Gastro-oesophageal Disease (GORD) (Heartburn), Functional Dyspepsia (Indigestion), Gastroparesis,

Antacid (PPI or H2 Agonist) withdrawal.

 

Definition:
Upper gastro-intestinal (GI) complaints possess distinct disease labels and diagnostic criteria, however all share common drivers and pathophysiological processes.
Gastro-oesophageal Reflux Disease (GORD) or acid reflux, is a chronic condition in which the content of the stomach regurgitates (backs up or refluxes) into the oesophagus causing inflammation and damage to the lining of the oesophagus.
Functional dyspepsia (FD) and gastroparesis (GP) are the two most common sensorimotor disorders of the upper GI tract, with shared symptoms of upper abdominal pain, postprandial fullness, early satiety and nausea. FD experiences abnormal
fundic accommodation and GP is defined by delayed gastric emptying of a solid food meal in the absence of a mechanical obstruction.
Classifying GORD, FD and GP is confusing as the symptoms and treatments are frequently the same.
Hyperacidity is often cited as a primary cause of upper GI complaints, however new research shows that upper GI disorders exhibit similar gut barrier defects to lower GI conditions, such as IBS and IBD. For example, both leaky oesophageal epithelium and oesophageal visceral hypersensitivity have been found in GORD. Factors which damage epithelial integrity (such as stress, certain medications, alcohol) combine with factors that interfere with gastric function and sphincter competency, which all lead to mucosal inflammation, nociceptor activation and visceral hypersensitivity. Depending on
individual differences, (such as genetics, diet and other comorbidities (such as obesity)), these events manifest as different symptom patterns in different individuals. That is, the same processes may manifest as GORD, gastroparesis, functional dyspepsia, functional dyspepsia or ulceration depending on the individual.
The key message is that the label of the disease is not as important as the upstream drivers, as correction of these will improve the likelihood of successful treatment.
Managing upper GI medications: Hyperacidity is seldom the cause of upper GI condit ions, and yet medical management targets acid production. Stopping antacid therapy (PPI and H2 receptor antagonist) is known to cause withdrawal symptoms as a rebound phenomenon of excess acid secretion. This rebound acid hyper-secretion occurs two weeks after withdrawal and lasts for two to three months in up to 40% of patients. It is recognised that these medications may actually be creating the disease that they were designed to treat. That is, the rebound hyperacidity that can develop after PPI withdrawal may actually cause an acid-related upper GI disorder, when there was no hyperacidity issue in the first instance.

If patients are using PPI and H2 receptor antagonists and wish to withdraw from these medications, the same treatment protocol can be used. Withdrawal should preferably be delayed until symptoms and primary drivers such as stress and diet are under control. Natural medicines such as Turmeric and Liquorice for Heartburn and Reflux should be initiated for at least two weeks prior to medication reduction. Close supervision of patients’ symptoms is important, with gradual medication withdrawal, such as using the medication every other day.

Aetiology / Risk factors Factors that contribute to Upper GI complaints include:
• Hiatus hernia, due to mechanical and motility problems.
• Obesity - creating pressure under the diaphragm
• Common dietary irritants - Fatty and fried foods, chocolate, garlic and onions, caffeinated drinks, acidic foods such as citrus fruits and tomatoes, spicy foods, mint flavourings
• Gluten sensitivity
• Stress or mood disorders
• Helicobacter pylori infection
• Poor eating habits – Excessive carbohydrates, eating too large meals, eating directly before bedtime
• Use of alcohol or cigarettes
• Poor posture (slouching)
• Congenital weakness of lower oesophageal sphincter
• Hypercalcaemia, which can increase gastrin production, leading to hyperacidity.
• Pregnancy
• Diabetes
Gastroparesis: (delayed gastric emptying of a solid food meal with no obstruction)
• Multifactorial aetiology; including diabetes, prior surgery, ischaemia, connective tissue disorders, radiation, inflammation, medications and vaccinations.
• Gastric outlet obstruction or pyloric stenosis
• The use of some medications may predispose to reflux, such as:
           • Calcium channel blockers
           • Theophylline (Bronchodilators)
           • Nitrates (used in angina management)
           • Antihistamines                 

Signs and Symptoms:

Note: severe and sudden upper GI symptoms may appear similar to/mimic myocardial infarction (heart attack).
Common symptoms of Functional Dyspepsia (indigestion) and Gastroparesis are:
• Upper abdominal pain
• Postprandial fullness and pressure
• Early satiety
• Nausea, vomiting
• Weight loss
The most-common symptoms of GORD are:
• Heartburn
• Regurgitation
• Dysphagia (Trouble swallowing)

Less-common symptoms include:
• Pain with swallowing
• Excessive salivation (this is common during heartburn, as saliva is generally slightly basic and is the body's natural response to heartburn, acting similarly to an antacid)
• Nausea
• Chest pain

If with oesosphageal injury from acid reflux:
• Reflux oesophagitis—necrosis of oesophageal epithelium causing ulcers near the junction of the stomach and oesophagus.
• Oesophageal strictures—the persistent narrowing of the oesophagus caused by reflux-induced inflammation.
• Barrett's oesophagus—metaplasia (changes of the epithelial cells from squamous to columnar epithelium) of the distal oesophagus.
• Oesophageal adenocarcinoma—a rare form of cancer.