Lauren Gerson MD, MSc, highlights the connection between sleep and gastroesophageal reflux disease and discusses the latest treatment options, including TIF.
With approximately 7 million people in the United States having some symptoms of gastroesophageal reflux disease (GERD) and 60% of the adult population experiencing some type of GERD within a 12-month period according to Healthline, it is imperative to understand the contributing factors to this condition as well as the elements that may agitate it. Lauren Gerson MD, MSc, associate clinical professor of medicine at University of California, San Francisco, and director of clinical research, gastroenterology fellowship program, California Pacific Medical Center, speaks to Sleep Review about the connection between sleep disorders and GERD as well as what treatment options are available.
GERD and Sleep Disorders
Gerson says sleep deprivation can agitate GERD, which can prolong recovery and cause patient discomfort, and many people with GERD have symptoms at night that awaken them from sleep. Patients with GERD who experience nighttime acid reflux are also more likely to be subject to sleep-related ailments including insomnia, sleep apnea, consistent daytime fatigue, and restless leg syndrome. Per a 2009 study co-authored by Gerson titled “A Systematic Review of the Definitions, Prevalence, and Response to Treatment of Nocturnal Gastroesophageal Reflux Disease,” Gerson says the research team was unable to determine a cause and effect relationship between GERD and sleep apnea. However, Gerson says, “We think that they are both very common conditions that appear to co-exist in patients along with obesity, another risk factor.”
In addition, as some of the severe symptoms of GERD occur at night, it can leave patients restless and enduring coughing fits and painful acidic regurgitation. When patients lie down and sleep, there is several mechanisms that are reduced that normally help reduce GERD during the day, which includes decreased saliva production, decreased peristalsis, and decreased gravity, Gerson says, explaning why certain symptoms occur at night.
Presently, Gerson says there is no evidence that sleep deprivation aggravates GERD, though eating late-night meals may aggravate the condition. Gerson says, “Severe GERD can also occur at night when patients eat dinner within 3 hours of bedtime. Particularly if the meal is high in fat, the fat content delays stomach emptying, which then can cause more reflux symptoms.” As such, she advises patients with GERD to eat dinner early and only have light snacks at bedtime.
GERD Treatment Options
There are several therapeutic treatment options available for patients. Gerson says improved diet and exercise habits can help alleviate GERD symptoms, as can preventative medication called proton pump inhibitors (PPIs). Gerson says, “Most commonly patients are treated with antireflux medications like the proton pump inhibitor drugs. If patients have nighttime heartburn its important to take these drugs 30-60 minutes before dinner for maximum effect. They usually are not effective if used before bedtime and the effect may wear off if taken before breakfast.”
“PPIs are very effective in terms of healing of esophagitis in 70-80% of patients with providing symptom relief in 60-70%,” Gerson says. “They are safe to use as needed or daily if needed for control of symptoms.”
An additional treatment option is Nissen fundoplication, which is appropriate for patients with refractory symptoms, large hernias, or patients who wish to discontinue medication use. Gerson says this is effective and can last up to 10 years or longer. However, side effects from this procedure are possible, including the about 20 to 30% of patients who develop swallowing issues, bloating or difficulty belching after surgery, known as the gas-bloat syndrome.
TIF: A New Treatment
The aforementioned treatment options may not be effective for all patients. As such, a new endoscopic procedure called transoral incisionless fundoplication (TIF) has been developed for the treatment of GERD. TIF is an incisionless procedure that allows physicians to reconstruct the anti-reflux valve. Gerson says, “The surgeon or endoscopist puts an instrument into the stomach, tightens the valve, advances stylets into the tissue of the esophagogastric junction and then deploys plastic fasteners through the valve to keep it tightened.” Presently, there are between 100 to 150 facilities administering this procedure.
In order to determine if a patient is a candidate for the new procedure, patients need to undergo endoscopy to determine if they have esophagitis and a hiatal hernia. If the hernia is larger than 2 cm, it should be repaired before performing a TIF procedure. Additional recommendations to determine candidacy for this procedure include the conducting of esophageal manometry to determine if they are TIF candidates and to exclude other conditions and a pH study to confirm the diagnosis of GERD if no erosions are present..
In two randomized controlled studies, published in Gastroenterology and BMC Gastroenterology, the TIF procedure for reflux not only eliminated regurgitation in many patients but was also found to be an effective treatment over PPIs.The fact that the procedure does not involve abdominal incisions is a significant benefit, Gersen says. Also, patients have not reported gas-bloat syndromeafter the procedure.
However, the therapy may have disadvantages as well. Gerson says, “Disadvantages currently are that the durability of the procedure is not completely known—there is data showing durability up to 2-3 years. So far outcomes data have suggested that it is as effective as a Nissen surgery.”
Comprehensive Care
Sleep medicine professionals should be aware of the connection between GERD and sleep disorders in order to provide thorough and complete care to patients. Gerson says, “As mentioned we have been unable to prove that GERD causes sleep apnea but they are both common conditions, and CPAP may improve GERD. So sleep medicine doctors should evaluate for the presence of GERD as well.”
In addition, Gerson believes general care physicians should ask patients with GERD when their symptoms occur; specifically, if they occur when they try to lie down, if they wake from sleep and when this occurs, and if they wake up with acid in the throat. Gerson says that patients do not often volunteer this information so it is vital for physicians to ask patients these questions to provide proper care. She adds, “Medical therapy should [then] be adjusted appropriately.”
Cassandra Perez is associate editor for Sleep Review. CONTACT [email protected]
