers

• Readily available over the counter • Inexpensive • Provides quick relief of mild symptoms • Can relieve symptoms during a reflux episode • Can prevent heartburn if taken before a meal that is known to produce heartburn • Safe

Concerns about Acid Reducers

• Short duration of symptom relief • Ineffective in long-term management of symptoms • Ineffective in relieving moderate to severe symptoms

Side Effects of Acid Reducers

Few side effects have been associated with acid neutralizers. In fact, some that have calcium in their formula actually can act as a nutritional calcium supplement.

Histamine-2 Receptor Antagonists (H2 Blockers)

Examples: Pepcid, Zantac, Tagamet, cimetidine, ranitidine H2 blockers are a category of drugs that work by deactivating the cellular receptors within the stomach responsible for signaling the production of acid. When the H-2 receptor is blocked, acid secretion by the cells in the stomach is decreased. If reflux occurs while this blockage is in place, the likelihood of heartburn is decreased. These drugs take longer to reduce gastric acid than acid neutralizers, but produce a more sustained acid reduction. H2 blockers are less effective than proton pump inhibitors (PPIs) in suppressing acid secretion on a long-term basis, but they act more quickly to reduce acid than PPIs. They are sometimes used with PPIs to augment the efficacy of those drugs.


Benefits of H2 Blockers • Readily available over the counter • Provide longer term relief from symptoms than acid neutralizers • Act more quickly than PPIs in reducing acid secretion • Less expensive than PPIs • Fewer complications than PPIs

Concerns about H2 Blockers

• Less effective than PPIs in the long term • Ineffective in relieving severe symptoms because the total amount of acid reduction

achieved is much lower than PPIs

Side Effects with H2 Blockers

Few side effects have been associated with H-2 receptor antagonists, with the exception of cimetidine. Users of this variant of the medication have been known to experience hypotension, headache, fatigue, dizziness, confusion, constipation, diarrhea, and/or rash.

Proton Pump Inhibitors (PPIs)

Examples: Prilosec, Prevacid, Zegarid, Nexium, Protonix, omeprazole, esomeprazole, lansoprazole

PPIs provide the most powerful method for decreasing acid production in the stomach. PPIs work by inhibiting the proton pump in the stomach’s acid-producing cells. When used correctly, PPIs can provide relief from acid reflux for 14-18 hours each day. PPIs typically require 3-4 days to begin working and are not very useful when taken to control symptoms as they occur. These drugs are generally prescribed for a period of two weeks or longer. To be effective, PPIs need to be used continuously to keep acidity levels low so that the damage and symptoms are lessened when acid reflux inevitably occurs.


Benefits of PPIs • Most powerful option for relief of acid reflux symptoms because they achieve the best

control of acid secretion available • Provide longer-term relief from symptoms than other medications • Heal erosive esophagitis and prevent ulceration and stricture formation in the

esophagus.

Concerns about PPIs

• FDA warning label includes concerns with long-term use of PPIs that include an increased risk of bone fractures, vitamin B12 deficiency, increased incidence of C-Difficile infections, and magnesium deficiency.

• May increase severity of symptoms if treatment is discontinued because of a rebound acid secretion when the drug is withdrawn

• Ineffective for quickly treating symptoms as they occur • Does not address the cause of reflux disease. LES damage is permanent and not

reversed by PPIs. • Does not prevent Barrett’s esophagus or cancer

Side effects with PPIs

Direct side effects may include headache, diarrhea and abdominal pain. Long-term side effects may include increased risk of hip fracture, increased risk of Clostridium difficile (C. diff) infection, and interactions with other medications.

No drug can provide permanent relief When considering medication as a treatment option for reflux disease, remember that no drug can provide permanent relief. Though these medications can help control symptoms, they do not address the cause of acid reflux, a damaged or defective LES. Additionally, complications of reflux disease such as Barrett’s esophagus and esophageal cancer are not addressed through medication. Remember, improving your diet, losing weight, and making other lifestyle modifications can have a profound effect on your day-to-day symptoms and overall health, without exposing you to potential side


effects or health complications. Consult your doctor before beginning and/or stopping any drug treatment regimen for reflux disease.

Additional Resources What you should know before taking PPIs

How GERD medications work: Gastric acid reduction

Medications to control GERD symptoms: Pros and Cons

Are long-term PPIs ever the right choice for my GERD symptoms?

Case study: Ten years of PPIs - now what?

http://www.refluxmd.com/learn/resources/medications-tool-manage-symptoms?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH8.1

http://www.refluxmd.com/connect/physician-expert-blogs/1567/how-gerd-medications-work-gastric-acid-reduction?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH8.2

http://www.refluxmd.com/connect/physician-expert-blogs/1566/medications-control-gerd-symptoms-pros-and-cons?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH8.3

http://www.refluxmd.com/connect/physician-expert-blogs/6975/are-long-term-ppis-ever-right-choice-my-gerd-symptoms?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH8.4

http://www.refluxmd.com/learn/resources/2013-10-16/5678/case-study-ten-years-ppis-now-what?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH8.5


Chapter 9 Surgical Alternatives for GERD

“The objective of the surgical and endoscopic procedures for GERD is to restore the integrity of the damaged LES to stop reflux.”

Surgical alternatives repair the LES Unlike acid suppressive medical therapy, the objective of the surgical and endoscopic procedures for GERD is to restore the integrity of the damaged LES to stop reflux. This consists of augmenting or repairing the LES’s function to restore its barrier capabilities and achieve a permanent correction. Surgical alternatives should reduce or eliminate symptoms and stop stomach contents from reaching the esophagus. The goal is to stop all reflux, which can be validated by a post-operative pH study. The complete cessation of reflux will result in the elimination of GERD symptoms and the elimination of the need for medications. However, if reflux is not completely eliminated, symptoms and medications should be significantly reduced. With each procedure, the desired outcome must be balanced with risks, side effects, and durability.

Laparoscopic Procedures

Nissen Fundoplication The “gold standard” to which all anti-reflux procedures

Key Points • Surgical and procedural

alternatives directly address the underlining cause of GERD by restoring the barrier between the esophagus and the stomach.

• The Nissen Fundoplication is the “gold standard” for LES repair.

