JFOA Journal

Introduction

GERD is becoming a challenge for medical profession because its prevalence is increasing, requires long-term risky drug-therapy and/or surgical interventions and the recurrence rate is high with any mode of treatment. Worldwide prevalence of GERD was found to be 13.98%, varying from 4.16% in China to 22.4% in Turkey [1]. In South Punjab, Pakistan, a study reported prevalence rate of 26.6% [2]. A Japanese study reported that irregular dietary habits had the strongest association with GERD, and Proton Pump Inhibitors (PPIs) in usual doses could not control the disease [3]. Because a meal on top of the meal causes more release of acidic gastric juice and dilates upper stomach, which generate Transient Lower Oesophageal Sphincter Relaxations (TLESRs) and trigger reflux [4]. Repeated acid refluxes damage lower oesophagus, which becomes inflamed and ulcerated; causing heart burn, sore throat, dysphagia, metaplasia, hyperplasia and cancer [5].

PPIs are considered safe and given as first-line drugs for management of GERD. But their prolonged use, which is mostly required, causes severe achlorhydria leading to serious infections such as diarrhoea, pneumonia and candidemia. Their long-term use also causes deficiency of Vitamin B12 and minerals (such as iron, calcium and magnesium), linked to anaemia, osteoporosis, spontaneous fractures and cardiac arrhythmia. Moreover, the recurrence rate is high after they are discontinued [6]. In a clinical study conducted on more than 2600 patients who had primary laparoscopic anti-reflux surgery for GERD, the recurrence rate was reported to be 17.7%; and they were treated with long-term PPIs or H-2 receptor antagonists (83.6%), whereas16.4% underwent secondary anti-reflux surgery [7]. A systemic review of 81 studies, 4584 reoperations in 4509 patients, reports that frequent reflux and dysphagia were the most prevalent indications for surgical reintervention, intraoperative complications occurred in 21.4% and postoperative complications in 15.6% with an overall mortality rate of 0.9% [8].

Considering the pathophysiology of GERD and its strong association with irregular diet, a new life-style change, “Akram’s life-style”, two moderate regular meals a day, morning and evening, with only liquids (Water, fruit juice, tea, coffee and milk, etc.) during the intervening period whenever patient feels hungry or thirsty, has been suggested as an alternate remedy for the management of GERD.

Methods

The present mini-review is a summary of some studies relevant to practice of Akram’s life-style for treatment of GERD. Firstly, a cases report (n=4) to demonstrate benefits of the practice of our suggested dietary regimen for 2-3 weeks [9]. Secondly, a pilot study conducted on endoscopically diagnosed GERD patients (n=20), who practiced our dietary schedule for two weeks [10]. Thirdly, report of a patient shown to have inflammation, erosions, Schatzki‘s ring and small Barrett at gastroesophageal junction on endoscopy, continued our dietary regimen for long time and endoscopy done after 7 years to see the prognosis [11]. Finally, a clinical study (n=60) conducted at Gastroenterology Unit of Rawalpindi Medical University (RMU), to evaluate the effect of Akram’s life-style on typical GERD symptoms, using questionnaire with Yes/No response and VAS [12].

Results

Results of studies included in present work are summarized in Table 1. In initial cases report (n=4), all patients were relieved of GERD symptoms in 2-3 weeks. In pilot study on 20 patients, 15 (75%) were free of GERD symptoms and 2 (10%) showed partial improvement, without medication in 2 weeks (Table 2). One patient, endoscopically depicted to have inflammation, erosions and small Barrett at gastroesophageal junction, continued our dietary regimen for long time and remained symptom free. Occasional heart burn due to breach in dietary protocol was relieved with antacids for 2-3 days. Endoscopy done after 7 years showed competent lower oesophagus, no inflammation, Schatzki‘s ring, or Barrett (Figures 1 and 2). Lastly, the clinical study (n=60) demonstrated marked improvement in GERD symptoms (P=0.000) when evaluated after two weeks of Akram’s life-style adaptation (Tables 3 and 4, showing the results of Yes/No response and VAS, respectively).

Table 1: Studies relevant to practice of Akram’s Life-style for treatment of GERD.

Table 2: Summary of the results of 20 cases of GERD (Pilot study) who took the suggested meal regime, showing frequency of LA grades and overall response rate.

Figure 1. (a) Inflammation and erosions at gastroesophageal junction and a small Barrett’s (Arrow). (b) Incomplete Schatzki’s ring (Arrow). (c) Moderate diffuse erythema with mild erosions in the antrum. (d) Pylorus and initial part of duodenum appear normal.

Figure 2: (a & b) Normal gastroesophageal junction, no erosions, Barrett, or Schatzki’s ring (c) Erosions in antrum, possibly age related (d) Normal pylorus.

Table 3. Yes/No [Y/N] response to gastrointestinal symptoms, before and after intervention. Improvement was estimated from % reduction in Y response, demonstrating marked reduction (69.1 to 88.6 %) in Y-response.

Table 4. Cumulative VAS of various gastrointestinal symptoms of GERD, before and after intervention (n=60 and 45, respectively), showing highly significant reduction in severity of GERD symptoms (P=0.000).

Discussion

Irregular dietary habits are reported to have the strongest association with GERD [3]. Because intake of meal when stomach already has food causes another surge in gastric acid secretion and distention of the upper stomach, which trigger generation of Transient Lower Oesophageal Sphincter Relaxations (TLESRs). TLESRs are important cause of gastric acid reflux. Moreover, meal during fasting phase prevents development of migrating myoelectric complexes (MMC) in distal stomach which also travel to intestines. MMCs develop during fasting, clear stomach of debris and propel food onwards (Figure 3). Poverty of MMCs delays gastric emptying and favours reflux [13].

Figure 3: During fasting, cyclic contractions & relaxations at regular intervals (MMCs), propel food onwards. In post-prandial state; irregular tonic contractions, prevent propulsion of food [13].