Chapter 4 Gastro-oesophageal reflux disease
AETIOLOGY
Gastro-oesophageal reflux disease (GORD) is commonly encountered in clinical practice. Recent research has estimated the prevalence at 10–20% in Western nations.1 GORD has been defined as ‘a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications’.2 Signs and symptoms of GORD result primarily from the recurrent reflux of gastric contents into the oesophagus (Figure 4.1). The pathogenesis of GORD is complex and multifactorial with a number of mechanisms appearing to be involved (Figure 4.2):
RISK FACTORS
CONVENTIONAL TREATMENT
Conventional treatment aims to reduce the symptoms of GORD and reduce oesophageal damage through the use of antisecretory therapies, such as proton pump inhibitors or histamine type 2 receptor antagonists (H2RAs). Although these agents have been found to be effective in reducing the oesophageal symptoms of GORD and, to a lesser extent, extraoesophageal symptoms,26 their use is also associated with significant side effects and risks. Common adverse events of antisecretory therapies include diarrhoea, nausea, abdominal pain and headaches.27 Longer-term use of anti-secretory drugs is associated with increased risk of gastroenteritis,28 pneumonia,29 spinal fracture30 and vitamin and mineral malabsorption.31,32 More recently, the surgical procedure laparoscopic fundoplication has been advocated in the treatment of GORD.
KEY TREATMENT PROTOCOLS
The naturopathic protocols adopted to treat GORD usually focus on dietary and lifestyle modifications, in addition to botanical treatments. After relieving symptoms, the aim is to initially identify any factors that contribute to GORD and remove these triggers. If inflammation, ulceration or poor motility/sphincter tone is present, herbal or nutritional prescription may be of benefit.
Relieve symptoms
Relief of heartburn is paramount in the management of GORD. Gastrointestinal demulcents are typically very effective in providing prompt relief of heartburn symptoms (usually within minutes of ingestion). Effective demulcents include Althaea officinalis radix, Ulmus fulva cortex and Glycyrrhiza glabra.44 Gastrointestinal demulcents are most effective when administered in powdered form—mixed into a little water or apple juice to form a slurry or gruel. Tablets and capsules will be significantly less effective. Demulcents can be used ‘on demand’ or taken after meals and/or before bed for a preventative effect.
Eliminate exacerbating factors
Dietary factors
The naturopathic axiom tolle causum (‘treat the cause’) is particularly relevant to the management of GORD. While herbal demulcents can relieve heartburn symptoms effectively and promptly, their use, in some respects, is only palliative if patients continue to indulge in dietary factors known to exacerbate their condition. Avoidance of foods and drinks known to precipitate reflux episodes (for example, chocolate, alcoholic beverages, caffeinated beverages and fatty foods) is an important therapeutic strategy that may produce excellent clinical outcomes (see Chapter 5 on food intolerance/allergy),33 although it should be noted that an ‘evidence-based review’ of dietary changes was inconclusive due to insufficient research.18 The authors did, however, note that there is a definitive link in some sufferers of GORD with food and alcohol, as physiological evidence has demonstrated decreased LOS tone.
Other recommendations, such as taking time when eating, consuming smaller meals and avoiding fluid consumption with meals (both should decrease gastric distension) and chewing food adequately, are traditional naturopathic recommendations.34 Chewing food as thoroughly as possible is a traditional recommendation which may result in improved salivary gland function over time and, hence, improved oesophageal acid clearance. Changing the evening meal time to earlier in the evening (at least 3–4 hours before bedtime) can also be helpful.35
In infants and toddlers with GORD, a dairy-free diet should be implemented. If they are formula-fed, the mother should be encouraged to relactate. The use of an extensively hydrolysed whey formula is the next best option. Soy and goat’s milk formulas should be avoided as they share a significant amount of cross-reactivity with cow milk proteins. There have also been a number of studies demonstrating the efficacy of carob bean powder (Ceratonia siliqua) as a formula additive.36,37 Carob powder has been found to significantly decrease the severity and frequency of vomiting in infants with GORD, as well as increasing weight gain.36 If the infant is exclusively breastfed, then the mother should be placed on a dairy-free diet, as small, but clinically significant, amounts of dairy proteins do appear in the breast milk.
Lifestyle factors
In addition to the dietary factors discussed above, lifestyle factors such as obesity and smoking should be addressed. Weight loss has been shown in some research to result in reduced reflux episodes and should be encouraged in all overweight and obese patients.38 Cessation of smoking could be recommended for a number of compelling reasons, not the least of which is its effect on oesophageal reflux. Short-term studies (of 24–48 hours duration) have not consistently found a reduction in reflux episodes after smoking cessation.39,40 However, no longer-term studies have yet been performed and, in light of smoking’s well-known adverse effects, GORD patients who smoke should be encouraged to give up. Herbal thymoleptics, anxiolytics and adaptogens could play an important supportive role in this process (see the section on the nervous system).
Raising the head of the bed is another easy-to-implement lifestyle intervention that has demonstrated beneficial effects in GORD.18 This recommendation is based on the theory that acidic stomach contents will be more likely to reflux when patients are lying flat. Research has, thus far, mostly supported this theory, with intervention trials finding reduced frequency of reflux episodes, shorter reflux episodes and fewer reflux symptoms when bed heads were raised (one trial raised the head by 28 cm).41
