Tuesday, 17 February 2015

(2th edited )Most common diseases of Elders- Upper gastrointestinal (GI) diseases: Gastro-esophageal reflux disease (GERD)

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By Kyle J. Norton Health article writer and researcher; Over 10.000 articles and research papers have been written and published on line, including world wide health, ezine articles, article base, healthblogs, selfgrowth, best before it's news, the karate GB daily, etc.,.
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Some articles have been used as references in medical research, such as international journal Pharma and Bio science, ISSN 0975-6299.

Upper gastrointestinal (GI) diseases

The prevalence of upper gastrointestinal (GI) diseases is increasing in subjects aged 65 years and over. Pathophysiological changes in esophageal functions that occur with aging may, at least in part, be responsible for the high prevalence of
1. Gastro-esophageal reflux disease (GERD) in old age.
2. The incidence of gastric and duodenal ulcers and their bleeding complications is increasing in old-aged populations worldwide.
3.  H. pylori infection in elderly patients with H. pylori-associated peptic ulcer disease and severe chronic gastritis
4.  Almost 40% of GU and 25% of DU in the elderly patients are associated with the use of NSAID(1) and/or aspirin(2).(a)

                Gastro-esophageal reflux disease (GERD)

 Gastroesophageal reflux disease (GERD), also known as gastro-oesophageal reflux disease (GORD), gastric reflux disease, or acid reflux disease, is a chronic condition of liquid stomach acid refluxing back up from the stomach into the esophagus, causing heartburn. According to the study of “Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease.” by DeVault KR, Castell DO; American College of Gastroenterology, GERD is defined as symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus.

I. The Symptoms 
1. Heartburn
Heart burn is one of common symptom of Gastroesophageal reflux disease (GERD) in adult, as a result of acid reflux cause of burning sensation or pain in the middle of the chest mostly after meal(3)(4)(5).

2. Regurgitation
In gastroesophageal reflux disease (GERD), regurgitation is the expulsion of a small amount of digested foods to the mouth from esophagus. frequent or prolonged regurgitation can lead to acid-induced erosion of the teeth, bad breath or damage to the esophagus(3)(5).

3. Trouble swallowing(dysphagia)
It is caused by damage of the muscles and tissues that must flex for swallowing, as a result of prolonged period of acid reflux that has left untreated(6).

4. Pain when swallow
It may be caused by esophageal motility disorders, due to deglutitive contraction waves that die out in the upper esophagus(6a).

5. Asthma
Approximately, 59% of patients with GERD are experiences symptoms in asthma, according to the Baylor College of Medicine(7).

7. Other symptoms according to Texas A&M University(6) include
a, Stomach pain,
b. Stomach discomfort when eating,
c. Food and drink limits, 
d. Nausea and vomiting,
e. Gas and bloating,
f. Constipation,
g. Blood, and
h. Diarrhea

II. The Causes
1. Slower in emptying of the stomach after eating
Most uncommon causes of Gastroesophageal reflux disease (GERD) is due to the distention of the stomach with food over prolonged period of time that can lead to reflux(7). Approximately 20% of Gastroesophageal reflux disease (GERD) are caused the reason above.

2. Cardia
Cardia is the area between the part of the stomach and the esophagus, a angle where the esophagus enters the stomach acted as a valve to prevent foods and others to reflux back to the esophagus. If the cardia is not functioning well(8), it can cause Gastroesophageal reflux disease (GERD with burning sensation of the esophagus(9).

3. Esophageal contractile defection(11)
If the esophageal contraction fails to performed its function of proper swallowing food, it may not generate enough waves of contractions to push the foods down to the stomach after swallowing and the acid back into the stomach(6a)(10).

4. Hiatal hernia
Hiatal hernia is a condition of a portion of the stomach protrudes upward into the chest, through a tear or weakness in the diaphragm. Hiatal hernia of the esophagus and GERD had been shown to induce hemorrhage(13). GERD patients consuming a late-evening meal had significantly greater supine acid reflux compared to when they consumed an early meal, especially in overweight patients, and in patients with esophagitis or HH(12).

5. Obesity
Obesity increase the risk of Gastroesophageal reflux disease (GERD). Weight loss, through caloric restriction and behavioral modification, may improve reflux inobese patient with GERD(14). Bariatric surgery and Roux-en-Y gastric bypass (RYGB) has been consistently associated with improvement in the symptoms of GERD(14).

6. Esophageal mucosa
 Erosive changes in the esophageal mucosof of  the lower esophagogastric junctionwere strongly associated with GERD(15).

7. Medication
The use of medication such as NSAIDs product can increase the risk of Gastroesophageal reflux disease (GERD)(16).

