SANGRAM PURI

1ST YEAR MD
NATUROPATHY[CLINICAL]

Population based survey revealed that 59 % of

the population reported monthly heartburn
and 19.8 % suffered from heartburn or acid
regurgitation at least once a week.

(Zuckschwerdt, W. 2001)

 GERD is more common in whites

compared with other ethnic groups.
However, the prevalence is increasing in
Asians.
(Fennerty, 2003)

It is also more common in women, however

men & people over the age of 60 develop
more complications.
(Fennerty, 2003)

Any symptoms or esophageal mucosal damage

that results from reflux of gastric acid into the
esophagus

Classic GERD symptoms

Heartburn (pyrosis): substernal burning
discomfort
Regurgitation: bitter, acidic fluid in the
mouth when lying down or bending over

Gastro = stomach
Esophogeal = food tube
Reflux = back flow
Disease = abnormal condition
of physiologic functioning.

The esophagus is very muscular and collapses when

empty. It is 10 inches or 25cm in length
Food is passed from the pharynx into the esophagus by
a mechanism called peristalsis. This propelling
motion is carried out by the muscles and the Central
nervous system.
(Porth, 1998)

The food is carried

from the esophagus
to the stomach
where acid
production is
formed.
(Porth,1998)

The bicarbonate buffers the acid

and mucus forming a protective
barrier.

This creates an environment in the esophagus of a

higher pH than that of the stomach. The pH in the
esophagus is normally about 7-8, whereas the pH in
the stomach is generally 2-4. (Kahrilas, 2003)

There are specialized cells deep in the

stomach lining that affect the rate of acid
production.
The primary cells which contribute to acid
production are known as parietal cells.
(Kahrilas, 2003)

PARIETAL
CELLS

Acetylcholine

Gastrin

Histamine

Each gastric parietal cell contains

about 1 million acid pumps.

Exchange hydrogen ions from the parietal cells to

potassium using energy derived from splitting
ATP.
(Kahrilas, 2003)

The stomach produces an average of 2

liters of HCL a day, which in
combination with the protein-splitting
enzyme pepsin, breaks down
chemicals in food.
There is a rare disorder, called
Zollinger-Ellison syndrome:
With this, the body produces an
excessive amount of acid, this
can increase the risk of
GERD.

The Lower esophageal

Sphincter is the
Primary focus relating
to GERD.

If the Lower Esophageal

Sphincter (LES) is not
working properly creating a
dysfunction the acid from
the stomach can backflow into
the esophagus. (Porth, 1998)

Percentage of time the esophagus is exposed to a

low PH. Clearance of the acid depends on
peristalsis & exposure to the saliva.
(Porth, 1998)
People with this dysfunction, often experience an
uncomfortable feeling in the chest, neck, and throat area due
to acid exposure.

This uncomfortable feeling can

sometimes be confused with other
conditions, even a heart attack.

Swallowed saliva which helps neutralize

stomach acid.
Sweeping muscles contractions that act to
cleanse the lower esophagus of stomach
acid.
Protective contracture of the LES.
(Jackson Gastroenterology - 2005)

Pressure in the LES is greater than that of the

stomach.

High levels of Acetylcholine, a neurotransmitter

increases constriction of the LES.

Gastrin, a hormone also increases constriction of the

LES.

Factors associated with the development of GERD

OBESITY - excess weight puts extra pressure on the

stomach & diaphragm.

Pregnancy results in greater pressure on the stomach &

also has a higher level of progesterone. This hormone
relaxes many muscles, including the LES.

ASTHMA it is unsure why, but, is believed that the

coughing leads to pressure changes on the diaphragm.

HIATAL HERNIA -

In individuals with hiatal hernia, the

opening of the esophageal hiatus is
larger than normal, and a portion of
the upper stomach slips up or passes
(herniates) through the hiatus and
into the chest.

The diaphragm
supports and puts
pressure on the
sphincter to keep it
closed when
swallowing.

But a hiatal hernia raises the sphincter above the

diaphragm, reducing pressure on the valve. This
causes the sphincter muscle to open at the wrong
time.

