In this slide discussed all about GERD & its management through Naturopathy. diagnostic methods, all possible mechanisms

1. Dr. Satyendra Singh
BNYS, MD

2. 1
2
3
4
5
INTRODUCTION
EPIDEMIOLOGY & RISK FACTORS
PATHOPHYSIOLOGY
CLINICAL MANIFESTATION OF DISEASE,
DIAGNOSIS
MANAGEMENT

3. Histology

4. 9 Regions
of
Abdomen

5. 05
09
07
Parts - cardia (where
content of the esophagus
empties into stomach),
fundus (upper curved
part), body (main, central
region), pylorus (empties
the chyme into the
duodenum)
Stomach
Function - secretion of
gastric acid (hydrochloric
acid +sodium chloride +
pepsin) that digests
proteins and converts
bolus to chyme
S p leen Gall Bladder
06 08 10

6. 05
14
12
J ejunum - absorbs small nutrients
that have been previously digested
in duodenum
Ileum - absorbs vitamin B12, bile
salts and all necessary material that
were not absorbed in jejunum
Cecum - a pouch that marks division
between small and large intestines -
>connects the ileum with ascending
colon
Small Intestine
Duodenum -mixes chyme with bile,
secretes bicarbonates to rise pH in
order to activate pancreatic
enzymes which digest the chyme
Large Intestine Anal Canal
11 13

7. ANATOMY
Also known as - digestive tract, the GI tract, the alimentary canal.
30 feet in length in adults.
Series of connected organs leading from the mouth to the anus.
System allows us to break down the food we eat to obtain energy and
nourishment.
Divided into several parts: the mouth, pharynx, larynx, the esophagus, the
stomach, the small intestine and the large intestine with the liver, pancreas, and
gallbladder adding secretions to help digestion.
To perform six tasks: ingestion, secretion, propulsion, digestion, absorption, and
defecation. Process of digestion.
Clinical
Significance
Applied
Physiology
Applied
Anatomy

8. PHYSIOLOGY
Clinical
Significance
Appled
Physiology
Applied
Anatomy
• Digestion is the process of mechanically & enzymatically breaking down food into substances for absorption into the
bloodstream.
• The food contains three macronutrients that require digestion before they can be absorbed: fats, carbohydrates, and
proteins.
• Through the process of digestion, these macronutrients are broken down into molecules that can travels the intestinal
epithelium and enter the bloodstream for use in the body.
• Digestion is a form of catabolism or breaking down of substances that involves two separate processes: mechanical
digestion and chemical digestion.
• Mechanical digestion involves physically breaking down food substances into smaller particles to more efficiently undergo
chemical digestion.
• The role of chemical digestion is to further degrade the molecular structure of the ingested compounds by digestive
enzymes into a form that is absorbable into the bloodstream. Effective digestion involves both of these processes, and
defects in either mechanical digestion or chemical digestion can lead to nutritional deficiencies and gastrointestinal
pathologies.
• The products of digestion, including vitamins, minerals, and water, which cross the mucosa and enter the lymph or the blood
(Absorption).
Reference: Guyton & Hall, Medical Physiology; Patricia JJ, Dhamoon AS. Physiology, Digestion. [Updated 2020 Sep 18]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544242/

9. PHYSIOLOGY
Clinical
Significance
Reference: Guyton & Hall, Medical Physiology; Patricia JJ, Dhamoon AS. Physiology, Digestion. [Updated 2020 Sep 18]. In: StatPearls [Internet]. Treasure
Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544242/
Clinical
Significance
Appled
Physiology
Applied
Anatomy
• Digestion of the major food macronutrients is an orderly process involving the action of
a large number of digestive enzymes.
• Enzymes from the salivary and the lingual glands digest
carbohydrates and fats.Enzymes from the stomach digest proteins.
• Enzymes from the exocrine glands of the pancreas digest carbohydrates, proteins, lipids,
RNA, and DNA.
• Other enzymes that help in the digestive process are found in the luminal membranes and
the cytoplasm of the cells that lines the small intestine.
• The action of the enzymes is promoted by the hydrochloric acid (HCl), which is secreted by
the stomach, and bile from the liver.
PHYSIOLOGY

