Gastro-esophageal reflux, or GERD, is a very common condition that affects up to 20% of the population in America. If you have diabetes, this problem may be even more common and more severe. When blood sugars are elevated and diabetes is poorly controlled, the stomach does not empty properly, leading to an increased frequency of reflux, heartburn, and indigestion.
Feeling the Burn of GERD
For most people, GERD is simply a mild nuisance condition that leads to heartburn after large meals or overindulging. For others, it can be a very serious condition leading to complications such as ulcers, bleeding, and even cancer. The stomach normally secretes acid that aids in the first stages of digestion. Although the lining of the stomach is resistant to the damaging effects of acid, the esophagus is not, and even small amounts of acid regurgitation can injure the lining causing pain and ulceration. A one-way valve known as the lower esophageal sphincter is present between the stomach and esophagus. It is designed to allow food and fluid to enter the stomach and prevent backflow into the esophagus; unfortunately, this valve frequently malfunctions and allows acid reflux to occur.
The most common symptom that occurs is a burning feeling in the chest called heartburn (even though there is no relationship to the heart itself). Other symptoms may include chest pain, regurgitation of fluid, nausea, vomiting, and difficulty swallowing. If acid backs up all the way to the throat, then “extra-esophageal” symptoms may occur. These include sinus irritation, hoarseness, laryngitis, worsening asthma, and even pneumonia.
The Association of a Hiatal Hernia
Many people with GERD will also be diagnosed with a hiatal hernia. This occurs when the opening in the diaphragm through which the esophagus passes enlarges and the stomach slides upward into the chest. The “sliding” hiatal hernia pre-disposes the individual to acid reflux. Unlike other hernias, hiatal hernias usually do not need to be repaired surgically.
How Do You Know If You Have GERD?
A diagnosis of GERD is often made solely on the basis of symptoms, and treatment can be started right away. In some cases, further testing is necessary. A barium swallow or upper gastrointestinal x-ray may be advised. Upper endoscopy is a more accurate test that allows the physician to pass a slim tube with a digital camera on the tip into the mouth, esophagus, stomach, and intestine (under sedation of course!). This provides detailed information regarding the tissue lining of these various organs, and also allows biopsies to be taken. In some cases, measurement of esophageal acid exposure over a 24-hour period may be advised.
What Can You Do?
Treatment of GERD first entails lifestyle modifications. These include weight loss (if you are overweight), smoking cessation, avoidance of eating for three or more hours before going to bed at night, and elevation of the head of the bed by six-eight inches. A diet that is low in fat and spices may be beneficial, and of course one should avoid any foods that tend to precipitate symptoms. Control of diabetes is especially important as high blood sugars may slow down the rate at which the stomach empties, leading to worsening GERD. In addition, if diabetes is poorly controlled for many years, then intestinal nerve damage can occur, leading to worsening problems with stomach emptying as well as abnormal movement of the esophagus itself.
Numerous medications are available for the treatment of GERD. Antacids such as Maalox, Mylanta, Tums, and Gaviscon may provide relief for mild heartburn. H2 blockers are a group of medicines that decrease acid output from the stomach and are effective for the treatment of mild GERD. These are available over the counter and by prescription. The most commonly used agent is Famotidine or Pepcid. Proton pump inhibitors or PPIs are a stronger group of medicines that suppress stomach acid secretion to a greater degree and are more effective in healing ulcerations of the esophagus associated with GERD. These include Prilosec, Prevacid, Aciphex, Protonix, Nexium, Dexilant, and Zegrid. Many of these are available over the counter. All of these medications are safe to take long-term if needed, although some recent studies have raised questions about potential risks.
For those who do not do well with medications, an effective surgical procedure called fundoplication may be considered. Minimally invasive endoscopic procedures are available to stop GERD, but their long-term effectiveness is uncertain and many consider these to still be experimental.
GERD is one of the most common conditions for everyone on the planet, but it’s especially common in people with diabetes. Many people with poorly controlled type 2 may not experience any significant symptoms related to their diabetes when their A1c is above 10%, but elevated glucose levels can cause GERD and make it significantly worse. Keeping your blood sugars in a healthy range can improve your condition. There are many treatments available for GERD, so it’s important to speak with your physician if you are having persistent symptoms.