• Newer procedures include: o LINX Reflux

Management System

o Transoral Intraluminal Fundoplication (TIF)

o Stretta • When performed by an

experienced surgeon, these procedures can be highly effective at stopping reflux and reducing/eliminating the need for medications.


are compared is the laparoscopic Nissen fundoplication. This minimally invasive surgical procedure is performed under general anesthesia via several small incisions. A slender scope (laparoscope) is inserted into the abdomen that produces a high-resolution image on a monitor which the surgeon carefully observes as he performs the procedure. The procedure involves repairing the hiatal hernia (typically present) and recreates a functional valve by wrapping part of the stomach around the lower esophagus at the site of the LES. The procedure takes approximately 1-2 hours with an overnight stay in the hospital. Most people are back to light, “every day” activity within a week. A successful laparoscopic Nissen fundoplication stops the reflux approximately 80-85% of the time and typically 90% of all patients are satisfied with the procedure after 5 years. Side effects can include excess gas and bloating, as well as the inability to belch or vomit. The Nissen stops the reflux with reliability above all other existing therapies.

LINX Reflux Management System

The FDA approved the Linx Reflux Management System in March 2012. This procedure is performed using the same minimally invasive technique as the Nissen; however, it is much less complex and is performed on an outpatient basis and may not require a hospital overnight stay. The LINX device is a specially designed “bracelet of magnetic beads” that is placed loosely around the esophagus, augmenting the damaged LES. As food passes into the stomach, the magnetic beads separate allowing swallowed contents to pass into the stomach and then close, preventing reflux. The procedure takes approximately 30 minutes and patients return home the same day. The results are similar to the Nissen, but with minimal side effects. Presently, this procedure is only available at select centers, but availability is expected to expand rather quickly. This procedure is also reversible. Since the LINX procedure is new, there is no long-term outcome data available.

Endoscopic Procedures


There are several procedures designed to repair the sphincter. They are performed orally (through the mouth) and are classified as endoscopic anti-reflux procedures. There are no abdominal incisions. Several of these have been introduced in recent years and RefluxMD will comment on them as clinical evidence is available. Transoral Intraluminal Fundoplication The transoral intraluminal fundoplication (TIF), sometimes referred to as Esophyx, is one such procedure that is available today. Under general anesthesia, a special endoscope is used to perform a partial fundoplication from inside the stomach. This procedure been available for several years and improves GERD symptoms in most patients. It is not as effective as the Nissen fundoplication, but it improves symptoms and decreases medication requirements in most patients with few side effects. Additionally, the side effects of the TIF procedure are substantially less than a Nissen, making it attractive for many seeking a surgical procedure.

Stretta Sretta’s technology uses radiofrequency waves to remodel tissue and improve muscle tone in the LES. The procedure involves lowering a radiofrequency transmitter device to the LES. Once in place, a mini-balloon inflates and begins to deliver radiofrequency energy to the muscle tissue. The patient is under conscious sedation while the procedure is being administered and is able to return to their normal lifestyle the following day, without any overnight stays in the hospital. The full impact of the Stretta is not realized until 2-6 months after the procedure when the esophagus is fully healed.

Conclusion Understanding each of the available surgical and endoscopic treatments for GERD is difficult. Conflicting information and data exists about each procedure and the information you receive may be confusing at times. You should contact a reflux expert for education on these procedures. A qualified GERD surgeon will discuss the facts regarding each treatment alternative so that you can make an informed decision. If you


elect a surgical alternative, you should have the procedure performed by a GERD expert who has performed many successful procedures.

Additional Resources GERD Treatment: Procedures at-a-glance

When should I consider surgery for acid reflux?

How do I select a doctor for my anti-reflux surgery?

Why I chose LINX

A foodie chooses surgery to stop his reflux once and for all

http://www.refluxmd.com/learn/resources/2013-06-06/3139/gastroesophageal-reflux-disease-gerd-treatment-procedures-glance?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH9.1

http://www.refluxmd.com/connect/ask-dr-dengler/when-should-i-consider-surgery-acid-reflux?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH9.2

http://www.refluxmd.com/connect/ask-dr-dengler/what-should-i-ask-choosing-doctor-perform-my-anti-reflux-surgery?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH9.3

http://www.refluxmd.com/learn/resources/2014-02-17/7420/foodie-chooses-surgery-stop-his-reflux-once-and-all?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH9.4

http://www.refluxmd.com/learn/resources/2014-04-10/8388/why-i-chose-linx?utm_source=gerdguide&utm_medium=pdf&utm_campaign=CH9.5


Chapter 10 Complications if GERD is Not Treated Properly

“The risk of developing esophageal cancer is small, but also very real.”

GERD can progress to cancer

GERD is a progressive disease and as such, the risk of complications increases with its duration. The main complication that most clinicians worry about is cancer, and its precursor, Barrett’s esophagus.

Adenocarcinoma, reflux-induced esophageal cancer, is the most rapidly increasing cancer in the Western World. This cancer has increased more than six-fold in the USA between 1975 and 2000 and continues to increase each year. Many GERD experts estimate that approximately 20,000 people in the USA will develop this cancer in 2014. What’s worse is that esophageal adenocarcinoma is one of the most lethal human cancers. Approximately 85% of those who develop esophageal cancer die of their disease, often within 1-2 years of diagnosis.

The risk of developing cancer is small, but

also very real At the outset, several facts should be emphasized:

1. Deaths from esophageal cancer are increasing, and yet they remain small as a percentage of all adults

Key Points • GERD is a progressive

and irreversible disease that can lead to esophageal cancer.

• Esophageal cancer is the most rapidly increasing cancer in the western world.

• The risk of esophageal cancer is low, but because the risk is low, there is very little screening performed on early stage GERD patients.

• Early detection of precancerous conditions such as Barrett’s esophagus improves the survival rate substantially.

• If you’re been diagnosed with Barrett’s esophagus, regular screening is critical to catch any additional cellular changes.

• If precancerous cells are found, ablation treatment is the most recent and promising procedure for this condition.


with GERD symptoms. However, the probability of cancer increases with each of the following risk factors: males, age of 55 or older, disease term of over 10 years, smoking, drinking, obesity, and/or a diagnosis of Barrett’s esophagus (a pre-cancerous condition).

2. The very small risk of getting cancer has made physicians complacent. The management guidelines for treating GERD basically ignore the risk of cancer. While this may be appropriate, it is a devastating policy for the 20,000 people who are destined to get cancer in 2014. No effort is made by present treatment guidelines to identify those at risk and to assist them to do whatever is possible to decrease the chance of death. This policy is certainly not optimal, and researchers are working to identify indicators that predict those who are more likely to get cancer.

3. There is evidence of a method to decrease the likelihood of death from GERD induced cancer. This is to detect a premalignant condition called Barrett’s esophagus by performing endoscopy and biopsy. Once Barrett’s esophagus is identified, putting those individuals on surveillance permits early detection of cancer if it occurs. Early detection allows treatment by minimally invasive techniques rather than major surgery. As with many cancers, early detection increases the chance of cure.

