This is the protocol for Gastroesophageal Reflux Disease:GERD
Let’s break it down!
Gastroesophageal Reflux Disease (GERD), or better known as “acid reflux“, occurs when the acidic contents of your stomach make their way into the esophagus and cause uncomfortable symptoms like the notorious “heartburn” sensation. The lower esophageal sphincter typically keeps acidic content inside the gut, but when it loosens, GERD rears its ugly head.
To some degree, it’s normal to experience some form of acid reflux. Most people have felt what it’s like to have heartburn after eating spicy foods or a fatty meal. But long term GERD can cause macroscopic damage to the esophagus and lead to more severe complications.
GERD is a common issue, even among soldiers. Approximately 10-20% of the western world carries the burden of this disease. Without a doubt, you’ll have soldiers in your aid station in need of symptomatic relief at some point in your career.
For a more in-depth review: check out the video below:
There are a variety of symptoms associated with GERD. The two most common symptoms are heartburn (sensation from acid burning the esophagus) and regurgitation (commonly noted by a sour taste in the mouth from gastric contents). Some of the less common symptoms include dysphagia (difficulty swallowing) and chest pain, which can sometimes mimic acute coronary issues.
There are different levels of severity when it comes to GERD; some only find it a nuisance while others can experience overwhelming and sometimes scary symptoms. The video below shows a patient who experienced horrible episodes of GERD:
1. Avoid high-fat, onion, tomato, chocolate, peppermint, citrus, tobacco, coffee, alcohol
Diet restrictions haven’t been shown to be quite as effective as other lifestyle modifications like weight loss or elevating the head while sleeping, but it can still be very effective if the patient can identify their “trigger foods”. Usually, these will be foods that increase the amount of acid in the stomach like fatty foods, spices, citrus, alcohol, etc.
2. Elevate the head of the bed when sleeping, do not eat just before bedtime, do not sleep on right side
Patients with GERD often experience their worst episodes while sleeping. This is mostly due to poor positioning. Elevating the head of the head will allow gravity to work in the patient’s favor, keeping the contents of the stomach at a lower position. Restricting food before bedtime will minimize the chances of creating excessive stomach acid before sleeping. Avoiding sleep on your right side will also help keep the contents in your stomach due to the bean-like shape of the stomach that favors the left side.
Ranitidine is an anti-histamine that specifically targets Histamine-2 receptors on the parietal cells of the stomach; thus reducing gastric acid secretion. This is usually the first-line medication for managing GERD due to its low-side effect profile. It has a slow onset (takes 2.5 hours to reach peak concentrations), but it typically lasts 4-10 hours.
When ranitidine fails, omeprazole is our next go-to. Omeprazole is a proton-pump inhibitor, which means it suppresses gastric acid secretion by inhibiting the H+, K+, -ATPase enzyme system [the acid (proton H+) pump] in the parietal cells of the gut. Omeprazole is significantly more effective than Ranitidine, but it also comes with a higher frequency of side effects (headache, abdominal pain, nausea/vomiting, etc.)
Doxycycline is an antibiotic commonly given to soldiers in high-risk areas to take daily to prevent malaria. It works well, but it irritates and damages the esophagus, which is harmful to patients who already suffer from GERD. By taking it with a meal, the patient can minimize the damage being done.
GERD isn’t usually life-threatening or significantly problematic when given proper treatment. For soldiers who experience long-term or severe episodes of GERD may eventually have surgery done to tighten or reinforce the lower esophageal sphincter. But until then, keep your soldiers in the fight!
Good luck out there!
- UpToDate: Medical Management of Gastroesophageal Reflux Disease in Adults
- UpToDate: Clinical manifestations and diagnosis of gastroesophageal reflux in adults
- Advanced Tactical Paramedic Protocols Handbook. 10th ed., Breakaway Media LLC, 2016.