There is evidence that genetics is a factor in

pediatric patients. This is reported in the
Journal of the American Medical Association
from the July issue in 2000. (Spice, B., 2000)
The specific gene has not been identified as of yet,
however research has narrowed it to a portion of
chromosome 13
(Hu, Fen Ze MS; et al 2000)
As far as adults, studies have been performed on identical
twins who share the same genes & it has been identified that
there is a 43% chance of genetic influence.

Stress is a complex physiological response to

changes in the environment.
Prolonged stress has the ability to decrease the
immune system, making the body susceptible to
inflammation and infection.
In an effort to cope with the disruption in routine,
caused by stress, unhealthy lifestyles become
evident.

Classic GERD.

Extraesophageal/Atypical GERD.

Complicated GERD

Pulmonary
Asthma
Aspiration pneumonia
Chronic bronchitis
Pulmonary fibrosis
Other
Chest pain
Dental erosion

ENT
Hoarseness
Laryngitis
Pharyngitis
Chronic cough
Dysphonia
Sinusitis
Subglottic stenosis
Laryngeal cancer

 Edema and hyperemia of

larynx
Vocal cord erythema,
polyps, granulomas,
ulcers
Hyperemia and lymphoid
hyperplasia of posterior
pharynx
Interarytenyoid changes
Dental erosion
Subglottic stenosis
Laryngeal cancer
Vaezi MF, Hicks DM, Abelson TI, Richter JE. Clin Gastro Hep
2003;1:333-344.

Dysphagia
Difficulty swallowing: food sticks or
hangs up
Odynophagia
Retrosternal pain with swallowing
Bleeding

Uncertain diagnosis
Atypical symptoms
Symptoms associated with
complications
Inadequate response to therapy
Recurrent symptoms
Prior to anti-reflux surgery

Barium swallow.

Endoscopy.

Ambulatory pH monitoring.

Esophageal manometry

Useful first diagnostic test for

patients with dysphagia
Stricture (location, length)
Mass (location, length)
Birds beak
Hiatal hernia (size, type)
Limitations
Detailed mucosal exam for
erosive esophagitis, Barretts
esophagus

Indications for
endoscopy
Alarm symptoms
Empiric therapy
failure
Preoperative
evaluation
Detection of Barretts
esophagus

Physiologic study

Quantify reflux in
proximal/distal esophagus
%

time pH < 4

Symptom correlation

Wireless, Catheter-Free Esophageal pH

Monitoring

A slim catheter with a terminal radiotelemetry

pH-sensitive probe above the gastrooesophageal junction.

The intraluminal pH is recorded whilst the

patient undergoes normal activities, and
episodes of pain are noted and related to pH.

A pH of less than 4 for more than 6-7% of the

study time is diagnostic of reflux disease.

Ambulatory 24 hr. pH Monitoring

Normal

GERD

Limited role in GERD

Assess LES pressure,

location and relaxation

Assist placement of 24
hr. pH catheter

Assess peristalsis
Prior to antireflux
surgery

Erosive/ulcerative esophagitis

Esophageal (peptic) stricture

Barretts esophagus

Adenocarcinoma

Often the suffix of itis leads the reader to know

there is inflammation. Therefore, inflammation
caused by GERD is called, Esophagitis.
Inflammation is the bodys response, as a protective
measure against infection and injury.
Repeated exposure to acid in the esophagus will cause
inflammation and injury to the mucosa.

Inflammation as a result of GERD can

cause epithelial changes, marked by
polymorphonuclear or mixed
polymorphonuclear and round cell
infiltration.
(Fennerty, 2003)

There are 3 inflammatory processes

that can occur with esophagitis:
Erosive Esophagitis.
Esophageal Strictures.
Barretts Esophagus.

Erosions

appear in esophageal mucosa as eroded

endothelium.
(Fennerty, 2003)
Contributing factors of Erosive Esophagitis:
Hiatal Hernia.
Decreased pressure in the lower
esophageal sphincter (LES).
Impaired ability of the tissue to resist injury.
Impaired esophageal clearance.
Increased volume of acid.

People with erosive esophagitis will

have mild to severe symptoms of pain.,
redness, ulceration and bleeding.

A:Ulcerated lower
gullet(esophageous)
B:Early strcture

A stricture is an abnormal narrowing of passage.