Long-term symptoms increase the likelihood of complications Unfortunately, endoscopy cannot be recommended for everyone displaying symptoms of GERD due to the excessive cost burden on the US healthcare system. However, we can identify high risk factors that increase the likelihood of progressing to Barrett’s esophagus. One such risk factor is the time duration of this disease. Those experiencing symptoms for more than ten years should view this as a significant warning flag, regardless of the strength of the symptoms. However, it should be noted that stronger and more frequent symptoms present a greater likelihood of progressing to Barrett’s esophagus and / or cancer in the future.


If you have experienced symptoms for over ten years, particular diligence and awareness of your disease is recommended. It is now time for you to take ownership and control of your disease and determine if you have Barrett’s esophagus. This is true whether or not your symptoms are controlled by drug therapy. Medications do not stop the progression of GERD and do not significantly decrease your risk of developing Barrett’s esophagus or adenocarcinoma.

Consider endoscopy if you’ve had symptoms for more than ten years If you have had reflux symptoms or have taken antireflux medications for over 10 years, irrespective of any other factors, consider undergoing endoscopy to determine if you have Barrett’s esophagus. In most cases, this test will be negative, but regardless, this is valuable information, and it is an important screening test for those at risk. If you have Barrett’s esophagus then you should establish a “surveillance protocol”, which will improve your chances of survival if you are one of the unlucky people who develops esophageal cancer. The most common surveillance is observation with repeated endoscopies as often as once every one to three years. The objective is to detect progression of any abnormality that could indicate a transition to cancer. Early identification of dysplasia (low-grade and high-grade), or even an early stage cancer, offers an enhanced chance of treating the abnormality compared to later-stage detection.

Ablation for Barrett’s Esophagus Rather than participate in the traditional surveillance program, other management strategies for Barrett’s esophagus have been developed. The most recent and promising is called radiofrequency ablation (sometimes referred to as RFA, ablation, or Halo). This procedure involves using very controlled radiofrequency energy to eliminate or “ablate” the areas where Barrett’s have developed in the normal lining of the esophagus. Once the Barrett’s tissue is eliminated, the normal lining of the esophagus regenerates over several months.


What happens during the ablation procedure? The ablation is done under sedation, in conjunction with a standard endoscopy. After precisely locating the area of Barrett’s tissue, a tube-shaped balloon, 3cm in length and containing special electrodes, is inserted through the mouth and into the esophagus. The electrodes are then positioned to contact the area with Barrett’s tissue. A short burst of energy, less than 1 second, is delivered to the balloon’s electrodes and the undesirable Barrett’s tissue is ablated. Several areas can be treated at a single setting but most patients must return for one or more additional treatments to assure that all of the areas of Barrett’s have been ablated.

After the procedure, patients are given a prescription for twice daily PPIs to control the symptoms of reflux. The ablation procedure does not affect the symptoms of reflux. The patients return yearly for endoscopies to ensure Barrett’s does not return. If it does, the area can be retreated.

Is ablation safe?

RFA is generally a safe procedure if performed correctly. There is some chest discomfort for several days following treatment. Occasionally a narrowing of the esophagus might develop that can be treated with a simple procedure called dilation. The greatest concern is that there could be Barrett’s tissue located deeper in the esophageal wall that survived ablation. When the normal esophageal lining grows back there is a possibility that this deeper Barrett’s tissue can remain and be active beneath that new lining. The term for this is “buried glands.” This can be a potential problem since these glands cannot be seen through the endoscope, yet they carry the cancer risk associated with Barrett’s. However, research to date suggests that this occurs only rarely with RFA.

Is ablation effective? Extensive research suggests that RFA either prevents or delays the progression of Barrett’s esophagus to a more serious state, including cancer. However, all of the research studies recommend follow-up endoscopies at specific time intervals such as 6


months, 2 years, or 3 years. Since medical experience with the procedure has been less than 20 years, sufficient evidence has not been gathered to conclusively prove that RFA prevents cancer. To date, the medical literature supports the premise that RFA makes the development of cancer less likely. The caveat is that ablation must be performed by an experienced physician on patients who will reliably return for follow-up endoscopies and be retreated if indicated.

If you are diagnosed with Barrett’s esophagus, it’s important that you understand the condition, the risk of cancer, and the management options available to you. Talk to your doctor if you think RFA might be right for you.

Additional Resources Inside your esophagus: The damage caused by GERD

If you’ve been diagnosed with Barrett’s esophagus

Defining esophageal cancer

Are we being honest with GERD patients?

The role of biopsies is the diagnosis of GERD

Esophageal cancer survivor offers hope

http://www.refluxmd.com/learn/resources/2013-08-22/4871/inside-your-esophagus-damage-caused-gerd?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH10.1

http://www.refluxmd.com/learn/resources/2012-09-19/368/if-you%E2%80%99ve-been-diagnosed-barretts-esophagus?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH10.2

http://www.refluxmd.com/learn/resources/2012-10-24/533/defining-esophageal-cancer?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH10.3

http://www.refluxmd.com/connect/physician-expert-blogs/5185/are-we-being-honest-gerd-patients?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH10.4

http://www.refluxmd.com/learn/resources/2013-02-20/1425/role-biopsies-diagnosis-gerd?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH10.5

http://www.refluxmd.com/learn/resources/2013-02-18/1417/esophageal-cancer-survivor-offers-hope?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH10.6


Chapter 11 Home Remedies to Manage Your Symptoms

“Some patients claim they’re able to manage their symptoms through treatments not found in the neighborhood pharmacy. Instead, many pay a visit to their home pantries.”

Alternatives to traditional medicines When choosing a treatment for acid reflux, alternatives to traditional pharmaceuticals are often overlooked or ignored. While medications are the most common treatment method for reflux, some patients claim they’re able to manage their symptoms through treatments not found in the neighborhood pharmacy. Instead, many pay a visit to their home pantries.

The following list provides an overview of several home remedies that have been reported to reduce the symptoms of reflux. Since everyone is different, it is not possible to predict if these will work for you. Scientific research into the effectiveness of these alternative treatments is ongoing, and the evidence to date is largely anecdotal – with the exception of baking soda and chewing gum. Though some individuals have reported relief from heartburn with alternative remedies, consult your doctor before trying any of these. There is always the possibility that your symptoms could be caused by something other than GERD and using these remedies could delay finding

Key Points • While medications are

the most common treatment method for reflux, some patients turn to home remedies to manage their symptoms.

• Baking soda and chewing gum are proven to reduce GERD symptoms.

