Sleeping Disorders

Gastroesophageal Reflux Disease (GERD)

Gastroesophageal Reflux Disease (GERD) is a sleep disorder characterized by repeated awakenings during the night due to unpleasant burning and choking sensations resulting from stomach acid flowing upward into the throat while asleep.

Symptoms

The main symptoms of GERD in may include one or more of the following:
· Chronic chest pain,
· Difficulty swallowing (dysphagia),
· Esophagitis (reflux esophagitis),
· Inflammatory changes in the esophageal lining (mucosa), and,
· Strictures.
Less commonly, other symptoms of GERD may include one or more of the following:
· Changes of the voice,
· Chronic ear ache or sinusitis.
· Cough
· Hoarseness,
In children and infants, GERD may be difficult to detect.  Symptoms may include any of the symptoms above as well as one or more of the following:
· Bad breath,
· Coughing and other respiratory problems,
· Effortless spitting up,
· Failure to gain adequate weight,
· Inconsolable crying,
· Refusing food,
· Repeated vomiting,

Causes

GERD can be caused by a range of factors, including:
· Heartburn, which is the major symptom of acid in the esophagus, is characterized by a burning discomfort behind the breastbone (sternum).  Occasional heartburn is common but does not necessarily mean one has GERD.  Patients that have heartburn symptoms more than once a week are thought to be at risk of developing GERD.  Increased acidity or production of gastric acid can contribute to the problem.
· Incompetence of the Lower Esophageal Sphincter (LES) or transient LES relaxation.
· Hiatal hernia,
· Being overweight or obese,
· Wearing tight-fitting clothes,
· Pregnancy,
· Yeast infections of the digestive tract can cause GERD-like symptoms.
· Sleeping on your stomach / front, instead of your side or back.
The immature digestive systems in infants are usually the cause of their GERD-like symptoms, and most infants stop having acid reflux by the time they reach their first birthday.  Some children don't outgrow acid reflux, however, and continue to have it into their teen years.  Children that have had heartburn that doesn't seem to go away, or any other symptoms of GERD for a while, should talk to their parents and visit their doctor.

Diagnosis

Taking a detailed history is vital to the diagnosis of GERD.
Useful investigations may include:
· Barium Swallow X-Rays,
· Esophageal Manometry,
· Esophageal pH Monitoring, and,
· Esophagogastroduodenoscopy (EGD).
EGD is a form of endoscopy which involves the insertion of a thin scope through the mouth and throat into the esophagus and stomach (often while the patient is sedated) in order to assess the internal surface of the esophagus, stomach, and duodenum.  In general, an EGD is done when the patient does not respond well to treatment, has had symptoms or required medications for a prolonged time (generally 5 years), has dysphagia, anemia, blood in the stool (detected chemically), has weight loss, or has changes in the voice.

Complications / Issues

In addition to causing a disturbed sleep and often intense pain, GERD has also been linked to laryngitis, chronic cough, pulmonary fibrosis, earache, ulcers of the vocal cords, and asthma.
The complications of GERD may also include stricture formation, and the development of Barrett's esophagus and esophageal ulcers.  GERD may also lead to the development of esophageal cancer.

Treatment

The rubric "lifestyle modifications" is a term that many physicians use when recommending non-pharmaceutical treatments for GERD.  In 2006, a review of the treatments for GERD found that dietary changes are far less successful in treating GERD.  However, weight loss and elevating the head of the bed were found to be very successful treatments for GERD.

Weight Management

If you are overweight or obese, then the best way to reduce and eliminate your GERD symptoms may be to lose weight.  This is not easy however, and you will need to work hard and be disciplined to achieve sufficient weight loss.  A healthy, balanced diet, low in fats and sugars, and regular exercise are the keys to weight loss.

Dietary and Lifestyle Changes

Certain foods and lifestyle are considered to promote gastroesophageal reflux:
· Avoid coffee (as found in tea, coffee, soft drinks, etc), alcohol, calcium supplements, antacids (containing calcium), and excessive amounts of Vitamin C supplements especially within a few hours of bedtime as these are stimulants of gastric acid secretion.
· Foods high in fats and smoking reduce lower esophageal sphincter competence, so avoiding these tends to help, as well.  Fat also delays emptying of the stomach.  Milk and milk-based products contain calcium and fat, so should be avoided before bedtime.
· Having more but smaller meals also reduces the risk of GERD, as it means there is less food in the stomach at any one time.
· Avoid eating for at least 2 hours before bedtime.
· Do not lie down after a meal.
· Avoid the chocolate, peppermint, spicy foods, acidic foods (such as oranges and tomatoes), and cruciferous vegetables (such as onions, cabbage, cauliflower, broccoli, brussel sprouts) especially within 2-3 hours of bedtime.

Elevating The Head Of The Bed

Elevating the head of the bed is an easy change to implement and also highly effective for the treatment of GERD.  This can be accomplished by using wooden blocks, or even plastic or wooden bed risers which support bed posts or legs, a bed wedge pillow, or an inflatable mattress lifter that fits in between mattress and base.
The height should be elevated 6 to 8 inches high in order to be as effective as possible in hindering the backflow of gastric fluids.

Drug Treatment

A number of drugs are registered for the treatment of GERD, and they are among the most-often-prescribed forms of medication in most Western countries. They can be used in combination with other drugs, although some antacids can impede the function of other medications:
· Antacids: before meals or symptomatically after symptoms begin can reduce gastric acidity (increase the pH).  Alginic acid may coat the mucosa as well as increase the pH and decrease reflux.  Warning: some antacids can impede the function of other medications – so, as always, check with your doctor before use.
· Antihistamines (Gastric H2 Receptor Blockers): such as ranitidine or famotidine can reduce gastric secretion of acid and relieve complaints in about 50% of all GERD patients.
· Proton Pump Inhibitors: such as omeprazole are the most effective in reducing gastric acid secretion, as they stop the secretion of acid at the source of acid production.  To maximize effectiveness of this medication the drug should be taken a half hour before meals.
· Prokinetics: help strengthen the Lower Esophageal Sphincter (LES) and speed-up gastric emptying.

Surgical Treatment

The standard surgical treatment, sometimes preferred over longtime use of medication, is the Nissen Fundoplication.  In this procedure, the upper part of the stomach is wrapped around the Lower Esophageal Sphincter (LES) to strengthen the sphincter and prevent acid reflux, and to repair a hiatal hernia.

Prevention

The best way to prevent the onset of the symptoms and complications of GERD is to seek medical advice and treatment as soon as possible after you notice the symptoms.

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