GERD/ Acid Reflux/ Hyperacidity

Gastro-Oesophageal Reflux Disease/GERD, commonly known as ‘Acidity’ is one of the Gastro Intestinal or digestive Disorder.  The prevalence of GERD ranges from 7.6%-22.2% in India.¹ The Gastric Juice, which is present in the stomach is pushed back to the Oesophagus (food pipe) and since the gastric juice is very corrosive in nature, it seems like the entire food pipe is burning and exhibits the symptoms. The most common symptoms include Regurgitation, Heartburn/Chest burn and chest pain (Which is not Cardiac in origin)

WHAT HAPPENS IN GERD? PATHOPHYSIOLOGY.

Pathophysiology of GERD is complex. The common Pathologies involved are –

• Weak or Dysfunctional LES
• Failure in Oesophageal Mechanism
• Delayed Gastric Emptying

1. Weak or Dysfunctional LES: Normally, gastric contents do not reflux back into the oesophagus because the pressure created by the Lower sphincter closes by itself preventing the backflow. One of the most common causes of GERD is weak LES or the pressure is low enough to restrict the gastric contents. Some amount of reflux can happen in a healthy individual because of the spontaneous sudden relaxation of the LES after the heavy meals, which is called transient spontaneous LES relaxation. This relaxation is more predominant in the case of GERD caused due to Weak LES.

2. Failure in Oesophageal Mechanism: After the acid reflux, peristaltic movement in the oesophagus returns the refluxed acid back into the stomach and the acid is cleared in the oesophagus. The residual acid is neutralised by the bi-carbonate present in the saliva. Therefore, reduced secretion of saliva or decreased peristaltic movement in the oesophagus causes GERD.  

3. Delayed Gastric Emptying: Because of delayed emptying of the food content, there will be increased intra-gastric pressure inside the stomach, which disrupts the gastric reflux mechanism of the LES. The most common causes of increased intra-abdominal pressure are Obesity, Hiatus Hernia, and Pregnancy.

AYURVEDIC PERSPECTIVE: 

In Ayurveda, GERD is co-related with disease named AMLAPITTA. It is caused due to the aggravation of Pitta in the Body. Pitta ‘present in the stomach’ (according to the Ayurvedic text books) refers to the bodily elements, which controls the Digestion, Metabolism and Energy production and does its functions.  Due to the etiological factors, which leads to the vitiation of Pitta in the body, and causes imbalance in its normal function, it gets aggravated and then the acid is pushed upwards exhibiting the symptoms.

CAUSES:

Dietary factors which induce GERD are:

• Intake of fat rich diet like deep fried food items, curries with multiple spices, etc.
• Excess intake of Vegetables like green chilli, capsicum, tomato, mint, onions, ginger, garlic, fermented vegetables, apple cider vinegar etc.
• Excess intake of citrus fruits like lemons, oranges etc.
• Intake of more chocolates, carbonated drinks like soda, food prepared out of Maida (refined flour) etc.
• High protein diet, milk-based sweets or deserts in excess, and meat eating in excess etc.
• Excessive intake of Alcohol, Smoking, and regular or high intake of pain killers, and 

Note: All these above-mentioned food items, on taking in excess, will cause either excess acid production or damages the LES ending up in GERD. 

FEW OTHER CAUSES INCLUDE:

• Obesity: Causes excess pressure over the sphincter.
• Hiatus hernia 
• Defective Oesophageal Sphincter
• Delayed gastric emptying
• Anaemia
• Parasitic and Bacterial infections
• Certain medications like Statins (Drugs for Hyper Cholestremia), Calcium Channel Blockers (Drugs for Hypertension/Cardiac diseases), Anti Diabetic drugs like Metformin, NSAIDS (Non-Steroidal Anti-Inflammatory Drugs), Analgesics (Pain killers), few of the drugs given for psychological disorders, Aspirin, and Iron Supplements.  
• STRESS: Physical, emotional or mental stress is one of the major causes of GERD among adults. It is significantly associated with stress. Many studies have shown the relationship between the degree of stress correlates with severity of the GERD     

SYMPTOMS OF GERD/AMLAPITTA

Oesophageal Symptoms:

1. Pyrosis: Burning sensation in the chest region and throat. Commonly called as Heartburn.
2. Regurgitation: Sensation of Acid in the throat, commonly experienced as sour or bitter taste in the mouth or throat. 
3. Dysphagia: Difficulty in swallowing food, a strange sensation of food being stuck in between the chest. 