• Other popular home remedies include: o Apple cider vinegar o Ginger o Licorice o Chili peppers o Alkaline water o Coconut oil

• The evidence supporting the effectiveness of these remedies is largely anecdotal.

• Be sure to talk to your doctor before changing your medication or trying an alternative remedy.


the definitive cause.

Baking Soda Similar to many acid reflux medications, baking soda alleviates symptoms by reducing the acidity of your stomach acid. A proven alternative treatment, the alkalinity of baking soda allows it to temporarily neutralize stomach acid, resulting in less painful and noticeable symptoms if the stomach contents reflux into the esophagus. To try this remedy, dissolve a heaping teaspoon of baking soda in 8-12 ounces of water and drink the mixture. However, there are some drawbacks. First, this remedy tastes terrible! Try adding a touch of honey or sugar to offset the unpleasant taste of the baking soda. Second, the overuse of baking soda can produce an excess of digestive gases, resulting in increased belching, bloating, stomach cramps, and slight pain or discomfort.

Gum Chewing Temporary relief from reflux symptoms might be as simple as following up a meal with a stick of gum. Independent scientific studies have found that patients who chewed gum for 30 minutes to an hour immediately after meals experienced a noticeable decrease in symptoms. It’s believed that the increased saliva caused by chewing gum has the effect of clearing acidic and painful reflux contents from the esophagus. Additionally, the alkaline nature of saliva can help neutralize the stomach acid before it passes into the esophagus. It is also recommended to avoid peppermint or spearmint flavored chewing gum since they are known to make symptoms worse.

Apple Cider Vinegar As a sufferer of acid reflux, the idea of consuming an acidic substance like apple cider vinegar might not sound appealing. Yet, many individuals swear by its effectiveness in alleviating symptoms. Despite anecdotal evidence of apple cider vinegar’s effectiveness, the science behind these claims is not substantiated due to a lack of research on the subject. Some believe that by helping to balance the stomach’s acidity, the vinegar may prevent the stomach from overcompensating with excess acid. Be warned however, the taste of this remedy makes it difficult to drink. Mixing a tablespoon


of apple cider vinegar with honey and water can make this home remedy easier to swallow.

Ginger Used as an herbal treatment for a variety of ailments, ginger is sometimes taken to alleviate acid reflux symptoms. While there is no “hard” evidence suggesting that ginger has any effect on reflux, it’s thought to have a calming effect on digestion, thus giving some users relief. A warm cup of ginger tea is a simple and relaxing way to consume the herb. Just make sure to avoid ginger teas containing caffeine, as it can make your symptoms worse.

Probiotic Supplements If you’ve visited the dairy section of your local grocery store lately, it’s likely that you’ve come across probiotics. Typically found in yogurts and dietary supplements, probiotics are living organisms, much like yeast, that are thought to be beneficial for the body’s digestive systems. Research into the potential benefits of probiotics for reflux is ongoing. However, some researchers have theorized that a daily probiotic supplement can strengthen the lining of the gastrointestinal (GI) tract, potentially protecting it from harmful bacteria and excess acid.

Alkaline Water Some GERD suffers find that at the onset of heartburn, a few swallows of water may sometimes work to relieve heartburn. This may be a result of the water neutralizing and rinsing away the acids that have found their way into the esophagus. Of course, if a meal portion was too large, this water may also add to the contents of the stomach, aggravating an existing problem of an overfilled stomach. Tap water has a neutral pH of 7 and alkaline water typically has a pH of 9 indicating that it is 100 more basic, or less acidic. Thus, alkaline water has similar characteristics to baking soda in water in that it can reduce stomach acid.


Chili Peppers Chili peppers have been used as a digestive aid in cultures around the world for centuries. Capsaicin, the compound in peppers responsible for the heat, has been shown to relieve pain and itching, boost weight loss relief, and fight inflammation. One study even found that capsaicin seems to slow the growth of prostate cancer. So what does this have to do with heartburn? Well, while spicy food can be a trigger for some people, some studies have shown that capsaicin can actually reduce heartburn symptoms. Capsaicin binds to receptors present in the cells of the stomach called TRPV1 receptors. This binding has many physiologic effects, including increased gastric motility and emptying. When you increase the rate at which the stomach empties during a meal, you prevent it from filling and placing excess pressure on the LES, thereby decreasing reflux.

Licorice When people refer to taking licorice for heartburn relief, they’re usually talking about an herbal supplement and not the candy. In fact, most of the licorice candies you find in the grocery store aisle do not contain licorice “extract” (and if they do, it’s usually clearly marked on the label). Licorice is marketed as a remedy for a variety of gastrointestinal issues, including ulcers, heartburn, and gastritis. Like most herbal remedies, there hasn’t been much clinical research into the effectiveness of licorice. According to the National Medicines Comprehensive Database, licorice has been rated as “possibly effective” for heartburn relief based on the study of a supplement that included licorice and a variety of other herbs. However, excessive consumption of licorice extract can be toxic. Licorice contains a substance called glycyrrhizic acid, which has been linked to headaches, swelling, sodium retention, loss of potassium, and high blood pressure. So if you try this home remedy, be sure to go slow and take it in moderation.

Coconut Oil Some experts believe that coconut oil suppresses the appetite and quickly gives your stomach a feeling of being full. This decreases the desire to ingest more food and


encourages smaller portions at mealtimes. It is well known that overeating can trigger acid reflux; too much food in the stomach creates pressure, and the pressure forces acid up into the esophagus resulting in pain and burning sensations. Eating smaller portions is one of the keys for avoiding acid reflux symptoms. If you want to try coconut oil, substitute the amount of oil you use daily with extra virgin coconut oil. For instance, if a recipe calls for 2 tablespoons of butter, margarine, vegetable or olive oil, simply replace it with the equal amount of coconut oil.

Use caution and talk to your doctor As mentioned earlier, there is very little scientific evidence supporting the effectiveness of these home remedies as treatment alternatives for GERD. We encourage you to discuss these with your doctor before you use them to treat your reflux. But you never know, you might just find something in your pantry that works for you!

Additional Resources An alternative treatment for GERD

Natural remedies for acid reflux: Probiotics

Can water stop GERD symptoms?

