GERD treatment: Past, present and future

[6 MIN READ]

In this article:

• Gastroesophageal reflux disease (GERD) is a chronic digestive disease that occurs when the liquid of the stomach travels back up the esophagus, which can lead to tissue damage.
• GERD has a long treatment history that dates back to the 16th century.
• Maintaining a healthy lifestyle and eating habits can help you reduce the risk of GERD.
• GERD is treatable by medications and sometimes surgery such as the transoral incisionless fundoplication (TIF) procedure.

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) has estimated that gastroesophageal reflux disease (GERD) affects about 20 percent of individuals in the United States. Anyone can develop GERD and without treatment it can lead to serious health complications such as: esophagitis (inflammation in the esophagus); abnormal narrowing of the esophagus that causes problems with swallowing; and Barrett’s esophagus, which may lead to a rare cancer called esophageal adenocarcinoma.

What causes GERD?

GERD symptoms might seem obvious when reported, but they can be silent and sometimes lethal. There isn’t a single cause behind the formation of the disease; however, research has shown that it is a mechanical failure of the bottom of the esophagus that, over time, can shorten and weaken which causes acid reflux. Food (how, when and what we eat) seems to be closely related to the formation of GERD since it occurs when the esophageal reflexes are overwhelmed by food and stomach content goes back into the esophagus causing irritation and symptoms.

 Symptoms of GERD include:

• Heartburn
• Chest pain
• Difficulty swallowing
• Chronic and constant dry cough
• Food regurgitation
• Shortness of breath and nausea
• Burning feeling in the middle of your chest

GERD most often occurs in people who:

• Do not exercise, are overweight or obese
• Do not follow a healthy diet and often consume trigger foods or overeat
• Smoke or are exposed often to secondhand smoking
• Are pregnant because the hormones cause the digestive system to slow down
• Are taking medications such as: benzodiazepines, sedatives that make you calmer or sleepy; calcium channel blockers, which are used to treat high blood pressure; certain asthma medicines; nonsteroidal anti-inflammatory drugs (NSAIDs); and tricyclic antidepressants (source: NIH)
• Have a hiatal hernia, a condition where the opening of your diaphragm lets the upper part of the stomach move up into your chest (this condition can increase the risk of getting GERD)

GERD treatments have changed over time and thanks to scientific innovation, new procedures and treatments, plus adopted lifestyle changes, patients can now live happy and healthy lives after care.

A story of living with GERD

For this heart health podcast, Dr. Phuong Nguyen, MD, Director of Advanced Endoscopy at Providence and Lorraine Peterson, a GERD patient, provide us with in-depth insights into the experience, treatments and procedures needed to cure and manage the disease. Lorraine shares her very personal journey of overcoming the challenges and finding the strength to make lifestyle changes.

Lorraine encourages people to learn how to take control of their health, be an advocate for themselves, and learn as much as possible: “you really have to be a captain of your own ship,” she says. Listen to the full story below:

Jump to GERD and its treatments

History of GERD 

As Dr. Phuong Nguyen and Lorraine Peterson talk about in the podcast above, GERD is very common, but every patient requires unique care. To better understand the evolution of and innovation around clinical treatments to help patients with GERD, it’s important to understand the past, present and future of the disease.

As early as the 16^th century, the medical terms “hartburne” and “pepsis” started appearing in diagnosis descriptions for symptoms stemming from the abdominal area. Remedies ranged from herbal teas, bismuth (a chemical element) to even leech therapy. Much later in the 19^th century, doctors accepted that stomach acid directly caused digestion. However, that same acid could be pathogenic to the mucosal lining of other digestive tract organs, mainly the esophagus. Following these discoveries more sophisticated therapies such as milk-based agents, antacids and neutralizing compounds improved treatment of acid related disorders.

Esophagitis, or inflammation of the internal lining of the esophagus caused by acid, is described as far back as 1792 by John Peter Frank in Vienna ⁽¹⁾ and has been consistently associated in the modern era with objective diagnosis of gastro-esophageal reflux disease, or GERD ⁽²⁾. These original findings by Frank were based on examinations during open surgery or autopsy and further validated by Mackenize in 1884⁽¹⁾.

Why is the history of reflux disease important?