Fibrous strictures develop as a consequence of longstanding oesophagitis that is irreversible .
Contributing Factors of Esophageal
Strictures
Decreased pressure in the lower
esophageal sphincter (LES)
Hiatal Hernia
Ineffective peristalsis

Barium Swallow

Endoscopy

People with strictures often feel like

there is something stuck in their
throat. Severe strictures result in
difficulty swallowing (dysphagia) which
is worse for solids than for liquids.

Those with severe strictures usually have

less symptoms of heartburn, acid is not
able to reflux due to the narrowing of the
esophagus.

Those with strictures may also have weight loss,

due to a change in their diet to accommodate the
strictures.

As mentioned earlier, as a result

of inflammation: cellular
changes can occur.

These cellular changes can be a

precursor to cancer.
Some articles may refer to these changes as
metaplasia. This is the actual transformation of
cells or tissue from normal to abnormal; whereas,
dysplasia is the growth of abnormal cells or tissue.

Cells in the lining of the esophagus are actually

replaced with abnormal cells similar to those in the
stomach.
(Fennerty, 2003)
This is a condition in which the squamous epithelium of the
esophagus is replaced by metaplastic columnar epithelium
containing goblet and columnar cells (specialized intestinal
metaplasia)

The exact mechanism is not known. However, these

cellular changes are believed to be a protective response to
adapt to the repeated inflammation of exposure to stomach
acid.
(MedicineNet.com)

Barretts Esophagus

Pink columnar mucosa

extending from the cardia to
the lower esophageous.

Ulcers, although not a common symptom, can be found

with Barretts Esophagus. The ulcers can lead to
Gastrointestinal bleeding.
(Fennerty, 2003)

CLO is the major risk factor for Oesophageal

Adenocarcinoma

Barium Swallow

Endoscopy

The molecular events underlying the

progression of CLO from metaplasia to
dysplasia to cancer are not well understood
but
E-cadherin
polymorphisms,
p53
mutations, transforming growth factor-
(TGF-), epidermal growth factor (EGF)
receptors, COX-2 and tumour necrosis factor (TNF-) may play roles in neoplastic
progression.

Negative impact on health-related quality of life1

Risk factor for esophageal adenocarcinoma2

1. Revicki et al. Am J Med 1998;104:252.
2. Lagergren et al. N Engl J Med 1999;340:825.

Davidsonsons Principles and practice of medicine Page 626, fig 9.22 .

Elevate head of bed 4-6 inches.

Avoid eating within 2-3 hours of bedtime
Lose weight if overweight
Stop smoking
Modify diet
Eat more frequent but smaller meals
Avoid fatty/fried food, peppermint, chocolate,
alcohol, carbonated beverages, coffee and tea.

There are 3 categories of medications that can help

alleviate or prevent symptoms from occurring.
(Kaynard, Flora, 2001)

Antacids.

H-2 receptor blockers.

Proton pump inhibitors.

H2-Receptor Antagonists
(H2RAs)
Cimetidine (Tagamet)
Ranitidine (Zantac)
Famotidine (Pepcid)
Nizatidine (Axid)

Proton Pump Inhibitors

(PPIs)

Omeprazole (Prilosec)
Lansoprazole (Prevacid)
Rabeprazole (Aciphex)
Pantoprazole (Protonix)
Esomeprazole (Nexium )

These medications help to neutralize stomach acid. They

usually provide quick relief, however, will not heal any
inflammation.

Maalox

Mylanta

Tums

Rolaids

These medications reduce the acid production. They do

not act as quickly as antacids, but provide longer
relief. They start working in about 30 minutes.

Tagamet

Zantac

Pepcid AC

These medications are long acting and block acid

production. Because of this, they have the
ability to allow time for damaged tissue to heal
from inflammation.

Prevacid

Prilosec

Aciphex

Protonix

Nexium

Endoscopic balloon dilatation or

bouginage are an additional option for
the endoscopist approaching an
esophageal stricture.