Apple cider vinegar for acid reflux

Eight natural remedies for acid reflux

http://www.refluxmd.com/learn/resources/2012-12-05/851/alternative-treatment-gerd?utm_source=gerdguide&utm_medium=pdf&utm_campaign=CH11.1

http://www.refluxmd.com/learn/resources/2014-03-12/7819/natural-remedies-acid-reflux-probiotics?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH11.2

http://www.refluxmd.com/slideshow-eight-natural-remedies-acid-reflux?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH11.3

http://www.refluxmd.com/learn/resources/2013-10-25/5809/can-water-stop-gerd-symptoms?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH11.4

http://www.refluxmd.com/learn/resources/2013-05-01/2427/apple-cider-vinegar-acid-reflux?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH11.5


Chapter 12 The Importance of a GERD Friendly Diet

“Watch how much you eat, what you eat, and maintain a healthy BMI and you might be surprised how good you feel with fewer GERD symptoms.”

Your diet is critical Diet is a highly discussed topic relative to GERD. To avoid symptoms, most people focus on WHAT they eat; however, HOW MUCH you eat along with your BMI (body mass index – weight to height index) is equally important. These three factors not only drive the symptoms of acid reflux symptoms, but they are highly related to your overall health, as well. One of the first recommendations of most GERD experts to their patients pertains to developing a GERD-friendly diet that balances “what you eat” and “how much you eat.” Managing acid reflux symptoms without addressing diet changes is inviting long-term health issues, including the potential progression of GERD.

The ideal GERD friendly diet has several attributes:

• It avoids known trigger foods that increase the likelihood of GERD symptoms.

• It targets the appropriate number of calories to achieve or maintain a target BMI.

• It is low in saturated fats, cholesterol, and total fat.

Key Points • Maintaining a healthy

weight is an essential part of managing GERD.

• A low-sodium and low-fat diet that steers clear of trigger foods will be most effective in reducing GERD symptoms and being healthier in general.

• GERD Diet Strategies: o Eat smaller portion

sized meals. o Chew your food

longer and take more time in-between bites.

o Resist fatty foods. o Avoid your triggers. o Skip carbonated

drinks. o Aim to eat healthy

foods. o Limit alcohol.


• It is rich in fish, poultry, beans, seeds, and nuts. • It focuses on fruits, vegetables, and fat-free or low-fat dairy products. • It contains fewer sweets, added sugars, sugary and carbonated beverages, and

red meats.

Although sodium is not a known GERD concern, it is an important overall factor for good health and weight management. As such, any GERD diet should also target lower sodium consumption than the typical American diet.

How much you eat matters Obesity is one factor most experts believe is driving the increase in acid reflux in adults. However, even a few extra pounds can contribute to increased GERD symptoms. An over-filled stomach is the most common cause of reflux. Excessive consumption puts upward pressure on the LES from below, causing the stomach contents to rise. While a healthy LES can tolerate a lot of pressure and resist heavy meals without leading to reflux, a partially damaged LES can deteriorate over time, allowing reflux with smaller and smaller meals. Long-term reflux sufferers are very familiar with this phenomenon.

What you eat matters too Certain foods are harder to digest and stay in your stomach for a longer period of time, increasing the likelihood of an episode of reflux. Foods high in fat digest slower and stay in the stomach longer. Although GERD is not a reversible condition, eating smaller meals with less fat content can decrease the frequency of reflux along with the resulting symptoms like heartburn. For example: you are more likely to get heartburn after eating a double, 75% lean cheeseburger than if you eat a single 90% lean hamburger patty; or if you ate a salad with low-fat dressing versus a salad with high-fat dressing. Eating less and consuming less fatty meals will reduce GERD symptoms and may also help to decrease your body weight, so you are “killing two birds with one stone”.


Trigger Foods Consuming a “trigger food” can cause quick onset of painful symptoms. Fortunately, this close relationship between your diet and GERD-related symptoms can work to your advantage when searching for relief. With a little work and some trial and error, you can identify foods and beverages that aggravate your acid reflux. Likewise, you can also find and identify items that may alleviate your symptoms, too.

As indicated earlier, any food that is high in fat might trigger your symptoms since it takes longer for your body to fully digest fat. A classic example to highlight as a meal to avoid is a double cheeseburger, fries, and chocolate malt. Fatty foods also include dairy products such as cheeses, butter and cream – so watch out for those as well.

Citrus fruits are well known trigger agents for those with GERD. Tomatoes and anything that is tomato-based should be avoided. Chocolate is a known troublemaker and anything with mint flavoring can be very tough on your stomach, as can spicy foods.

Most people hate to see alcohol on this list, but it must be near the top. Not only is it a trigger food, but alcohol can also relax the lower esophageal sphincter (LES), which can promote more reflux episodes. Red wine, which has some reported heart benefits, can be particularly problematic for those with GERD.

But rather than focus on what you CAN’T EAT, let’s talk about what you can, and should be eating. More non-citrus fruits and vegetables will reduce your symptoms, which are essential to a healthy body as well. As for main courses, replace high fat beef with lean meats, skinless poultry and fish.

Strategies to Manage Your Diet

Keep a diet journal If you’re not sure which foods contribute to your acid reflux, a written log of what you’re eating can be a simple way to narrow down the culprits.


Eat small meals

This may mean that you eat more, smaller meals each day rather than three large meals. You will be surprised how little food is required to appease your hunger urge. Slow it down Eating too quickly places stress on your stomach and often causes symptoms to flare up. Resting your fork between bites is an easy way to slow down your pace. Read the food labels

Check the fat content on the food package label; use less cheese, butter, and cream in food preparation. Ask for the nutrition information when dining out to learn more about what you pick from the menu. Identify your triggers Avoid your particular “trigger” foods that make your heartburn worse. These foods may include citrus fruits, tomato-based foods, chocolate, mint flavoring, caffeine, and spicy foods. Avoid carbonated beverages Avoid carbonated beverages, which contribute to over distension of the stomach. Chose healthy foods and drinks Consume foods that have a lower likelihood of triggering acid reflux such as fresh (non-citrus) fruits, vegetables, lean meats, fish, skinless poultry, and drink fruit juices as well as herbal tea.


Limit alcohol Avoid high volumes of alcoholic beverages including beer and wines, especially red wine, which has been known to trigger heartburn. Developing a healthy GERD friendly diet is important to reduce your symptoms and for a longer, healthier life. Watch how much you eat, what you eat, and maintain a healthy BMI and you might be surprised how good you feel with fewer GERD symptoms.

