Mention GERD and most of patients probably think of heartburn. But the GERD story does not begin and end with the esophagus. The connection between GERD and laryngeal, pharyngeal, and pulmonary symptoms is the focus of a seminar, “An Eye and Nose Opening Experience—Chronic Complications of GERD,” at the upcoming American College of Gastroenterology Annual Scientific Meeting (ACG 2011) October 31 to November 2 in Washington, DC.
ConsultantLive caught up with Ronnie Fass, MD, to ask him about his talk, “GERD and Sleep—Which is the Chicken and Which is the Egg?” Dr. Fass is Professor of Medicine in the section of gastroenterology at the University of Arizona in Tucson. Winner of numerous awards and a prolific author and researcher, Dr. Fass has a special interest in GI motility and functional bowel disorders. He shared his thoughts on the connection between GERD and sleep disorders.
CL: You’ll be chairing the symposium on GERD. Your talk will be on GERD and sleep disorders. This is a discussion that’s been ongoing for a while, especially with respect to which disorder comes first.
RF: This lecture addresses the relationship between GERD and sleep. What happens first—reflux, then waking up? Or waking up, and then reflux? We’re trying to decipher which is the chicken-- and which is the egg.
Our research has shown that sleep itself alters esophageal physiology. This is important because many normal defense mechanisms against reflux are compromised during sleep.
CL: Is sleep position a factor?
RF: Position certainly is one of a few factors. Because of the anatomic relationship between the stomach and esophagus, sleeping on your back or your right side increases the potential for reflux more than sleeping on your left side or your belly.
Other things also come into play. For example, during sleep, salivary production and swallowing both decrease. Swallowing is an important defense against reflux. It initiates primary peristalsis, which helps clear the esophagus of stomach contents and prevents acid from refluxing.
wallowing also helps bring saliva down the esophagus, which reduces the amount of reflux and washes the acid back down into the stomach.
Saliva, in and of itself, is an important defense against GERD because it helps neutralize the esophageal pH. So swallowing after reflux reduces the volume of reflux and re-neutralizes esophageal pH. All of these changes during sleep may have an important impact on the ability of the esophagus to deal with reflux.
CL: Which patients are at most at risk for reflux during sleep?
RF: People who already have GERD are at increased risk for problems during sleep. So those with anatomical or functional abnormalities—hernia or transitory transesophageal sphincter relaxation, for instance—that predispose them to reflux are going to have more problems at night. Those without GERD are not at increased risk.
CL: Does nocturnal reflux increase a person’s risk of esophageal cancer?
RL: Yes. These patients are more likely to have esophageal inflammation, ulcerations, and stricture, as well as Barrett’s esophagus and cancer.
CL: How is nighttime reflux managed?
RL: Treatment primarily consists of a combination of lifestyle modifications and medications. Not eating within 3 hours of bedtime, and elevating the head of the bed are 2 preventive measures that patients can follow easily. Medications—primarily, H2 blockers and proton pump inhibitors—are helpful. Reflux surgery helps.
There’s new evidence to suggest that improving sleep can improve reflux. So, good sleep hygiene is important. Patients should go to bed and sleep. . . they should not lie in bed and watch television or work on the computer.
CL: Dr. Fass, thank you.
RF: You are most welcome.