 

• To better understand its critical impact on the development of esophageal cancer
• Dr. Norman Barrett in 1957 invented the term “reflux esophagitis” to describe the damage of the esophageal lining caused by abnormal acid exposure from the stomach
• His findings, although challenged at the time, went on to show the lethalness of acid exposure and help establish a scientific standard to monitor the progression of esophagitis, known today as “Barrett’s Esophagus"

Abdominal and thoracic surgeons were also making their own advances concerning the treatment of reflux disease. In 1955, Dr. Rudolph Nissen in Switzerland operated on a patient who displayed symptoms of reflux esophagitis and ulcers. His strategy was to “wrap” the fundus (top portion) of the stomach around the distal end (bottom) of the esophagus to hopefully prevent stomach acid from reaching the lower esophagus. It worked and he published a series in 1961 of patients who received his “gastroplication” ⁽³⁾ known today as the “Nissen fundoplication.” (Figure 1 source)

While the Nissen procedure stopped reflux and its symptoms in most patients, it also created unwanted post-operative side effects such as poor gut motility (when the digestive muscles contract). Nissen and his colleagues modified the technique and experimented with partial wraps to alleviate the initial complications. ⁽¹⁾ 

A fun and interesting fact regarding Dr. Nissen was that he treated Albert Einstein for abdominal aortic aneurysm in 1948. The great genius inventor and theorist of our time was 69 years of age and survived 7 more years after the surgery. Read more about the fascinating but simple technique used to treat Einstein’s rather serious condition in the references at the end. ⁽⁶⁾

While Nissen was focused on the wrap, or “gastroplication,” some of his colleagues were concentrating on the importance of a proper hiatal hernia repair 
(the figure shows the relationship between the structures of stomach, diaphragm and esophagus). P.R. Allison of Leeds, England was one such colleague that thought doing “the wrap” was indeed unnecessary and a proper hernia repair alone fixed the problem (figure 2 source). ⁽⁴⁾

This debate raged on for years and spawned many new variations of the wrap and hiatal hernia repair technique including the abdominal and thoracic approach. E.R. Woodward showed in 1971 that both were needed to achieve optimal success in outcomes with clinically significant control of reflux post-operatively. ⁽⁵⁾   

GERD and proton pump inhibitors (PPI)

In 1988, omeprazole, a proton pump inhibitor, or PPI, was launched under the brand name Prilosec and prescribed to treat gastric ulcers. ⁽⁷⁾ The drug works by chemically bonding to “parietal” cells in the stomach lining that secrete or “pump” acid into the gut and turning off that pump.

PPIs were also successful in treating the symptoms of heartburn and reflux disease (figure 3 source). The reduced acid made it less painful and tolerable for most heartburn patients. However, acid is very important for proper digestion of proteins and other critical substances in a healthy diet. Numerous negative side effects have been published over the decades that show long term use of “daily” PPIs is harmful. ⁽⁸⁾

The market for PPI therapy to treat reflux disease has been booming for decades. It was estimated in 2020 that the market value reached $2.75 billion and is estimated to grow to $3.5 billion by 2026. Asia is the fastest growing market with North America representing the largest. It is worth mentioning that in the continental North America, GERD prevalence has now reached 27% with 11,000 for every 100,000 people in the USA alone reporting problems with GERD. Interestingly, a recent USA study also showed that daily PPI consumption increases risk of contracting COVID-19. ⁽⁹⁾

Why you should be concerned about GERD and its treatments

• Primarily the extreme rise in incidence of esophageal cancer relative to other cancers ⁽¹⁰⁾
• Side effects of prescribing long-term daily PPIs for GERD patients ⁽⁸⁾
• 50% of Barrett’s and esophageal cancer patients never report GERD symptoms pre-diagnosis⁽¹¹⁾

Currently, the American College of Gastroenterology guidelines for screening endoscopy for Barrett’s is narrow. Men must have frequent GERD symptoms over 5 years and at least two risk factors. For women, routine screening is not recommended unless there are multiple risk factors and/or a family history. ⁽¹¹⁾

With over half of the diagnosed patients for Barrett’s and esophageal cancer never reporting symptoms to their physician, it begs the question: should more liberal criteria for screening be implemented? (figure 4 source)

GERD and cancer risks

We know Barrett’s Esophagus is a precursor to cancer and we know that we are not screening half of the patients because they do not present symptoms until they have the disease. ⁽¹¹⁾ Would an established age for Barrett’s screening be a good idea? Age-based screening has certainly contributed to early detection for colon, breast, prostate and even lung cancers.