10. PHYSIOLOGY
Clinical
Significance
Appled
Physiology
Applied
Anatomy
• In the small intestines, they have a brush border made up of numerous microvilli lining their apical
surface,this border is rich in enzymes.
• It is lined on its luminal side by a layer that is neutral & is rich in amino sugars[the glycocalyx]. The
membranes of the mucosal cells contain the glycoprotein enzymes that hydrolyze carbohydrates
and peptides, and glycocalyx is made up in part of the carbohydrate portion of these glycoproteins
that extend into the lumen of the intestine.
• Following the brush border and the glycocalyx is an unstirred layer similar to the layer adjacent to
the biological membrane. Solutes must diffuse across this layer to reach the mucosal cells. The
mucous coat overlying the cells also continues a significant barrier to diffusion. Most substances
pass from the lumen if the intestines into the enterocytes and then out of the enterocytes to the
interstitial fluids.
• Process of digestion
Reference: Guyton & Hall, Medical Physiology; Patricia JJ, Dhamoon AS. Physiology, Digestion. [Updated 2020 Sep 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544242/

11. Vascularisation & Innervation
Supplied by the branches of abdominal aorta:
Celiac trunk - supplies the liver, stomach, spleen,
upper 1/3 of duodenum, pancreas
Superior mesenteric artery - supplies distal 2/3 of
duodenum, jejunum, ileum, cecum, appendix,
ascending colon, proximal 1/3 of transverse colon
Inferior mesenteric artery - supplies distal 1/2 of
transverse colon, descending colon, sigmoid
colon, rectum, anus
Parasympathetic supply - vagusnerve and
pelvic splanchnic nerves
Sympathetic supply - thoracic and lumbar
splanchnic nerves

12. Significance
Clinical
Significance
Applied
Physiology
Applied
Anatomy
Clinical testing based on physiology of digestive system?
Example - lactose intolerance
• May occur due to a lactase defect or deficiency.
• Lactase is a disaccharidase produced by the pancreas that hydrolyzes the glycosidic bond in lactose to form the
carbohydrate monomers glucose and galactose
• And is necessary, as glucose and galactose are absorbable by the SGLT1 cotransporters on the luminal surface of
enterocytes in the small intestine, but lactose cannot.
• As such, in lactose intolerance, lactose remains undigested in the lumen of the small intestine and serves as an osmotic
force that draws fluid into the lumen of the small intestine, causing osmotic diarrhea.
• A common test for lactose intolerance involves the oral administration of a bolus of lactose to the patient. Blood
glucose levels are then measured at periodic intervals. In a patient with normal lactase function, blood glucose levels
will rise after oral administration of a lactose bolus because lactase will digest lactose into glucose and galactose, with
the glucose absorbed into the bloodstream, and thus blood glucose levels will rise.
Forsgård RA. Lactose digestion in humans: intestinal lactase appears to be constitutive whereas the colonic microbiome is adaptable. Am J Clin Nutr. 2019 Aug 01;110(2):273-279. [PMC free article] [PubMed]
Sakai D, Hirooka Y, Kawashima H, Ohno E, Ishikawa T, Suhara H, Takeyama T, Koya T, Tanaka H, Iida T, Nishio R, Suzuki H, Uetsuki K, Matsushita M, Yamamura T, Furukawa K, Funasaka K, Nakamura M, Miyahara R, Watanabe O,
Ishigami M, Tsuruta A, Shin W, Goto H. Increase in breath hydrogen concentration was correlated with the main pancreatic duct stenosis. J Breath Res. 2018 Mar 12;12(3):036004. [PubMed]
Mattar R, de Campos Mazo DF, Carrilho FJ. Lactose intolerance: diagnosis, genetic, and clinical factors. Clin Exp Gastroenterol. 2012;5:113-21. [PMC free article] [PubMed]

