RESEARCH FINDINGS USING GUIDED
IMAGERY FOR
GERD
(GERD, ACID REFLUX, OR HEARTBURN)
August, 2006
Definition
of the Problem
Gastro-esophageal Reflux
Disease (GERD) occurs when the valve between the esophagus
and stomach fails to keep stomach contents from leaking up
into the esophagus. This valve, usually called the Lower
Esophageal Sphincter (LES), is a ring of muscle.
When working normally, it opens to allow swallowed food
into the stomach, then shuts to prevent acidic stomach
contents from coming back up into the esophagus. When the
valve is weakened or enlarged, or when the pressure of
gastric contents is too strong, leakage can occur,
sometimes in large amounts.
The stomach is protected against acid, but the esophagus is
not. So, people experience burning pain and pressure
(heartburn). They can also have other acid-related symptoms
not only in the esophagus, but also in the unprotected
throat, windpipe (trachea) and bronchial tubes (Wolfe and
Nesi, 1997).
Authors of a recent study estimated that 25% of Americans
suffer from heartburn at least once a week (Moyaaedi and
Talley, 2006). To be classified as GERD, heartburn or other
symptoms must be frequent and severe. GERD is frequently
accompanied and made worse by hiatal
hernia.
GERD is a major public health problem. Some experts
estimate that one third to one half of all asthma cases are
caused or worsened by GERD (Harding, 2001; Harding, Suzzo,
and Richter, 2000; Wolfe and Nessi, 1997). Acid reflux can
also cause chronic bronchitis and pneumonia (Everhart,
1994).
Severe cases lead to a condition called “Barrett’s
Esophagus,” in which the esophageal wall becomes lined with
gastric cells for protection against acid. These cells are
often pre-cancerous (Wolfe and Nesi, 1997).
Other complications
include painful ulcers and narrowing of the esophagus. Both
of these conditions can interfere with swallowing and
nutrition.
Scope
and Costs of the Problem
Heartburn, in one form or
another, affects more than 100 million Americans, according
to Dr. M. Michael Wolfe, Chief of Gastroenterology at
Boston Medical Center, with more than 25 million take
antacids at least twice a week (Wolfe and Nesi, 1997).
Heartburn sufferers spend over $6 billion a year on
over-the-counter and prescription heartburn medications
(Kleinman, McIntosh, et al, 2002). There are nearly 200,000
emergency room visits per year by people with heartburn who
fear they are having a heart attack (Wolfe and Nesi).
Work loss due to GERD average about $1,000 per year per
patient (Henke, Levin, et al, 2000). Total direct and
indirect costs of GERD were about $10 billion in 2000,
making it the most expensive digestive disease, according
to the American Gastroenterological Association (Frequently
asked questions about GERD, 2001). Treatment costs of
GERD-related esophageal cancer and asthma are unknown but
probably substantial.
Medical
Treatment
Medicinal treatments include
antacids, which neutralize the acid. These are available
over-the-counter and are purchased by 25 million Americans
every month (Wolf and Nesi, 1997). They are effective for
mild, occasional heartburn, but inadequate for moderate to
severe cases.
A class a prescription medicine called H2-
blockers, such as
Tagamet, Zantac, and Pepcid AC, reduce the output of
stomach acid. They are more effective than antacids, but
must be taken three to four times a day for maximum effect.
Propulsid (Cisapride) helps to get some contents out of the
stomach before they can leak through the LES. The newest
and most effective drugs for GERD are the proton-pump
inhibitors.
These are usually taken only once a day and reduce acid
production much more than other medications. About 10% of
patients on these drugs experience side effects, including
diarrhea and headache. The drugs don’t cure GERD, however;
they often must be taken for life, or until lifestyle
changes reduce the need for them.
Laparoscopic surgery is sometimes performed to tighten the
LES to keep acid from getting back up into the esophagus
(Guidelines for surgical treatment, 2001).