The pathway for today’s GERD patient is complex. The limitations around screening for Barrett’s, concerns over long term PPI use and variations across surgical therapy technique and outcomes likely have patients and their primary care physicians pondering the best course of action.

Surgical treatments for GERD

A significant number of patients seek treatment for GERD but finding the right therapeutic team can be challenging. Treatment for GERD, as previously discussed, is primarily medical but does not address the underlying cause (a defective lower esophageal sphincter (LES) or presence of hiatal hernia), nor does medicine effectively treat extra-esophageal symptoms and regurgitation.⁽¹²⁾ The surgical therapeutic options are largely divided into lap Nissen, partial fundoplication and magnetic sphincter augmentation (MSA), also known as LINX. These solutions are underused due to adverse side effects deemed less acceptable to gastroenterologists and patients. ⁽¹²⁾

A new procedure entering the mainstream of GERD treatment is an endoscopic therapy with similar success as surgery but without the unwanted side effects. The TIF procedure (transoral incisionless fundoplication) addresses a smaller GERD population but when combined with surgical therapy (known as cTIF) the majority of reflux patients can benefit from this approach. The critical element is finding the gastroenterologist--surgeon team with expertise and a patient-centric approach in place. (figure 5 source: Cary Endoscopic Center)

cTIF promises to increase the benefits of surgical therapy and patients are more likely to accept this approach when a collaborative team of providers present it as the way to fully heal from GERD. ⁽¹²⁾ Especially when considering that the risk of long-term side effects is nearly eliminated.

GERD procedures at Providence

Providence offers the TIF and cTIF procedures at centers across our network, including:

Southern California Region for Providence: 

• Providence St. Jude Medical Center in Fullerton, CA
  Gastroenterologist: Phoenix Nguyen
  Surgeons: Nikolai Bildzukewicz and Caitlin Houghton
• Providence Mission Hospital in Mission Viejo, CA
  Gastroenterologists: Phoenix Nguyen and Andrew Ko
  Surgeon: Sameer Kannan
• Providence Holy Cross in Mission Hills, CA
  Gastroenterologist: Mahendra Patel
  Surgeon: Walid Arnaout

Northwest Region for Providence:

• Providence Portland Medical Center in Portland, OR
  Surgeon: Christy Dunst
• Providence - Swedish First Hill Campus in Seattle, WA
  Surgeon: Ralph Aye
• Providence St Patrick in Missoula, MT
  Surgeon: Christopher Maki

Article sources

1. Historical perspectives on the treatment of gastroesophageal reflux disease 

Irvin M Modlin, MD, PhD, FACS, FRCS (Eng & Ed), Mark Kidd, PhD, Kevin D Lye, MD 

Gastrointestinal Endoscopy Clinics Volume 13 Issue 1 Pages 19-55 (January 2003) DOI: 10.1016/S1052-5157(02)00104-6: https://www.giendo.theclinics.com/article/S1052-5157(02)00104-6/fulltext

2. Esophagitis grading system: https://www.sciencedirect.com/science/article/pii/S2212097113700463#tbl1
3. Nissen publication: https://link.springer.com/article/10.1007%2FBF02231426
4. Allison publication: https://pubmed.ncbi.nlm.nih.gov/14835197/
5. Woodward:https://journals.lww.com/annalsofsurgery/Citation/1971/05000/Comparison_of_Crural_Repair_and_Nissen.18.aspx
6. Einstein: https://columbiasurgery.org/news/2015/08/27/history-medicine-ingenious-surgery-saved-world-s-smartest-man-1
7. PPI history
8.    Adverse effects of PPI: https://en.wikipedia.org/wiki/Proton-pump_inhibitor#Adverse_effects
9. PPI market and COVID risks: https://www.mordorintelligence.com/industry-reports/proton-pump-inhibitors-market
10. Esophageal Cancer rise: https://www.eventscribe.com/2018/ACG/ajaxcalls/PosterInfo.asp?efp=RFNSWFFHSFY2NDI0&PosterID=160489&rnd=0.2979961
11. BE and Cancer w/o symptoms: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6140158/
12. Novel interdisciplinary approach to GERD: https://pubmed.ncbi.nlm.nih.gov/33346082/

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Find a doctor 

Managing your gut health can lead to better overall health. The Providence gastroenterology team can help you manage chronic conditions like GERD and acid reflux. To schedule an appointment with a gastroenterologist, search our online provider directory. 

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