13. Clinical
Significance
Applied
Physiology
Applied
Anatomy
• In a patient with defective or deficient lactase, a rise in blood glucose levels after oral
administration of a lactose bolus will not occur because lactose will remain undigested in the lumen of
the small intestine and no glucose will enter the bloodstream.
• A second test for lactose intolerance involves a similar administration of oral lactose and then a
measurement of hydrogen gas levels in the breath.
• In a patient with lactose intolerance, lactose will remain undigested and pass into the colon. Colonic
bacteria can use lactose as an energy source, producing hydrogen gas as a byproduct. This production of
hydrogen gas by colonic bacteria not only causes bloating and flatulence but is also measurable during
exhalation.
• Thus, a patient with lactose intolerance will show increased hydrogen gas levels in the breath after
administration of oral lactose, whereas a patient with normal lactase function will not.
Forsgård RA. Lactose digestion in humans: intestinal lactase appears to be constitutive whereas the colonic microbiome is adaptable. Am J Clin Nutr. 2019 Aug 01;110(2):273-279. [PMC free article] [PubMed]
Sakai D, Hirooka Y, Kawashima H, Ohno E, Ishikawa T, Suhara H, Takeyama T, Koya T, Tanaka H, Iida T, Nishio R, Suzuki H, Uetsuki K, Matsushita M, Yamamura T, Furukawa K, Funasaka K, Nakamura M, Miyahara R, Watanabe O, Ishigami M,
Tsuruta A, Shin W, Goto H. Increase in breath hydrogen concentration was correlated with the main pancreatic duct stenosis. J Breath Res. 2018 Mar 12;12(3):036004. [PubMed]
Mattar R, de Campos Mazo DF, Carrilho FJ. Lactose intolerance: diagnosis, genetic, and clinical factors. Clin Exp Gastroenterol. 2012;5:113-21. [PMC free article] [PubMed]
Significance

14. Clinical
Significance
Applied
Physiology
Applied
Anatomy
• Lactose intolerance results from defective or deficient lactase and can result in bloating, flatulence, diarrhea, and the
inability to acquire glucose and galactose from lactose. Management can involve avoiding dairy products, which
contain significant amounts of lactose. Inthis case, supplemental calcium may be necessary. Additionally, beta-
galactosidase (lactase) tablets are available as supplements for people who are lactose intolerant.
• Paralytic ileus is a condition where the normal peristaltic movements of the gastrointestinal tract are inhibited due
to abdominal surgery or the use of anticholinergics. Inhibitory neurons in the myenteric plexus between the inner
circular and outer longitudinal muscle layers of the gastrointestinal tract release excessive vasoactive intestinal
peptide (VIP) or nitric oxide (NO), inhibitory neurotransmitters that prevent peristalsis. Anticholinergics can interfere
with the action of acetylcholine, a stimulatory neurotransmitter from the parasympathetic nervous system that
stimulates peristalsis. Inboth cases, peristalsis is inhibited, hindering the movement and mechanical digestion of food
through the gastrointestinal tract.
• Sjogren syndrome is an autoimmune condition that destroys the salivary and lacrimal glands. Without the production
of saliva, the patient develops xerostomia or dry mouth. The lack of saliva results in difficulty speaking and swallowing,
dental caries, and halitosis.
Significance