8. Chronic diseases
Chronic diseases, including cough(17)(18)(19)pulmonary fibrosis(21), earache and asthma(20) are also associated with the higher risk of develop Gastroesophageal reflux disease (GERD).

9. Infection
Infection caused by H. pylori can increase the risk of Gastroesophageal reflux disease (GERD)(22) through the bacteria pylori suppression of gastric acid secretion  (Gastroenterology 1997 Jul;113(1):15-24).

10. Etc.

III. Complications In some severe cases as a result of frequent acid reflux.
1. Ulcers
Damage of the esophagus can lead to result of ulcers as a result of inflammation forming of scar(23).

2. Esophageal strictures
Prolonged period and frequent acid reflux, if keft untreated can lead to inflammation cause of narrowing of the esophagus(24)(25).

3. Barrett’s esophagus
Symptoms of gastroesophageal reflux disease (GERD) are the primary risk factor for Barrett's esophagus (BE)(26). The highest yield for Barrett’s is in older (age 50 or more) Caucasian males with longstanding heartburn(27).

4. Esophageal adenocarcinoma
In GICS 2009: EGF Genetic Variant Increases Risk for GERD-Associated Esophageal Adenocarcinoma ” by Roxanne Nelson posted by Medscape Newa Today, the author wrote that January 16, 2009 (San Francisco, California)

5. Etc.

IV. Diagnosis and tests
If you are experience some of the above symptoms, after recording your family history and physical exam, the following test may be recommended by your doctor.

1. Esophagogastroduodenoscopy (EGD)
Esophagogastroduodenoscopy (EGD) also known as upper gastrointestinal endoscopy is a diagnosis procedure allowed your doctor to check for any abnormality in the lining of the esophagus, stomach, and upper duodenum after a flexible endoscope inserted down the throat.

If any abnormality is found, your doctor order further examinations.
2. Barium swallow
Barium swallow is a medical imaging procedure allowed your doctor to examine the upper GI (gastrointestinal) tract, to exam the lining of the esophagus and the stomach, after you have drunk a suspension of barium sulfate.

3. Chest X-rays
A chest x-ray is an x-ray of the chest that allows your doctor to examine the lining of the esophagus, stomach, and upper duodenum.

4. Biopsy
A biopsy is a test of removal sample of cells or tissues for examination and determination of the grade and type of the tumors examined under a microscope by a pathologist or chemically, if the location of the tumor allows the test to be done without major risk to the patient.

4. Esophageal manometry
Esophageal manometry is a test with the use of a pressure-sensitive tube-like thin instrument passed through your mouth or nose and into your stomach to allow your doctor to examine the motor function of the Upper Esophageal Sphincter (UES), Esophageal body and Lower Esophageal Sphincter (LES).
5. Etc.

V. The GERD Diet
According to the GERD Diet (Gastroesophageal Reflux Disease) in McKinley Health Center of The university of Illinois at Urbana-Champaign
Dietary modifications are recommended to lessen the likelihood of reflux and to avoid irritation of sensitive or inflamed esophageal tissue. Listed below of several recommendations may help to manage GERD:
1. Decrease total fat intake – High fat meals and fried foods tend to decrease LES pressure and delay
2. Avoid large meals – Large meals increase the likelihood of increased gastric (stomach) pressure and reflux.
3. Decrease total caloric intake if weight loss is desired – Since obesity may promote reflux, weight loss
may be suggested by your healthcare provider to control reflux. Reducing both total fat and caloric intake will aid in weight loss.
4. Avoid chocolate – Chocolate contains methylxanthine, which has been shown to reduce LES pressure by causing relaxation of smooth muscle.
5. Avoid coffee depending on individual tolerance – Coffee, with or without caffeine, may promote gastroesophageal reflux. Coffee may be consumed if it is well tolerated.
6. Avoid other known irritants – Alcohol, mint, carbonated beverages, citrus juices, and tomato products all may aggravate GERD. These products may be consumed depending on individual tolerance.
B. Other modifications for treating GERD
7. Maintain upright posture during and after eating.
8. Stop smoking.
9. Avoid clothing that is tight in the abdominal area.
10. Avoid eating within 3 hours before bedtime.
11. Lose weight if you are overweight.
12. Sleep on your left side.
13. Chew non-mint gum which will increase saliva production and decrease acid in the esophagus.
14. Elevate the head of your bed 4-6 inches by placing bricks under the headboard. (Source)

VI. Treatments
A. Conventional medicine
A.1. Medication
1. Proton-pump inhibitors
Proton-pump inhibitors including omeprazole, esomeprazole, pantoprazole, are used to reduce the production of gastric acid in the stomach(28)(29).