Non-drug
Therapy Including Relaxation and Imagery
Stress
plays a major role in gastrointestinal disorders including
GERD (Baker, Lieberman, and Oehlke, 1995). Experimentally
induced stress increases reported GERD symptoms in 40–50%
of patients. The effect of stress on actual acid exposure
in the esophagus is still in question (Kamolz, Granderath,
et al, 2001). Relaxation training and hypnosis have been
shown to reduce GERD symptoms and medication usage in as
many as 58% of patients in various studies (Drossman, 1998;
McDonald-Haile, Bradley, et al, 1994).
In
many cases, the best treatment for GERD is behavior change
such as avoiding trigger foods and losing weight (Gitnick
and Cooksey, 2000). Relaxation and guided imagery
can aid patients undertaking behavior change (The Chronic
Disease Self-Management Workshop Leaders Manual,
1999).
Conclusion
Guided imagery can assist some
patients with behavior change, improve coping, and reduce
GERD symptoms and medication use.
References
Baker LH, Lieberman D, Oehlke
M. Psychological distress in patients with gastroesophageal
reflux disease. Am J
Gastroentero. 1995 Oct;90(10):1797-803.
[no authors listed] Burden of Chronic Gastrointestinal
Diseases Study. American Gastroenterological Association.
2001. May.
[no authors listed] The Chronic Disease Self-Management
Workshop Leaders Manual. Sandord Patient Education Research
Center. 1999. Stanford University.
Drossman DA. Presidential address: Gastrointestinal illness
and the biopsychosocial model. Psychosom Med.
1998
May-Jun;60(3):258-67.
Everhart JE, Ed. Digestive Diseases in the United States:
Epidemiology and Impact. National Digestive Diseases Data
Working Group. US Department of Health and
Human Services, Public Health Service.
National Institutes
of Health, NIH Publication No. 94-1447, May
1994.
Frequently asked questions about GERD. American
Gastroenterological Association (AGA).
www.gerd.com/faq/gerd-faq.htm#5
August, 2006.
Gitnick GL, Cooksey K. (2000). Freedom from Digestive
Distress. New York: Three Rivers Press. pp. 21-25.
[no authors] Guidelines for surgical treatment of
gastroesophageal reflux disease (GERD). Society of American
Gastrointestinal and Endoscopic Surgeons (SAGES)
Publication #22. June, 2001.
http://www.sages.org/sagespublicationprint.php?doc=22
Accessed August, 2006.
Harding SM. Gastroesophageal reflux, asthma, and mechanisms
of interaction. Am J Med.
2001 Dec 3;111
Suppl 8A:8S-12S.
Harding SM, Guzzo MR, Richter JE. The prevalence of
gastro-esophageal reflux in asthma patients without reflux
symptoms. Am J Respir Crit Care
Med. 2000 Jul;162(1):34-9.
Henke CJ, Levin TR, Henning JM, Potter LP. Work loss costs
due to peptic ulcer disease and gastroesophageal reflux
disease in a health maintenance organization.
Am. J.
Gastroenterol. 2000 Mar;95(3):788-92.
Kamolz T, Granderath FA, Bammer T, Pasiut M, Pointner R.
Psychological intervention influences the outcome of
laparoscopic antireflux surgery in patients with
stress-related symptoms of gastroesophageal reflux
disease. Scand J
Gastroenterol. 2001 Aug;36(8):800-5.
Kleinman L, McIntosh E, Ryan M, Schmier J, Crawley J, Locke
GR 3rd, De Lissovoy G. Willingness to pay for complete
symptom relief of gastroesophageal reflux disease.
Arch Intern
Med. 2002 Jun 24;162(12):1361-6.
McDonald-Haile J, Bradley LA, Bailey MA, Schan CA, Richter
JE. Relaxation training reduces symptom reports and acid
exposure in patients with gastroesophageal reflux
disease. Gastroenterology.
1994
Jul;107(1):61-9.
Moyaaedi P, Talley NJ. Gastro-oesophageal reflux
disease. Lancet.
2006 Jun 24:367(9528):2086-100
Wolfe MM, Nesi, TJ. (1997). Heartburn.
New York: W.W.
Norton. pp.12-13; 20; 103; 105-106; 176-8.