15. Significance
Clinical
Significance
Applied
Physiology
Applied
Anatomy
• Cystic fibrosis, aside from respiratory effects, also has consequences for the digestive tract. Incystic fibrosis, the CFTR
chloride channel is defective. This channel is important in the pancreas for transporting chloride into the lumen of
the pancreatic ducts, in order to draw sodium and water into the lumen. This serves to make the pancreatic secretions
less viscous and allow their passage through the duct of Wirsung and into the duodenum. Ifthis CFTR chloride channel
is defective, such as is the case in cystic fibrosis, the pancreatic secretions become extremely viscous and clog the
pancreatic ducts. This not only prevents the digestion of proteins, fats, and carbohydrates in the lumen of the small
intestine but also causes premature activation of pancreatic digestive enzymes within the pancreas, causing
autodigestion and pancreatitis. The inability to digest fats can lead to steatorrhea and fat- soluble vitamin
deficiencies. Patients with pancreatic insufficiency secondary to cystic fibrosis or other causes can take oral
pancreatic enzyme supplements to aid in digestion.
• Cholelithiasis, or gallstones, are solidified particles of bile that can obstruct the common bile duct. This results in the
inability of bile to enter the lumen of the duodenum, and, as such, fats are not emulsified. Pancreatic lipase cannot
access the triglycerides, and fats remain undigested. This also results in steatorrhea and can lead to deficiencies in
fat-soluble vitamins. Treatment often involves the removal of the gallbladder or cholecystectomy.
Forsgård RA. Lactose digestion in humans: intestinal lactase appears to be constitutive whereas the colonic microbiome is adaptable. Am J Clin Nutr. 2019 Aug 01;110(2):273-279. [PMC free article] [PubMed]
Sakai D, Hirooka Y, Kawashima H, Ohno E, Ishikawa T, Suhara H, Takeyama T, Koya T, Tanaka H, Iida T, Nishio R, Suzuki H, Uetsuki K, Matsushita M, Yamamura T, Furukawa K, Funasaka K, Nakamura M, Miyahara R, Watanabe O, Ishigami M, Tsuruta A, Shin W, Goto H. Increase
in breath hydrogen concentration was correlated with the main pancreatic duct stenosis. J Breath Res. 2018 Mar 12;12(3):036004. [PubMed]
Mattar R, de Campos Mazo DF, Carrilho FJ. Lactose intolerance: diagnosis, genetic, and clinical factors. Clin Exp Gastroenterol. 2012;5:113-21. [PMC free article] [PubMed]

16. A condition which develops when the reflux of stomach contents causes troublesome symptoms &/or
complications:
1
.>
2 Heartburn episodes/week.
2.Adversely affect an individual’s well being.
3.Prevalence of at least twice weekly heartburn and/or acid regurgitation
1.Vakil Nimish et al. American Journal of Gastroenterology, 2006;101:1900-
20 2.Dent J et al. Gut 2005;54:710-7
Definition

18. LA Classification of GERD

19. 1
0%
Global Incidence WGO
Asia <10%
Rai, S., Kulkarni, A. & Ghoshal, U.C. Prevalence and risk factors for gastroesophageal reflux disease in the Indian population: A meta-analysis and meta-regression study. Indian J Gastroenterol
(2021). https://doi.org/10.1007/s12664-020-01104-0

20. Lifestyle & Environment 44.4%
Demographic 33.3%
Genetic 22.2%
RiskFactors

21. RiskFactors
1. Predisposing factors- GERD is a sensorimotor disorder associated with impairment of the normal antireflux
mechanisms (e.g.,lower esophageal sphincterfunction,phrenicoesophagealligament),withchangesinnormal
physiology (e.g.,impaired esophageal peristalsis, increased intragastric pressure, increased abdominothoracic
pressure gradient) or, very rarely, excessgastric acidsecretion(Zollinger–Ellisonsyndrome).
2. Lifestyle- Overweight/obese/Ahighbodymass index(BMI), Highdietaryfat intake
• Carbonateddrinks
• Coffee-unclear
• Alcoholconsumption-unknownmechanism[malignancy] Smoking-weak
association[malignancy]
3. Medications: calcium channel blockers, anticholinergics, and NSAIDs. Bisphosphonates, antibiotics, potassium
supplements also cause upper GITinjuryandexacerbatereflux-likesymptomsorreflux-inducedinjury.
4. Pregnancy
5. Others:diabetes,metabolicsyndrome,cardiovasculardisease,andsleep apneaareallcommon.
6. Maycoexistswithothergastrointestinalsyndromes.

22. LES
• Physiological sphincter
• Zone of relatively higher
pressure that prevents
reflux
• Normal LES is 3-4cm in
length with pressure 10-
25mmHg

23. Anti-refluxmechanism

24. Angle of HIS

25. Esophageal Clearance
Epithelial protection
Thoraco-abdominal gradient

26. Esophageal Clearance
1.Esophagealmotility
2.Saliva production- mechanicalwashout
& buffering
Ineffective/improperclearanceresultsin
aggravationorcause

27. Esophageal mucus
produced by mucus
cells at the epithelial
surface
Submucosal
gland act as
pre-epithelial
barrier
Below this there is a
layer of bicarbonate rich
fluid [buffers acid which
penetrates the mucus]
And remaining H+ ion
are carried out by blood.
Epithelial Protection

28. TAPG
TAPG= Intra-abdominal pressure - Intrathoracic pressure [during inspiration]
calculation =TAPG minus the resting lower esophageal sphincter (LES) pressure
(LESP).

