Managing GERD/Acid Reflux: The Gastroenterologist’s Perspective

Associate professor of medicine and director of the IBD Center at MedStar-Georgetown University Hospital in Washington, DC

Do you treat many patients for acid reflux/GERD who also have hematologic malignancies or bleeding disorders?

Gastroesophageal reflux disease (GERD) or acid reflux is a common disorder among the general U.S. population, with up to 20 percent of Americans reporting acid reflux/GERD symptoms at least twice a week, such as a sensation of burning behind the chest that radiates from the stomach upward (i.e., heartburn). Acid reflux/GERD, however, has multiple other manifestations, such as nausea, cough, change in voice/raspy voice, asthma attack, bad taste in the mouth, enamel erosions, regurgitation of food, vomiting, and other symptoms affecting the mouth and throat.

Certain factors increase the incidence of acid reflux/GERD, including stress, smoking, age >40 years, change in weight, certain foods, and certain medications. So, it is not uncommon for the gastroenterologist to see patients with hematologic malignancies or bleeding disorders with a primary diagnosis of acid reflux/GERD, or with acid reflux/GERD developing through the course of their hematologic disease.

Do certain anti-cancer therapies increase the risk of developing acid reflux/GERD? 

For patients diagnosed with blood cancers or hematologic diseases, the stress of the disease and a sudden drop in weight or a decrease in muscle mass associated with anti-cancer therapies can definitely play a role in unmasking or exacerbating underlying acid reflux/GERD.

Certain chemotherapeutic agents can also cause ulcerations and inflammation  of the lining of the gastrointestinal tract (mucositis), intensifying the symptoms of acid reflux/GERD and making these symptoms more severe or painful. Patients with mucositis can also have difficulty swallowing large pills, meaning they are unable to take their acid reflux/GERD medications; in turn, these patients have worse heartburn symptoms.

Patients with malignancies also frequently require narcotic analgesics to manage their pain; constipation is often a side effect of these types of medications which, again, can exacerbate symptoms of acid reflux/GERD, such as heartburn and nausea.

When and how should the hematologist consult the gastroenterologist in the treatment of patients with acid reflux/GERD?

For hematologists treating patients with acid reflux/GERD, there are a few definite situations where referral to the gastroenterologist is absolutely necessary. For instance, if the patient:

  • has heartburn symptoms that persist despite medication and lifestyle modifications (described below in further detail)
  • experiences new-onset heartburn
  • has long-standing acid reflux/GERD
  • has unexplained weight loss
  • experiences nocturnal reflux, cough, or asthma-like symptoms
  • has dysphagia (difficulty swallowing food or food getting stuck in the throat)
  • has black stool
  • experiences recurrent vomiting or is vomiting blood

When a patient is referred to the gastroenterologist for any of these conditions, the gastroenterologist typically will perform an endoscopy to look for any damage caused by acid reflux/GERD. This could include erosions in the esophagus, stricture, or a change in the cells in the lining of the esophagus from normal to cancerous. The latter is called Barrett’s esophagus, a serious complication of acid reflux/GERD.

Performing an endoscopy will also help the gastroenterologist identify any factors exacerbating the patient’s acid reflux/GERD symptoms – for instance, a hernia, tumor or malignancy, or gastric outlet obstruction.

How can hematologists help their patients manage their acid reflux/GERD? 

When a hematologist is treating a patient with symptoms of acid reflux/GERD, he or she can recommend certain lifestyle modifications to better manage or prevent episodes of heartburn and other acid reflux/GERD–associated symptoms, including:

  • Stop smoking
  • Limit caffeine intake (i.e., soda, coffee, chocolate, and teas)
  • Stop or limit alcohol intake to one drink per day
  • Stop drinking carbonated beverages like sodas and sparkling water
  • Avoid eating two to three hours prior to going to bed, and, in general, avoid large meals around bedtime
  • When sleeping or lying down, elevate the head and avoid lying down after eating a large meal
  • Limit intake of or avoid foods and drinks that exacerbate heartburn (such as chocolate, citrus fruits, tomatoes, mints, fatty foods, and sweets)

The hematologist can also start a patient on antacid medications to alleviate the acid reflux/GERD symptoms – over-the-counter H2 blockers or proton pump inhibitors (i.e., omeprazole, lansoprazole) before referring the patient to the gastroenterologist. The hematologist can also add one of these agents to treat acid reflux/GERD–associated nausea and vomiting.

Hematologists should also be aware of the other conditions that can mimic acid reflux/GERD in immunocompromised patients and those undergoing chemotherapy to treat their malignancy. These include candida esophagitis (fungal infection of the esophagus) and viral infections (herpes simplex virus, cytomegalovirus, etc.).

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