Extra-oesophageal Symptoms:

1. Chest Pain: Which is not of cardiac origin. Usually sensed as a tightness of chest, or dull pressure over the chest region. 
2. Coughing: Coughing occurs usually during night. When a person goes to bed soon after the meals, the reflux sometimes enters the larynx and causes irritation to the throat.  
3. Wheezing: Is a sign of Asthma, which is not respiratory in origin in GERD. It is not diagnosed as Asthma, rather it is a sign of acid reflux entering the throat. Hence walking for about 100 steps after the meal is advisable since ages..     
4. Uneasiness: It will be because of the unpleasant taste, burning sensation etc. 
5. Hoarseness of Voice: Hoarseness of voice occurs in long run of GERD, is usually observed in the early morning hours. Caused due to the inflammation or irritation by the acid to the Larynx or the Vocal cords.  
6. Enamel Erosions: Enamel is the protective layer of the tooth. Continuous reflux or vomiting can damage the enamel and causes tooth decay. Therefore, GERD is also one of the causes of tooth decay,
7. Otitis media: In other words, Acute middle ear infection. When a person has Chronic GERD, it damages his Pharynx eventually due to the continuous reflux. But it not only causes pharyngeal problem, it ends up in eustachian tube dysfunction (Eustachian tube is a narrow passage from pharynx to the middle ear). 

METHODS OF DIAGNOSIS:

• Based on the Symptoms exhibited by the patients.
• Upper Gastrointestinal Endoscopy
• Oesophageal PH Monitoring
• Barium Meal X-ray

RISK FACTORS: 

1. Smoking
2. Alcohol
3. Tobacco
4. Tea/Coffee or any caffeine beverages
5. Obese persons
6. Pregnancy
7. Stress

MANAGEMENT: 

Non-Pharmacological:

1. Lifestyle Modifications: Avoiding the food items which are mentioned earlier in the article, losing weight, avoiding caffeine, alcohol, tobacco etc.
2. Avoiding large meals at once, instead, one can choose having small and frequent meals or can choose intermediate fasting (with proper guidance). Do not eat at all, if you are not hungry. 
3. Avoid sleeping soon after the meals. Instead, walking for around 100 steps would help. It is always better to have dinner 2-3 hours before going to bed.
4. Drinking sufficient amount of water.
5. Proper exercise.
6. Stress Management: Meditation, Yoga, Group Discussion etc. are very helpful to manage stress.

Ayurvedic Medications:

1. The Aggravated Pitta is the main factor involved in this disease and it is combated with one of the Panchakarma therapy – VIRECHANA. Virechana (Therapeutic Purgation) is a detoxification procedure, which takes for about 9-15 days for the complete procedure to be over. 
2. The Second procedure, which has shown the promising result is VAMANA. Vamana (Therapeutic Emesis) is also one of the Panchakarma, a detoxification procedure which also takes9-15 days 
3. In Chronic Cases, the third Procedure will be BASTI. Basti (Therapeutic Enema) is one of the Panchakarma, which has also shown the prompt result.
4. Important formulations: 

• Kamadugdha or Kamadudha rasa
• Sutashekara Rasa
• Dhatri Loha
• Swarna Makshika Bhasma 
• Amlapittantaka Loha
• Amalakyadi churna
• Vaishwanara churna
• Avipattikara churna

Note: The above mentioned classical Ayurvedic medicines are not like Over-the-Counter supplements, they should be used under the prescription and supervision of a qualified Ayurveda Physician. 

5. Single Drugs Usage: 

1. Shatavari – Asparagus racemosus
2. Guduchi – Tinospora cordifolia
3. Triphala – (Amalaki, Vibhitaki, Haritaki)
4. Yastimadhu – Glycyrrhiza glabra
5. Ajamoda – Trachyspermum ammi
6. Amalaki – Phyllanthus emblica
7. Shunti – Zingiber officinale
8. Shukta – Calcined Oyster shell
9. Shankha – Calcinated Conch Shell

References

1. Anthony S, Joseph B Martin et al. Harrison’s principles of Internal Medicine. 19th ed. Vol 2. P¹⁸⁹⁴
2. Anthony S, Joseph B Martin et al. Harrison’s principles of Internal Medicine. 19th ed. Vol 2. P¹⁹⁰⁶
3. Agnivesha. Charaka Samhita.Yadavji Trikamji Acharya editor. 2014.Chikitsa Sthana, Chapter 15 P³⁹¹
4. Agnivesha. Charaka Samhita.Yadavji Trikamji Acharya editor. 2014. Chikitsa Sthana, Chapter 15 P³⁹⁷
5. https://www.researchgate.net/publication/298808884_Prevalence_of_gastro-esophageal_reflux_disease_and_its_risk_factors_in_a_community-based_population_in_southern_India
6. Anthony S, Joseph B Martin et al. Harrison’s Principles of Internal Medicine. 19th ed. Vol 2. P^1906-1907
7. https://www.spectrumhealthlakeland.org/lakeland-ear-nose-and-throat/ent-health-library/Content/3/82937