Additional Resources Why diet matters for ALL people with GERD

GERD and your diet: The importance of portion control

Acid reflux: Identifying the triggers of your reflux disease

Rethink what you drink: Alcohol and acid reflux

Marathoner winning race against reflux disease

http://www.refluxmd.com/connect/physician-expert-blogs/2558/why-diet-matters-all-people-gerd?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH12.1

http://www.refluxmd.com/learn/resources/2013-04-18/2158/gerd-and-your-diet-importance-portion-control?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH12.2

http://www.refluxmd.com/learn/resources/2012-08-13/242/acidreflux-identifying-the-triggers?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH12.3

http://www.refluxmd.com/learn/resources/2013-03-13/1654/rethink-what-you-drink-alcohol-and-acid-reflux?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH12.4

http://www.refluxmd.com/learn/resources/2012-10-19/492/marathoner-winning-race-against-reflux?utm_source=gerdguide&utm_medium=pdflink&utm_campaign=CH12.5


Chapter 13 Lets Get Started: Next Steps to Relief and Better Health

“Your disease is YOUR responsibility. Get started now! Don’t wait until your quality of life deteriorates and treatment doors close to you.”

Take control of your GERD As we have stated earlier, GERD is a long-term chronic condition. It is a progressive disease that can significantly reduce the quality of your life. If untreated, for some, it may also become much more serious and life threatening. That sounds bad – right? But there is so much you can do to manage your disease if you have GERD. So let’s get started today! RefluxMD’s Six-Step Process I hope that you have decided to begin managing both your symptoms and your disease. What you do now can significantly impact the quality of your life today and in the years to come. Unfortunately, many people ignore their symptoms (or worse, mask their symptoms with medications) and some will certainly regret that decision. The great news for you is that many people with terrible symptoms have found relief and improved their health – and so can you. These six steps outline your roadmap to success. With assistance from others

Key Points • If GERD is left untreated,

it may also become much more serious and life threatening.

• To manage the disease you must create a plan: o Educate yourself

about the disease. o Find your GERD

Stage with the RefluxMD assessment.

o Build your support team.

o Understand all of your treatment options.

o Develop a plan of execution. Find the most practical path for realistic implementation.

o Find a GERD expert who really understands the disease.


and a small investment of your time, you can build your personal plan and begin to improve your quality of life.

Step #1 Learn as much as you can about your disease and treatment options Whatever symptoms you have, heartburn, chronic cough, regurgitation, etc., it’s not just a nuisance, so dig in and learn more about all aspects of this disease and possible treatments. RefluxMD has developed summary pages to access articles on the following topics:

The Causes of GERD - refluxmd.com/learn/causes Symptoms and Diagnosis – refluxmd.com/learn/symptoms GERD Medications – refluxmd.com/learn/medications Home Remedies – refluxmd.com/learn/remedies GERD Procedures – refluxmd.com/learn/procedures GERD Complications – refluxmd.com/learn/complications GERD Diet – refluxmd.com/learn/diet GERD Friendly Recipes – refluxmd.com/learn/acid-reflux-recipes Personal Stories – refluxmd.com/learn/real-life-stories

There are hundreds of articles and stories on RefluxMD’s website, so take your time and pick a few interesting articles every day or a few times each week until you believe that you have a good basic understanding of each topic.

Step #2 Find your GERD stage

Chapter 5 outlined the various GERD stages. Your options and treatment alternatives to manage your disease are all dependent on your GERD stage. Your choices concerning diet, lifestyle, medications, surgeries, and other treatment alternatives become more limited as your disease progresses. So determine your GERD stage

http://www.refluxmd.com/learn/causes?utm_source=gerdguide&utm_medium=pdf&utm_campaign=CH13.1

http://www.refluxmd.com/learn/symptoms?utm_source=gerdguide&utm_medium=pdf&utm_campaign=CH13.2

http://www.refluxmd.com/learn/medications?utm_source=gerdguide&utm_medium=pdf&utm_campaign=CH13.3

http://www.refluxmd.com/learn/remedies?utm_source=gerdguide&utm_medium=pdf&utm_campaign=CH13.4

http://www.refluxmd.com/learn/procedures?utm_source=gerdguide&utm_medium=pdf&utm_campaign=CH13.5

http://www.refluxmd.com/learn/complications?utm_source=gerdguide&utm_medium=pdf&utm_campaign=CH13.6

http://www.refluxmd.com/learn/diet?utm_source=gerdguide&utm_medium=pdf&utm_campaign=CH13.7

http://www.refluxmd.com/learn/acid-reflux-recipes?utm_source=gerdguide&utm_medium=pdf&utm_campaign=CH13.8

http://www.refluxmd.com/learn/real-life-stories?utm_source=gerdguide&utm_medium=pdf&utm_campaign=CH13.9


before you start to develop your viable alternatives. You can determine your GERD Stage at refluxmd.com/assess-your-reflux/terms.

Step #3 Build your support team Your path to relief and good health will be difficult and you will need help along the way. A high quality and knowledgeable support team should include a GERD expert, your spouse (if married), your family, your friends and possibly your co-workers. With their support you will have all the power you need to stay on a plan and on task. We also hope that you will include RefluxMD as part of your team.

Step #4 Identify and research all your treatment options

There are a wide variety of options available for those in GERD Stage 1 with fewer realistic options available as the disease progresses. Your new knowledge of reflux disease together with your GERD stage will result in a list of possible alternative treatment plans that can include diet modifications, weight loss, lifestyle changes, medications, and procedures.

Step #5 Develop your plan to relief and good health Be realistic as you develop your plan from all the alternatives available. How many changes can you realistically manage at one time, or do you develop a schedule of changes over a longer time period? If you do not think you have the discipline to lose weight at this time, then focus on something else like avoiding trigger foods. Aim for short-term success and build on your victories over time. Establish some goals, both in terms of the change you adopt (lose one-pounds per week for ten weeks) and in terms of your symptoms (10% improvement in symptom-free days). Set up a tracking plan for your goals and record your results daily or weekly. Make an appointment with yourself


once each month to review your goals, check your progress, and revise your plan if necessary. With your plan in place, be sure to discuss this with your doctor.

Step #6 Engage a GERD expert Most of us understand that if we have a heart condition we engage a cardiologist. For cancer, we would visit an oncologist. Unfortunately, most people that suffer with constant heartburn or other symptoms of reflux disease trivialize their condition and seek the counsel of their family practitioner. Unfortunately, most generalists are not experts on GERD and none of them can accurately diagnose the disease. Since this is a progressive, chronic condition, you must first confirm your diagnosis and then get accurate information with full disclosure so you can manage your disease. It is estimated that only 70% of those with GERD symptoms see a physician, and the majority of those exclusively see a family practice doctor. Since this is YOUR disease and it is YOUR responsibility to manage it – find the best resource you can and include that specialist on your team.