2. H2 receptor blocker(30)
H2 receptor blockers include ranitidine, famotidine, cimetidine, etc., Over-the-counter medications are effective in treating symptomatic gastro-oesophageal reflux disease, with 41% with histamine-2 receptor antagonists, 60% with alginate/antacid combinations, and 11% with antacids(31).

3. 5HT4 agonist

Mosapride 40 mg q.d.s. is effective in decreasing acid reflux in the oesophagus in patients with GERD(32).

4. GABA-B Receptor Agonists
 Baclofen, a GABA-B agonist, showed effectively in the treatment of patients with GERD, through inhibition pf 34% to 60% of Transient Lower Esophageal Sphincter Relaxation (TLESR) and improvement of basal lower esophageal sphincter pressure(33).

5. Antacids
Antacids are oral medicine used to relieve symptom of heartburn of gastroesophageal reflux disease (GERB)(34)(35).

4. Pro motility Agents
Promotility Agents are used to improve GERD symptoms for patients with slow gastric emptying by stimulating the muscles of the gastrointestinal tract to reduce acid reflux into the esophagus(36).
5. Etc.

A.2. Surgery: Fundoplication Surgery
The aim of the surgery is to reduce heartburn caused by acid reflux, in severe case of inflammation, such as  hiatal hernia, damage of esophagus, etc.. Fundoplication surgery(37)(38) is the procedure to treat Gastroesophageal Reflux Disease (GERD) by strengthening the valve between the esophagus and stomach as the upper curve of the stomach wrapped and satured around the lower end of the esophagus to prevent acid from backing up into the esophagus with a laparoscopic with a small tunnel made from the stomach muscle to allow foods of the lower part of the esophagus to pass through. The surgery is also by times for the esophagus to heal.
 Laparoscopic fundoplication is effective in controlling symptoms in the majority of patients with Barrett's esophagus(BE) to orevent  the possibility of developing esophageal adenocarcinoma(39)

B. Herbs
1. Deglycyrrhizinated licorice
Deglycyrrhizinated licorice used by people with gastric and peptic ulcers for nearly a hundred years. its three antiulcer agents FM 100, plaunotol, and teprenon showed to increase the content of endogenous prostaglandins in the gastric mucosa,  through its endogenous secretin released and antiulcer effect(40).

2. Aloe Vera
According to the article of “Effect Of Orally Consumed Aloe Vera Juice On Gastrointestinal Function In Normal Humans, excerpts By Jeffrey Bland, Ph.D. (Linus Pauling Institute of Science & Medicine) involved ten healthy subjects – five men (median age: 42; standard deviation: 14 years), and five women (median age: 32; standard deviation: 5 years) – engaged  Aloe vera juice oral supplementation in in a semicontrolled study,  promotes proper gastrointestinal function, such as gastrointestinal motility, increasing stool specific gravity etc. through its regulate gastrointestinal pH effect(41),

3. Mastic gum
 Mastic gum. a resin obtained from the mastic tree (Pistacia lentiscus), showed to consist an ability to support the health of patients with ulcers, GERD and acid reflux, according to the article of Strategies to Protect Against Potential Bone-Destroying Effects”By Chris D. Meletis, ND,

4. Ginger
Ginger has been used for thousands of years to enhance the function of digestive system and treated stomach distress including nausea, vomiting, diarrhea and in digestion, acid reflux, motion sickness, dyspepsia, etc. due to its anti-inflammatory, antimicrobial and analgesic properties.
The methanol extract of ginger rhizome showed to inhibite the growth of all 19 strains of bacteria in vitro with a minimum inhibitory concentration range of 6.25-50 micrograms/ml(42)

5. Peppermint
In vitro, peppermint exhibited significant antimicrobial and antiviral activities, strong antioxidant and antitumor actions, and some antiallergenic potential. Animal model studies demonstrate a relaxation effect on gastrointestinal (GI) tissue, analgesic and anesthetic effects in the central and peripheral nervous system etc.,… Caution are necessary for using peppermint oil therapy in patients with GI reflux, hiatal hernia(43).

