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I am on antacid medications for a long time now. My diet, nutrition, sleep, work, family and social life are affected. Even after consulting many gastroenterologist, I am unable to get my GERD under control. I am told by my doctors that this problems will remain with me lifelong, and I will need to take the antacid PPI medications lifelong. But I strongly feel that there should be some permanent solution for my GERD problem. I know it is just a matter of time, when I can find a doctor who can make a difference.
The above story is a relatively common one, one that we routinely encounter among our patients. A large percentage of the population suffers from this condition called GERD or Acid reflux. Sometimes, also called Acidity, heartburn or Gas problem in vernacular language. Fortunately, all who suffer from GERD do not have such a debilitating problem and a demoralising story. Of all those having GERD, only a small percentage of patients have severe GERD. Severe enough to trouble the patients for years, where patients need regular medications for years, at times not getting enough relief even with medications and affecting their quality of life.
“With proper treatment all GERD/Acid reflux patients should get a permanent solution, improving their quality of life.
If someone is still suffering, then something is missing in his/her treatment.”
Good news is that for most of these patients, their problems can be controlled and with time even medications be stopped. We aim not only to control their symptoms but also to rehabilitate them back to a normal diet, sleep, work, exercise, and social life. There has been a lot of research that has led to a better understanding of the problems related to digestion, including GERD and other esophageal (food pipe) problems. Newer and better modalities of evaluation like esophageal manometry and 24-hour pH Impedance study is a routine part of clinical evaluation in today’s time for all such patients. There is also a better understanding about the functional digestive problems (DGBI- Disorder of GUT Brain Interaction) affecting the food pipe and stomach, and improvement in their treatment. With all these updates, most of the patients can have a normal quality of life, with proper treatment, and not requiring lifelong regular medications.
Most of the patients who have been suffering for a long time, have an incomplete evaluation of their problems. We commonly consults such patients, who come with multiple endoscopy reports. But further evaluation for food-pipe and stomach function is not done. Repeating upper GI endoscopy in such a situation is less likely to add any more information about their problems. What is needed in an Esopahgeal manometry, 24 hr pH and Impedance study, and in some patients evaluation for delayed gastric emptying. Some rare conditions affecting digestion like thyroid function abnormalities, eosinophilia, celiac disease or autoimmune conditions can be ruled out by some blood tests.
A clinical assessment regarding the functional digestive problems or DGBI should also be done. DGBI that is a Disorder of Gut and Brain interaction where patients have symptoms due to increased sensitivity and altered motility of food pipe, stomach and intestines. A very common reason for poor symptom control is the presence of DGBI along with GERD/Acid reflux. And in many such patients as only acid reflux is treated, and DGBI is missed in evaluation and treatment, there is poor response to treatment. At times on evaluation, it becomes clear that a patient being treated for GERD does not have GERD at all. All their problems were because of other esophageal problems like motility problems, or hypersensitivity problems. The above problems will need a different treatment approach and a change in treatment approach leads to a positive outcome.
As mentioned previously, many patients have more than one digestive problem. Meaning, they may have constipation, IBS, functional heartburn and/or other oesophageal or gastric motility problems along with GERD. In such a situation, if only GERD is treated then the outcome would be poorer. Apart from this, in many patients due to the long duration of poorly controlled digestive symptoms, other problems like stress, sleep disturbances, fear of food and other behavioural changes may have also started. This needs to be addressed by medications, counselling, and proper changes in diet and stress management to get the best possible result in each patient’s case.
It is also not uncommon that patients fail to comply with the treatment and lifestyle advice. Sometimes there are long gaps in treatment, as patients stop treatment intermittently or try alternative medicine (Homeopathy or Ayurved). Due to the long duration of treatment, frustration and confusion, many patients change doctors frequently rather than continuing the treatment under a single doctor. This also many times leads to poor decision-making regarding the treatment and poor adherence to lifestyle changes, ultimately leading to more suffering for the patient.
The severity of GERD is a very important factor in the overall outcome of GERD. We need to understand the fact that the primary problem in GERD is a mechanical weakening of the valve between the food pipe and the stomach. So if the patient has a hiatus hernia and a significantly weakened LES valve (Lax LES), then despite proper treatment, diet and lifestyle changes, the outcomes may not be satisfactory. Such patients may continue to have some symptoms even on medications. Commonly, in such situation, heartburn remains under control till the medications are taken, but burping and food coming up (regurgitation) and throat problems (Globus sensation) persist even with medications. In some patients, all the symptoms are under control till medications are on, but the patient cannot tolerate stopping medications, at times not even for a day. For all such patients laparoscopic surgery for GERD/Acid reflux or hiatus hernia is the ideal option. If done after a proper evaluation, and done by an expert surgeon, the results of this surgery are excellent, even from a long-term perspective.
Another reason for poor outcomes is not following a normal healthy lifestyle. Smoking, tobacco and alcohol are very important factors that can not only lead to GERD but also other digestive problems seen in combination with GERD like IBS and DGBI. Some patients outrightly are not willing to stop these habits, while some resume them once their problems are controlled. Many such patients who resume these habits may have a resumption of their symptoms. Some patients only seek treatment so that they can resume these habits, otherwise, they feel absolutely fine when they stop these habits. One has to understand that if your body is not tolerating these unhealthy habits, there is no way to make your body robust to handle these abuses. It would be in the best interest of the patient to understand that he/she should change these habits.
Similar is the case with stress. Stress is a definite part of everybody’s life in today’s time. When we talk about stress, it does not necessarily mean the presence of big stressful situations in life. Smaller events like lack of sleep, thoughts about this illness, constant pain, and fear of eating are enough to cause certain symptoms. In many patients, there is a very clear factor of chronic stress either due to work pressure or schedule, family problems, health problems, competitive exams, change of city or country, social problems, etc.
At times it takes openness to understand and acknowledge the presence of these factors and their effect on their current medical problems. Once they are able to understand it, there is a solution to it with the help of medicine and stress management. Then it is only a matter of discipline regarding continuation of treatment and regular stress management exercise, and the patients will see a significant improvement in their problems, leading to a normal quality of life.
Much of the treatment approach is already discussed in the above discussion. Still, to summarise the treatment approach, let me enlist the steps
Following the above principles, we can say that in most of the patients, we are able to get excellent outcomes. On and off we do struggle in a few patients to either control their symptoms effectively or to stop their medications. But I strongly feel that with time, even these patients can get back to normal life without medications. We have seen many patients whose treatment was difficult initially, but are now leading a normal life and not needing any medications.
Somebody who is suffering from GERD and is losing hope to get back to normal life can contact us (WhatsApp no -8156078084/8469327630) and we will be happy to help. You can also share this article with someone known who is suffering from GERD, acid reflux, acidity or hiatus hernia. I am sure we will be able to make a difference.
For more information on GERD and related digestive problems, Esopahgeal manometry and 24 hr pH Impedance study, surgery for GERD/Acid reflux/Hiatus hernia and their outcomes you can visit GERD and acid reflux page on our website and our Youtube channel. All the information is also available in Hindi and Gujarati language.
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Dr Chirag Thakkar is a gastrointestinal surgeon. He has been carrying out gastrointestinal and weight loss surgery for the past 18 years. Surgery for GERD, hiatus hernia and Obesity are his core areas of interest and expertise. ADROIT is among the rare centres having an integrated approach to the treatment of GERD, having facilities for evaluation including endoscopy, esophageal manometry, 24 hr pH Impedance study and where treatment includes not only surgery but proper diet and psychology interventions along with long-term follow-up to give our patients excellent long term results.
Dr.Chirag Thakkar