What are you waiting for? There you have it, six steps to begin your process of managing your GERD. Take your time and do it right. Thoughtful action will be more effective than rapidly jumping into a disjointed set of changes hastily put together. Recognize that some activities will only minimize or eliminate symptoms, others may slow the progression of the disease, and some will address the fundamental problem. These decisions are yours and yours alone. But with the right support team and experts working with you, you too can realize an improved quality of life for many, many years to come.

Additional Resources OK, you have GERD. Let’s do something about it!

GERD Stage Assessment

http://www.refluxmd.com/its-time-you-get-started?utm_source=gerdguide&utm_medium=pdf&utm_campaign=CH13.10

http://www.refluxmd.com/take-action/assess-your-reflux/terms?utm_source=gerdguide&utm_medium=pdf&utm_campaign=CH13.11


Appendix A The Pasadena Protocol: The GERD Patient’s Bill of Rights

1. Educated and empowered patients are essential to success.

Knowledge is power. When it comes to choosing safe and effective treatment options for the long-term management of reflux disease, no saying could be truer. Unfortunately, healthcare cost containment today makes it impractical for medical practitioners to provide sufficient patient education.

By providing comprehensive information and education on reflux disease via the Internet and resources like this, physicians can fill the knowledge gap between patient and practitioner. This must include information on all treatment options, medications, symptoms, research results, and new treatment developments.

2. Reflux disease sufferers deserve an assessment of their disease along with

relevant recommendations.

Successful treatment of reflux disease relies on a successful diagnosis. But the progressive nature of the disease, combined with the likelihood for a misdiagnosis, requires specific and personalized recommendations. Every patient with reflux disease should be appraised of their GERD status since that determines what treatment options are available. Based upon that stage, relevant information and recommendations – like meeting with a qualified specialist who can re-confirm the disease’s status and approve further recommended treatments – are then made available.

3. Knowledgeable GERD experts should treat those with reflux disease.

Reflux disease is most often diagnosed by general practice or family physicians. In almost all cases, these generalists do not have the specialized equipment to perform the necessary diagnostic tests and definitively confirm GERD.


Unfortunately, only a small percent of those suffering from GERD ultimately visit a reflux disease specialist. As a result, the disease can be misdiagnosed, resulting in inappropriate treatment. Anyone with reflux disease should seek out a reflux disease specialist for accurate diagnosis and information on all aspects of the disease and its treatment.

4. Powerful anti-reflux medications must be appropriately prescribed.

Treatment for reflux disease has become dominated by the administration of powerful and costly medications. Research suggests that over 30 percent of those using medication are not experiencing reflux, meaning that nearly a third of users are doing so unnecessarily. Such inappropriate use needlessly exposes users to serious potential health complications, and economic expenditures estimated at upwards of $3 billion per year.

These medications, properly prescribed to those needing them, are an important tool for both medical professionals and sufferers, but further guidance is clearly needed for their usage to be safe and effective. Reflux disease experts have the diagnostic tools and experience to properly diagnose GERD and utilize these medications when appropriate.

5. A support team is essential to successfully manage reflux disease.

Most adults with reflux disease do not fully understand what they need to do to effectively manage their disease. Some, with adequate and appropriate education, will be confident and empowered to take control of their disease, but others will need a guiding hand. To succeed, a team approach is highly recommended. Doctors and their nursing staff must be part of this team, providing patient education and advocacy. However, financial constraints facing the healthcare system make it increasingly difficult for them to do so. Internet healthcare companies like RefluxMD can also play a role when medical professionals are not available. Finally, spouse, family members, friends and co-


workers should be included to ensure that support is there when it is most needed.

6. Reflux disease is a progressive chronic condition requiring long-term monitoring.

Accurate monitoring of reflux disease is an essential component of treatment. Yet, even the most attentive medical practitioner finds long-term monitoring of their patients extremely difficult, if not impossible. Patients, typically provided with only basic instructions, are often left on their own until the next office visit. Frustration, poor compliance, and ultimately, sub-optimal medical outcomes often result. Patients must assume responsibility for their disease, and that requires the knowledge and the tools to monitor their symptoms and stay on track. Periodic disease progression assessments should be performed to track year-to-year changes. Online or smartphone alerts and reminders should be used to ensure treatment compliance.

7. The reflux community must be informed and agile as new technologies, knowledge, and treatments become available.

The abundance of new clinical research studies and ongoing trials focused on reflux disease presents great opportunity and great challenge. The massive influx of new data makes it difficult for specialists, let alone general practitioners and those suffering from GERD, to stay abreast of the latest developments and breakthroughs. With Internet capability today, all ongoing research can be monitored, clinical advances tracked, clinical trials results evaluated, and current, relevant information can be made available to both consumers and medical professionals.

I Have GERD! Now What? Finding your path to relief 1

Appendix B Contributors Ronald Cornwell, MD FACS Boise, ID Dr. Cornwell attended Medical School at the University of Nevada, graduating with honors, and the completed his surgical residency at Wright State University. He has been serving Boise and southwest Idaho since 1995 where he has specialized in antireflux surgery, gastrointestinal cancers, and abdominal wall hernias. He has served as the President of the Idaho Chapter of the American College of Surgeons and he currently serves on the Board of Trustees for West Valley Medical Center as well as the Idaho Medical Association. Dr. Cornwell’s Physician Page on RefluxMD Advanced Surgery of Idaho Webpage Peter Denk, MD FACS (L) Fort Myers, FL Peter M. Denk, MD is Board Certified in General Surgery. He graduated from the University of Wisconsin and completed medical school at the University of Michigan Medical School. Dr. Denk specialized in General Surgery at the University of South Florida in Tampa and was then fortunate to obtain a Fellowship in Endoscopic and Minimally Invasive Gastrointestinal Surgery in Portland, Oregon. During his fellowship Dr. Denk was part of the team of surgeons that performed the first NOTES Transgastric Natural Orifice Cholecystectomy (incisionless gallbladder removal through the mouth) in the United States. Dr. Denk is also certified to perform the LINX surgical procedure to treat GERD. Dr. Denk’s Physician Page on RefluxMD GI Surgical Specialist’s Website Gopal Grandhige, MD (L) Tampa, FL Dr. Grandhige graduated from The Johns Hopkins University and received his medical training at the University of Michigan Medical School. After a surgical residency and fellowship training at Yale University he moved to Tampa, FL in 2009. Dr. Grandhige has a special interest in GERD. The majority of this his surgical practice consists of options for reflux, hiatal hernia surgery as well as the treatment of achalasia. Dr. Grandhige’s Physician Page on RefluxMD Suncoast Surgical Website

http://www.refluxmd.com/rcornwellmd?utm_source=GERDGUIDE&utm_medium=PDF&utm_term=GERD&utm_content=ColaboratorDR&utm_campaign=GUIDE

