Gastroesophageal Reflux - Research Paper Example

Gastroesophageal Reflux Introduction Gastroesophageal reflux diseae (GERD) is defined as “an abnormal reflux of the gastric contents into the esophagus at least once a week” (Festi, Scaioli, Baldi et al, 2009, p.1690) leading to symptoms including heartburn, acid regurgitation, esophageal mucosal damage, which can result in long-term complications such as Barrett’s esophagus. The disorder has a high rate of incidence, and appears to be increasing in prevalence particularly in the western world. GERD is a multifactorial disease in which anatomical and functional factors combine to play a pathogenic role. The transient lower esophageal sphincter relaxation (TLESR) accounts for the majority of reflux episodes in patients with esophagitis and those with non-erosive reflux disease (NERD).The underlying causes are still incompletely known, of functional disorders such as increasing number of TLESR episodes perhaps in combination with impaired lower esophageal sphincter (LES) basal tone or with gastric or esophageal motor dysfunction. Thesis Statement: The purpose of this paper is to investigate gastroesophageal reflux, the objectives in treating the disease, surgical intervention, and precise diet and nutrition specifications, as well as identification of foods which should be eliminated. Factors Contributing to Gastroesophageal Reflux Disease The chronic character of gastroesophageal reflux disease (GERD), and the fact that it can be either gastric or duodenal in origin is acknowledged by the Brazilian consensus conference (Herbella & Patti, 2010). The consensus defines GERD as a “chronic disorder related to the retrograde flow of gastro-duodenal contents into the esophagus and/ or adjacent organs, resulting in a spectrum of symptoms with or without tissue damage” (Moraes-Filho, Cecconello & Gama-Rodrigues, 2002, p.241). Further, the role of esophageal dysmotility in GERD and the significance of esophageal peristalsis as an antireflux mechanism has been confirmed by Diener, Patti, Molena et al (2001). Twin studies (Cameron, Lagergren, Henriksson et al, 2002; Mohammed, Cherkas, Riley et al, 2003) have indicated the role of genetic factors, by which hereditability accounted for 31% to 43% of the possibility of reflux disease. This suggests that both genetic and environmental components play important parts in the emergence of the condition. The environmental factors include lifestyle factors specifically the impact of being overweight and obese, improper dietary habits, the absence of regular physical activity, as well as smoking are considered as potential risk factors for GERD. However, Festi et al (2009, p.1691) qualifies that “the exact pathogenic role of these factors is still under debate, and the beneficial effect of specific recommended changes in lifestyle habits is also controversial”. Gastroesophageal Reflux Disease: Treatment Objectives The treatment objectives include the elimination of heartburn and reflux into the esophagus, neutralization of gastric acidity, achievement and maintenance of desirable body weight to improve mechanical and postural conditions, avoidance of large meals that increase gastric pressure and alter pressure on the lower esophageal sphincter (LES), thereby permitting reflux to occur. The LES limits the aspiration of gastric contents when functioning properly. Other significant aims of treatment relate to the provision of individual diets tailored to each patient’s needs, and the assessment of intake of fat, alcohol, spices and caffeine. Moreover, avoidance of wearing garments that fit tightly around the abdomen is essential. According to DeVault and Castell (2005), the treatment guidelines address lifestyle changes, patient-directed over-the-counter therapy, acid suppression, promotility therapy, maintenance therapy, antireflux surgery, and endoscopic therapy. Up to 70% of patients with gastroesophageal reflux disease (GERD) have non-erosive reflux disease (NERD) also known as endoscopy-negative reflux disease. Surgery is required for patients in life-threatening conditions of the disease, and in patients resistant to or dependent on acid-suppressive medication. Laparoscopic antireflux surgery has highly successful outcomes in the long-term for severe GERD, with speedier recovery and less post-operative pain (Escott-Stump, 2008). Surgical Intervention in Treating Gastroesophageal Reflux Disease Orlando (2000, pp.277-278) states that “the recent introduction of minimally invasive laparoscopic surgery has replaced conventional open fundoplication operation”. This procedure gathers, wraps and sutures the fundus of the stomach which is closest to the entry of the esophagus, around the lower end of the esophagus and the lower esophageal sphincter. However, laparoscopic fundoplication surgery should