31. Tack, J.,&Pandolfino, J.E. (2018). Pathophysiology of gastroesophageal reflux disease. Gastroenterology, 154(2), 277-288.

35. 01 03
DIAGNOSIS
02
Barium Swallow
• Useful in patients with dysphagia
[stricture, hiatal hernia]
• Cannot detect mucosal pathology
[BE, Esophagitis]
Endoscopy
When Rx fails & alarming sign is
present
Biopsy
Detects stratification & helps in
management
Ambulatory 24x7 pH &
impedance monitoring
Gold Standard
Catheter with 2 solid electrodes sense pH
ranging between 2-7
Connected to a data recorder
Detects- Total no. of reflux episodes, no. of
episodes of >5min, reflux in supine/upright
positions
04
Esophageal
Manometry
Detects motility disorder
Normal LES pressure 12-30 mmHg
Ineffective gastric motility <70 % peristalsis

39. Drug/Pharmacotherapy
Anta-acid
H2RA
PPI
Surgical &Endoscopic
procedure
Nissen/partial [ant./post]Fundoplication
Collis Gastroplasty
Plicating gastric mucosa
Radio-frequency ablation of sphincter
Submucosal polymer injections
EsophyX
LINX
Lifestyle modifications
Dietary habits
Sleeping position
General measure
Addictions

41. Radio frequency ablation Gastric mucosa plication
Esophyx
LINX

42. NATUROPATHIC MANAGEMENT
OF GERD

43. WHAT WE OFFER
Nature based Therapies Soothes Mind Synchronises with soul

44. • Lifestyle Intervention
• Reducing esophageal luminal
acid either by suppression of
excessive gastric acid secretion
or by localized neutralization
CORE PRINCIPLES
Gastroenterological disease
treatment are quiet expensive&
unaffordable
COST-
EFFECTIVE
Following a healthy lifestyle for 21st century
individual is very hard so with regular follow-up
proper counselling & motivation will be provided
FOLLOW-UP &
MOTIVATION
PRIMARY GOALS
Howwe
Approach
GERD
• Relieving symptoms Improving
HRQOL Healing esophagitis
Prevention of symptom
reoccurrence
• Prevention/treatment of
complications

45. Dietary Recommendations
• Drink caffeine-free herbal teas that contain chamomile, ginger, marshmallow, and
slippery elm, herbs that are soothing and help relieve heartburn.
• Drinking fluids between meals rather than with meals will also help prevent reflux.
• Eat vegetables, non-citrus fruits, whole grains, beans, fish, and lean meat.
• Eating small, frequent meals(every 3-4 hr) (instead of one or two large meals) will
prevent excess pro- duction of stomach acid and is also less stressful to the
esophageal sphincter. Eat slowly and chew your food thoroughly.
• Eat breakfast within 1hr of waking up.
• Small amounts of olive and vegetable oils are fine.
• Stay upright after eating and don’t eat within three hours of bedtime.
World Gastroenterology Organisation 2019 report, Canadian Naturopathic Association

46. Foods to Avoid
• Alcohol, carbonated beverages, spicy foods, tomatoes, citrus fruits,
spearmint, pepper- mint, and onions are irritating to the esophagus.
• Chocolate and coffee relax the esophageal sphincter and increase the risk of
reflux.
• High-fat foods worsen symptoms because they stay in the stomach longer
and increase the time the esophagus is exposed to stomach acids. Avoid or
minimize cream, butter, ice cream, gravy, oils, fried foods, sausage, and
processed fatty meats and cream soups.
World Gastroenterology Organisation 2019 report, Canadian Naturopathic Association