http://www.advancedsurgeryofidaho.com/ronald-cornwell?utm_source=GERDGUIDE&utm_medium=PDF&utm_term=GERD&utm_content=ColaboratorDR&utm_campaign=GUIDE

http://www.refluxmd.com/pmdenkmd?utm_source=GERDGUIDE&utm_medium=PDF&utm_term=GERD&utm_content=ColaboratorDR&utm_campaign=GUIDE

http://www.gisurgical.com/surgical-team/peter-m-denk-md/?utm_source=GERDGUIDE&utm_medium=PDF&utm_term=GERD&utm_content=ColaboratorDR&utm_campaign=GUIDE

http://www.refluxmd.com/ggrandhigemd?utm_source=GERDGUIDE&utm_medium=PDF&utm_term=GERD&utm_content=ColaboratorDR&utm_campaign=GUIDE

http://suncoastsurgicalassociates.com/105/dr-gopal-sai-grandhige/?utm_source=GERDGUIDE&utm_medium=PDF&utm_term=GERD&utm_content=ColaboratorDR&utm_campaign=GUIDE


Casey Graybeal, MD FACS (L) Braselton & Gainesville, GA Dr. Graybeal received his medical education at Emory University School of Medicine and did his residency at Parkland Hospital in Dallas, TX. He is experienced in every treatment technique currently available for reflux, including LINX, and he performs surgery for esophageal cancer as well. Dr. Graybeal provides consultation, complete testing for reflux, including endoscopic, pH, and manometry evaluations, and medical management as well as surgical treatment of GERD and Barrett’s esophagus. He is committed to designing treatment plans that meet the needs of his patients. Dr. Graybeal’s Physician Page on RefluxMD NGPG Surgical Associates Webpage David Johnson, MD FACS Palm Springs, CA Dr. Johnson earned his Bachelor of Arts degree magna cum laude in Biology from Boston University in Massachusetts, and his medical degree from the University of Hawaii John A. Burns School of Medicine in Honolulu. He is the author of numerous articles and abstracts published in peer-reviewed journals. In addition, Dr. Johnson has been an invited presenter at various surgical conferences and meetings. Dr. Johnson’s Physician Page on RefluxMD Premier Surgical Associates Webpage Jon King, MD FACS Phoenix, AZ Dr. King was born and raised in Seattle. He completed medical school at the University of Washington. He lives in Phoenix with his wife and 2 children. He has been in private practice since 1997. He has been recognized several times on the Phoenix Magazine Top Doc list. His commitment to his GERD patients is to provide an unbiased overview of the available treatment options. Dr. King’s Physician Page on RefluxMD Estrella Surgical Group Webpage Dan Lister, MD FACS (L) Heber Springs, AR Dr. Lister earned his undergraduate degree at Hendrix College in Arkansas and his medical degree at the University of Arkansas. He is board certified in General Surgery with a special interest in antireflux surgery and surgery of the colon, hiatal hernia, peptic ulcer, and the colon. Dr. Lister is a fellow of the American College of Surgeons. He is LINX certified.. He serves as the Chief of Surgery and Chief of Trauma Services at

http://www.refluxmd.com/cjgraybealmd?utm_source=GERDGUIDE&utm_medium=PDF&utm_term=GERD&utm_content=ColaboratorDR&utm_campaign=GUIDE

http://www.ngpg.org/casey-j-graybeal-md?utm_source=GERDGUIDE&utm_medium=PDF&utm_term=GERD&utm_content=ColaboratorDR&utm_campaign=GUIDE

http://www.refluxmd.com/dsjohnsonmd?utm_source=GERDGUIDE&utm_medium=PDF&utm_term=GERD&utm_content=ColaboratorDR&utm_campaign=GUIDE

http://www.palmspringsdesertsurgeons.com/meet-our-team/?utm_source=GERDGUIDE&utm_medium=PDF&utm_term=GUIDE&utm_content=OFFICES&utm_campaign=DOCTORS

http://www.refluxmd.com/jkingmd?utm_source=GERDGUIDE&utm_medium=PDF&utm_term=GERD&utm_content=ColaboratorDR&utm_campaign=GUIDE

http://estrellasurgical.com/staff/jon-king.aspx?utm_source=GERDGUIDE&utm_medium=PDF&utm_term=GERD&utm_content=ColaboratorDR&utm_campaign=GUIDE


Baptist Health Medical Center in Heber Springs, AR and is on staff at St. Vincent Medical Center / North in Sherwood, AR. Dr. Lister’s Physician Page on RefluxMD The Surgical Clinic of Central Arkansas Webpage Richard Nedelman, MD FACS Springfield, OH Dr. Nedelman has been practicing surgery for 20 years. He has a particular interest in the treatment of GERD and has performed hundreds of repairs. Dr. Nedelman was instrumental in establishing Ohio Valley Surgical Hospital, a highly rated physician managed surgical hospital to meet the specific needs of surgical patients. He received surgical training at the University of Cincinnati and specialty training in Edinburgh, Scotland. He is proud to be providing state of the art surgical care for patients in the Springfield Dayton Area. Dr. Nedelman’s Physician Page on RefluxMD SAS Surgery and Vein Specialists Website RefluxMD RefluxMD is a one-stop resource for help with gastroesophageal reflux disease, or GERD. Our goal is to empower people with reflux disease to take control of their health, to make informed decisions, and to find solutions that work for them. Unlike other healthcare websites, we are focused on reflux disease. We deliver authoritative, detailed, physician-approved information and we connect our RefluxMD members and visitors with physicians who specialize in reflux disease. You can learn more about RefluxMD at www.refluxmd.com/about. (L) Indicates LINX Certified Physician

http://www.refluxmd.com/dlistermd?utm_source=GERDGUIDE&utm_medium=PDF&utm_term=GERD&utm_content=ColaboratorDR&utm_campaign=GUIDE

http://www.stopmyreflux.com/about-us/dan-lister-md/?utm_source=GERDGUIDE&utm_medium=PDF&utm_term=GERD&utm_content=ColaboratorDR&utm_campaign=GUIDE

http://www.refluxmd.com/rnedelmanmd?utm_source=GERDGUIDE&utm_medium=PDF&utm_term=GUIDE&utm_content=OFFICES&utm_campaign=DOCTORS

http://www.sassurgeryandvein.com/our-physicians/richard-nedelman/?utm_source=GERDGUIDE&utm_medium=PDF&utm_term=GUIDE&utm_content=OFFICES&utm_campaign=DOCTORS

Documents

I have GERD! Now what?