6. Etc.

C. Traditional Chinese medicine
a. Ban Xia Xie Xin Wan
, also known as "Pinellia Drain Epigastrium Pills" was recorded in classic texts around 210 C.E. used in TCM to treat various gastrointestinal disorders such as gastritis, enteritis, gastric ulcer, gastralgia exhibits its anti-ulcer action (probably based on its ability to protect the gastric mucosa), through improvement of gastric emptying and an anti-emetic action,
according to the study of the effects of hange-shashin-to on gastric function in comparison with sho-saiko-to" by Y Kase, M Yuzurihara, S Iizuka, A Ishige, Y Komatsu,

b. Ingredients
b.1. Ban Xia (Pinellia Tuber)
Main use: Dries Dampness, Transforms Phlegm, Stops vomiting, Resolves masses, Disperses nodules....
b.2. Huang Qin (Skullcap Root)
Main use: Clears Heat, Dries Dampness, Expels toxins, Stops bleeding...
b.3. Dang Shen (Codonopsis Root)
Main use: Tonifies the Middle Burner, Strengthens Qi, Promotes generation of Body Fluids, Nourishes Blood....
b.4. Gan Cao ( Licorice Root)
Main use: Tonifies the Spleen, Benefits the Qi, Moistens the Lungs, Calms cough...
b.5. Huang Lian (Coptis Rhizome)
Main use: Clears Heat, Dries Dampness, Expels toxins...
b.6. Bai Shao
Main use: Nourishes Blood, Preserves the Yin, Nourishes the Liver, Calms pain....
b.7. Chen Pi
Main use: Regulates the Qi, Regulates the Middle, Dries Dampness, Transforms Phlegm...

(a) http://www.ncbi.nlm.nih.gov/pubmed/15588798
(1) http://www.ncbi.nlm.nih.gov/pubmed/16001646
(2) http://www.ncbi.nlm.nih.gov/pubmed/22542157
(3) http://www.ncbi.nlm.nih.gov/pubmed/25232262
(4) http://www.ncbi.nlm.nih.gov/pubmed/25212408
(5) http://www.ncbi.nlm.nih.gov/pubmed/24347282
(6) http://www.ncbi.nlm.nih.gov/pubmed/25148757
(6a) http://www.ncbi.nlm.nih.gov/pubmed/2237280
(7) http://www.ncbi.nlm.nih.gov/pubmed/17682001
(8) http://www.ncbi.nlm.nih.gov/pubmed/16377311
(9) http://www.ncbi.nlm.nih.gov/pubmed/?term=Cardia+and+burning+sensation
(10) http://www.ncbi.nlm.nih.gov/pubmed/24330081
(11) http://www.ncbi.nlm.nih.gov/pubmed/8608873
(12) http://www.ncbi.nlm.nih.gov/pubmed/?term=Administration+of+a+Standardized+Meal.+Does+Timing+Matter
(13) http://www.ncbi.nlm.nih.gov/pubmed/17633874 
(14) http://www.ncbi.nlm.nih.gov/pubmed/?term=weight+loss%2C+through+caloric+restriction+and+behavioral+modification+in+obese+with+GERD
(15) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2956342/
(16) http://www.ncbi.nlm.nih.gov/pubmed/23265146
(17) http://www.ncbi.nlm.nih.gov/pubmed/18046990
(18) http://www.ncbi.nlm.nih.gov/pubmed/25374758
(19) http://www.ncbi.nlm.nih.gov/pubmed/25327320
(20) http://www.ncbi.nlm.nih.gov/pubmed/16430100
(21) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3115688/
(22) http://www.ncbi.nlm.nih.gov/pubmed/10378360
(23) http://www.ncbi.nlm.nih.gov/pubmed/14986731
(24) http://www.ncbi.nlm.nih.gov/pubmed/24564071
(25) http://www.ncbi.nlm.nih.gov/pubmed/24482901
(26) http://www.ncbi.nlm.nih.gov/pubmed/23567358
(27) http://www.ncbi.nlm.nih.gov/pubmed/18341497
(28) http://www.ncbi.nlm.nih.gov/pubmed/21235462
(29) http://www.ncbi.nlm.nih.gov/pubmed/20124466
(30) http://www.ncbi.nlm.nih.gov/pubmed/11552905
(31) http://www.ncbi.nlm.nih.gov/pubmed/17229239
(32) http://www.ncbi.nlm.nih.gov/pubmed/9692698
(33) http://www.medscape.org/viewarticle/434528
(34) http://www.ncbi.nlm.nih.gov/pubmed/10886047
(35) http://www.ncbi.nlm.nih.gov/pubmed/15540548
(36) http://www.ncbi.nlm.nih.gov/pubmed/1349550
(37) http://www.ncbi.nlm.nih.gov/pubmed/25386679
(38) http://www.ncbi.nlm.nih.gov/pubmed/23943388
(39) http://www.ncbi.nlm.nih.gov/pubmed/14759403
(40) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1156688/
(41) http://www.desertharvest.com/physicians/documents/DH127.pdf
(42) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3761965/
(43) http://onlinelibrary.wiley.com/doi/10.1002/ptr.1936/abstract

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