be the first line of treatment only in dramatic situations such as obvious regurgitation, combined with aspiration and laryngospasm. Further, surgical correction of gastroesophageal reflux produces a dramatic improvement of asthma in the same patient, through eliminating all gastric reflux rather than merely reducing acid reflux. This provides strong evidence that GERD is either the cause or the contributing factor to asthma. Pre-operative nutrition for patients with gastroesophageal reflux includes a tolerated oral diet in the form of liquids because of dysphagia and obstruction. If oral feeding is unsuccessful, a feeding tube is used. On the other hand, if the esophagus is obstructed, preoperative parenteral nutrition is administered. Intraoperatively a jejunal feeding tube may be placed to facilitate postoperative enteral nutrition until the anastomosis is healed and oral intake is resumed. For the first two weeks after surgery, “soft, bland foods with a low fiber content should be consumed in small portions” (Williams & Schlenker, 2003, p.557). Simple sugars, lactose and fried foods should be avoided. Beverages should be consumed at least 30 minutes before and after meals, and foods rich in proteins and carbohydrates should be emphasized. Generally, these diet modifications are required only in the short-term after which a normal diet may be resumed; however some patients may need an antidumping diet indefinitely. Dietary Intervention through Food and Nutrition A reduced energy diet that promotes weight loss is recommended when patient is obese, since obesity has been positively correlated with the occurrence of gastroesophageal reflux, by research conducted by El-Serag (2008) and Prachand and Alverdy (2010) among others. Further, Body Mass Index (BMI) may cause symptomatic GERD independent of diet and exercise. During acute episodes, small frequent feedings should be provided. The patient should be instructed to remain upright for 2 hours after meals, and should avoid intake of food particularly fatty foods for several hours before bedtime. If required, the head of the bed should be elevated (Escott-Stump, 2008). To stimulate gastrin secretion and to increase lower esophageal sphincter (LES) pressure, diet should be high in protein. Foods that decrease LES pressure should be avoided “including chocolate, pepper, onions, garlic and spearmint” (Escott-Stump, 2008, p.370). Patients should be instructed to reduce or stop smoking, to restrict the use of salt and avoid carbonated beverages in the diet. The patient’s diet should be low in fat, with minimal use of “fried foods, cream sauces, gravies, fatty meats, pastries, nuts, potato chips, butter and margarine” (Escott-Stump, 2008, p.370). The inclusion of dietary fiber through whole grains, vegetables and fruits is recommended, while alcohol, coffee and tea are considered as only mild risk factors. Fluid intake between meals will help to avoid the abdominal distention and discomfort of consuming fluids with meals. Foods that should be Eliminated from the Patient’s Diet The foods that irritate the esophagus such as citrus juices, tomatoes and tomato sauce, and spicy foods according to individual experience. To identify potential allergens, a dietary elimination diet which adds back foods one at a time helps to determine potential allergens (Escott-Stump, 2008). On the other hand, from their comprehensive review of research studies on the recommended diet for GERD, Festi et al (2009) argue that there is no definitive data on the role of diet, particularly of specific foods or drinks to GERD clinical manifestations. Despite the insufficient evidence in this area, “some dietary interventions continue to be recommended as first-line therapy” (Festi et al, 2009, p.1696). Conclusion This paper has highlighted gastroesophageal reflux disease. The factors contributing to the disease have been identified, the treatment objectives have been outlined, the use of surgical intervention in advanced cases has been examined, and the importance of dietary intervention through food and nutrition has been determined. Although the recommended foods to be included in the patient’s diet and those that should be avoided have been determined, their significance remains inconclusive. Therefore, additional clinical studies and larger prospective controlled trials are required to conclusively recommend modifications in the treatment of gastroesophageal reflux. Overall, it is concluded that lifestyle factors such as meal-size and timing, remaining in an upright position after a meal, not smoking, eliminating alcohol, refraining from the intake of heavily spiced or fatty food, and pursuing a physically active life are vital instruments for the overall management of gastroesophageal reflux disease. 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