OESOPHAGECTOMY:
widely recommended for those with
HGD(high-grade dysplasia) as the
resected specimen harbours cancer in up
to 40%

ANTI-REFLUX SURGERY

Intractable GERD rare

Difficult to manage strictures
Severe bleeding from esophagitis
Non-healing ulcers

GERD requiring long-term PPI-BID in a

healthy young patient
Persistent regurgitation/aspiration
symptoms
Not Barretts esophagus alone

A treatment of last resort Fundoplication, a surgical

procedure to increase pressure on the LES by
stretching and wrapping the upper part of the
stomach around the sphincter.
Dr. Robert Marks and his colleagues at the University
of Alabama reported in 1997 on the long-term
outcome of this procedure. They found that 64% of
the patients in their study who had fundoplication
between 1992 and 1995 still suffered from heartburn
and reported an impaired quality of life after the
surgery.

Esophagitis relapses quickly after cessation

of therapy
> 50 % relapse within 2 months
> 80 % relapse within 6 months

Effective maintenance therapy is imperative

Naturopathy approach towards Gastro

Esophagial Reflex Disease [GERD].
PREVENTIVE APPROACH.
Prevent further worsening of the
condition and prevent suppression of
the manifested symptoms.

TREATMENT APPROACH.

Make a treatment protocol on the basis of law of

vitalism and theory of holism. Guided by symptoms
act on cause.

CURATIVE APPROACH

proper follow up advice and call for second session of

treatment if required.

Life style modification.

Dietary and herbal management .
Other modalities of Naturopathy:
Fasting therapy
Hydrotherapy.
Manipulative therapy.
Mud therapy.
Helio therapy.
Chromo and magneto therapy.
Acupuncture/Acupressure.
Rekhi and other healing therapy.
Dietary counseling.

Including yoga therapy and Counseling

To deal with the cause of the disease.

To eliminate symptoms
To manage or prevent the future
complication.
To give the physical and psychological
support.
To deal with the associated symptoms.
Heal Esophagitis
Maintain remission

Smoking Inhibits saliva, may also increase acid

production & weaken the
LES.

Certain exercising & bending that may

increase the abdominal pressure.

Wearing of tight clothing increases the abdominal

pressure.

Lying flat after a meal relaxes the muscles making

susceptibility for reflux.

Fatty, greasy foods - take longer to digest

keeping food in the stomach longer.
Peppermint, spearmint, and chocolate weaken
the LES.
Carbonated and alcoholic beverages increase
the acidity in the stomach.
Large meal portions produce large acid levels.
Citrus, onions, and acid from tomatoes can be
irritating to the esophagus.
(Howard, B., 2004)

The following protocol is designed to deal the

patient with GERD.

DIET AND TREATMENT PLAN

Naturopathy approach is neither disease basis
nor symptomatic. This plan is advice only
during the course of treatment minimum
4days in general.
Clinical approach should be individual.

Rx- Bajrasana 5min daily after meals.

REFRENCES
Fennerty, B. The Continuum of GERD Complications. Cleveland
Clinic Journal of Medicine. Nov. 2003
Vol. 70, Suppl. 5, p. 33-48.
HeartburnAlliance Retrieved March 2006
Hu, F. , Prestson, R., Post,J. et al. Mapping of a Gene for Severe
Pediatric Gastroesophogeal Reflux to Chromosone 13q14.
Journal of American Medical Association. Vol 284 (3), July
2000, p. 325-334. Retrieved Feb. 2006 from Ovid database.

Jackson Gastroenterology (2005) Retrived Feb. 2006,

Gale_Encyclopedia_of_Medicine._Vol._3._2nd_ed.

Kaynard, A., Flora, K. Gastroesophageal Reflux Disease:

Control of Symptoms, Prevention of Complications. Post
Graduate Medicine. Sept. 2001. Vol. 110, Iss. 3.MayoClinic
(n.d.) Retrieved Feb. 2006

Kahrilas, P. GERD: Pathogenesis, Pathophysiology,

and Clinical Manifestations. Cleveland Clinic
Journal of Medicine. Nov. 2003. Vol. 70, Suppl 5,
p. 4-18. Retrieved Feb. 2006

Zuckschwerdt, W. Definition, Epidemiology, and

Pathogenesis of GERD. (2001) Surgical Treatment:
Evidence Based Problem Oriented. Retrieved March, 2006
Cox JGC, Winter RK, Maslin SC, et al. Balloon or bougie
for dilation of benign oesophageal stricture? An interim
report of a randomized controlled trial. Gut 1988 29 17411747