47. Complementary Advises
• Calcium carbonate: Calcium helps to neutralize stomach acid and provides
short-term relief. Dosage: 500 mg three times daily with meals and before
bedtime.
• Deglycyrrhizinated licorice (DGL):[Mulethi] Soothes and coats the mucous
membranes of the stomach. It helps restore the mucous lining that protects
the stomach from hydrochloric acid (stomach acid). Dosage: Two to four
tablets before meals and at bedtime.
• Aloe vera juice: Helps reduce acid output and is soothing to the mucous
membranes. Research is limited at this point, but it is widely used by
naturopathic physicians. Dosage: 1 tbsp two or three times daily.
• Digestive enzymes: Improve digestion and may help reduce reflux. Dosage:
One capsule with each meal. [Amylase, Trypsin]
• Probiotics: Contain friendly bacteria, which improve digestion. Dosage: One
capsule twice daily.
• Canadian Naturopathic Association

48. Lifestyle Advises
• Early Dinner
• Drink plenty of water
• Ice water sipping
• Lose excess weight by eating healthy and exercising regularly.
• Do not bend over, lie down, or exercise right after eating. Wait two hours after
eating to exercise and three hours after eating before lying down.
• Do not wear tight belts or pants that are tight at the waist.
• Don’t smoke.
• Raise the head of your bed—use pillows or a block under the head of your bed.
Keeping your head higher than your stomach will help prevent acids from
refluxing.
1. Harrison’s Internal Medicine 19th Edition
2. World Gastroenterology Organisation 2019 report
3. Canadian Naturopathic Association

50. Naturopathy Therapies
• Massage – Abdominal, Aroma massage, Copper cup reflex massage
• - NHB, Sitz Bath, Enema
• Mudtherapy Hydrotherapy – Abd. Mud pk + Eye pk, Mud bath
• Heliotherapy- Plantain leaf bath
• Chromotherapy- Blue, Indigo, Charged water
• Raga therapy- Biaurnal tunes
• Acupuncture- CV-12,CV-6, P-6, St.36, St.25,Sp-4,6
• Fasting – Apple, Ash gourd juice fasting,
• Reflexology – Reflexology track

51. Title & Authors Aim/Objective Interventio
n
Outcome
Phytotherapeutic and
naturopathic adjuvant
therapies in
otorhinolaryngology -
Review
Raphael Richard Ciuman
European Archieves of Oto-
Rhino-Laryngology,
Springer-2012
Review –focusing
Phytotherapeutic
therapies well
established within the
European Community
for otolaryngologic
disease patterns by
referring to clinical
studies or meta-
analysis.
NA Gastroesophageal reflux affects wound healing
negatively.
Asian ginseng root (Panax ginseng, Araliaceae)
– Erosive Esophagitis due to its anticarcinogenic
effects.
Antacid- teaspoon of healing earth [medicinal
clay for internal-external use, Adolf Just] eg-
Luvos®, Heilerde-Gesellschaft Luvos Just GmbH
& Co KG equating 6.5 g has an acid-binding
capacity of 25 mVal that is recommended
Can yoga be used to treat
gastroesophageal reflux
disease? – Case Report
Dharmesh Kaswala & et al.
IJOY
NA
6 month follow up
Kapalbhati,
Agnisar
Regular practice of Kapalbhati and Agnisar kriya
along with PPI, patients with hiatal hernia had
improvement in severe symptoms of GERD,
which were initially refractory to PPI alone.

52. Title & Authors Aim/Objectiv
e
Intervention Outcome
Non-pharmacological
intervention for gastro-
oesophageal reflux
disease in primary care
Lesley B Dibley & et al.
British Journal General
Practice, 2010
To address behaviours
that promote GORD
symptoms results in
symptom
improvement, an
increased sense of
control, and a
reduced requirement
for prescribed
medication.
intervention focusing on
diet and stress was
delivered to patients
with reflux symptoms,
recruited in rural general
practices. (England)
Brief Illness Perception
Questionnaire (BIPQ) &
Hospital Anxiety and
Depression Scale (HAD).
The greatest improvements were
demonstrated in domains measuring the
patient's sense of control, perception of
symptoms, and understanding of reflux.
Patients reported benefits including
understanding relevant anatomy and
physiology, learning behavioural techniques
to change eating patterns and manage stress,
identifying actual and potential triggers, and
developing and executing action plans.

53. The perfect way to reset and refocus
is to simply take a pause.