By Josef Mohamed Mostafa El - Gendy https://www.facebook.com/youssef.el.gendyy/ GERD + LPR + Hiatal Hernia - Version 1 Online Research | Doctor Consultation | Natural Remedies Contents Objective ................................ ................................ ................................ ................................ ................................ ................................ ... 3 What is GERD / LPR? ................................ ................................ ................................ ................................ ................................ ........... 3 Surgeries ................................ ................................ ................................ ................................ ................................ ................................ ... 3 NISSEN FUNDOPLICATION ................................ ................................ ................................ ................................ .......................... 3 TRANSORAL INCISIONLESS FUNDOPLICATION (TIF) (TIF 2.0) ................................ ................................ .................. 3 LINX REFLUX MANAGEMENT SYSTEM ................................ ................................ ................................ ................................ .. 4 BANDED ANTI - REFLUX MUCOSECTOMY (ARMS) ................................ ................................ ................................ ............. 4 STRETTA RADIOFREQUENCY TREATMENT ................................ ................................ ................................ ........................ 4 ESOPHAGEAL VALVULOPLASTY (MODIFIED BELSEY) ................................ ................................ ................................ ... 5 BELSEY MARK IV ................................ ................................ ................................ ................................ ................................ .............. 5 Common Symptoms ................................ ................................ ................................ ................................ ................................ ............. 5 HEARTBURN ................................ ................................ ................................ ................................ ................................ ...................... 5 REGURGITATION ................................ ................................ ................................ ................................ ................................ ............. 5 DIFFICULTY SWALLOWING ................................ ................................ ................................ ................................ ........................ 5 PERSISTENT C OUGH ................................ ................................ ................................ ................................ ................................ ...... 5 UPSET STOMACH ................................ ................................ ................................ ................................ ................................ ............. 5 GLOBUS SENSATION ................................ ................................ ................................ ................................ ................................ ...... 6 TOOTH SENSITIVITY ................................ ................................ ................................ ................................ ................................ ...... 6 ACID REFLUX ................................ ................................ ................................ ................................ ................................ ..................... 6 DYSPHAGIA ................................ ................................ ................................ ................................ ................................ ......................... 6 LARYNGOPHARYNGEAL REFLUX (LPR) ................................ ................................ ................................ ................................ 6 TIGHTNESS OF CHEST / ANXIETY / HEART PALPITATIONS ................................ ................................ ....................... 6 Do you suspect GERD, LPR, or Hiatal Hernia? ................................ ................................ ................................ ........................... 6 WHAT SHOULD I DO? ................................ ................................ ................................ ................................ ................................ ..... 6 Proton Pump Inhibitors / H2 Blockers ................................ ................................ ................................ ................................ ........ 6 WHAT ARE THEY AND WHAT ARE THEIR DIFFERENCES? ................................ ................................ ........................... 6 WHAT ARE THE NAMES OF COMMON PPI’S AND H2 BLOCKERS? ................................ ................................ ............. 7 PPI’s: ................................ ................................ ................................ ................................ ................................ ................................ 7 H2 Blockers: ................................ ................................ ................................ ................................ ................................ .................. 7 ARE THERE ANY SIDE EFFECTS? ................................ ................................ ................................ ................................ .............. 7 PPI’s: ................................ ................................ ................................ ................................ ................................ ................................ 7 H2 Blockers: ................................ ................................ ................................ ................................ ................................ .................. 7 WHICH IS SAFER THAN THE OTHER? ................................ ................................ ................................ ................................ ..... 7 Page 2 Natural Remedies / Dietary Supplements ................................ ................................ ................................ ................................ .. 8 PROBIOTICS ................................ ................................ ................................ ................................ ................................ ....................... 8 MELATONIN ................................ ................................ ................................ ................................ ................................ ....................... 8 AMINO ACIDS / VITAMINS ................................ ................................ ................................ ................................ ........................... 8 GINGER ................................ ................................ ................................ ................................ ................................ ................................ 8 APPLE CIDER VINEGAR ................................ ................................ ................................ ................................ ................................ 8 ALOE VERA ................................ ................................ ................................ ................................ ................................ ......................... 8 DEGLYCYRRHIZINATED LICORICE (DGL) ................................ ................................ ................................ ............................. 8 ENDEFEN ................................ ................................ ................................ ................................ ................................ ............................. 9 GAVISCON (ADVANCE) ................................ ................................ ................................ ................................ ................................ .. 9 CHAMOMILE TEA ................................ ................................ ................................ ................................ ................................ ............. 9 IBEROGAST ................................ ................................ ................................ ................................ ................................ ......................... 9 SLIPPERY ELM ................................ ................................ ................................ ................................ ................................ ................... 9 Lifestyle Changes ................................ ................................ ................................ ................................ ................................ .................. 9 EAT SPARINGLY AND SLOWLY ................................ ................................ ................................ ................................ .................. 9 AVOID CERTAIN FOODS ................................ ................................ ................................ ................................ ............................. 10 DON'T DRINK CARBONATED BEVERAGES ................................ ................................ ................................ ........................ 10 STAY UP AFTER EATING ................................ ................................ ................................ ................................ ............................ 10 DON'T MOVE TOO FAST ................................ ................................ ................................ ................................ ............................. 10 SLEEP ON AN INCLINE ................................ ................................ ................................ ................................ ............................... 10 QUIT SMOKING ................................ ................................ ................................ ................................ ................................ .............. 10 Exercises ................................ ................................ ................................ ................................ ................................ ................................ 10 HEEL DROPS ................................ ................................ ................................ ................................ ................................ ................... 10 MASSAGES ................................ ................................ ................................ ................................ ................................ ........................ 11 IQORO ................................ ................................ ................................ ................................ ................................ ................................ 11 Diets ................................ ................................ ................................ ................................ ................................ ................................ ......... 11 COMMON CAUSES OF FLARE - UPS ................................ ................................ ................................ ................................ ......... 11 KETO DIET ................................ ................................ ................................ ................................ ................................ ....................... 11 ACID WATCHER DIET ................................ ................................ ................................ ................................ ................................ 11 DR. KOUFMANN’S ACID REFLUX DIET / DROPPING ACID ................................ ................................ .......................... 11 General Important Information (GII) ................................ ................................ ................................ ................................ ........ 12 Page 3 Objective The main objective for this paper is to gather years of meticulous research about the different options, remedies, exercises, surgeries, and diets that help with GERD, LPR , and hiatal hernias What is GERD / LPR? Gastro - esophageal reflux disease (GERD) , or Laryngopharyngeal reflux (LPR) are two chronic disorder s with significant impact on the quality of life of patients. It may also lead to several complications like peptic strictures, ulcerations, Barrett 's disease and subsequently adenocarcinoma of the e sophagus. Proton pump inhibitors (PPIs) are the mainstay of GERD /LPR treatment, with up to 90 % of patients with reflux disease becoming asymptomatic while taking PPIs. Surgeries Please seek the advice of your GI’s and surgeons. Every patient has a differe nt case, and must pass certain tests like the Bravo test to be considered a candidate for certain surgeries. NISSEN FUNDOPLICATION · The first ever surgery to arise for patients with GERD. Dubbed the “Gold Standard” Nissen fundoplication, is a minimally inva sive laparoscopic procedure . However, number of recognized complications are associated with fundoplication surgery; these include dysphagia, gasbloat syndrome, abnormal gastric motility, gastric hypersensitivity, and return of GERD symptoms. Nissen has a lot of versions, like the Nissen 360 - degree wrap , this is the main and original Nissen. The fundus is wrapped all the way around the bottom of your esophagus to tighten the sphincter. This prevents you from any burping or vomiting that may make your GERD w orse. Toupet 270 - degree posterior wrap , in this surgery t he fundus is wrapped about two - thirds of the way around the back side, or posterior, of the bottom of your esophagus. This creates a sort of valve that lets you more easily release gas through burps or vomit when necessary. Finally, the Watson anterior 180 - degree wrap , in this surgery t he part of the esophagus next to the diaphragm is reconstructed. Then, the fundus is wrapped halfway around the front, or anterior, of the bottom of the esophagus and a ttached to part of the diaphragm tissue. These procedure s should be considered only as a last resort as it typically includes side effects such as difficulty swallowing (26%), bloating (36%), and increased flatulence (65%) and have a high chance of failure o https://www.ncbi.nlm.nih.gov/books/NBK519521/ o https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015671/ TRANSORAL INCISIONLESS FUNDOPLICATION (TIF) (TIF 2.0) · The transoral incisionless fundoplication is a minimally invasive treatment for gastroesophageal reflux disease (GERD) that is performed in the outpatient setting. The TIF procedure is performed from inside the p atient’s stomach without incisions. This procedure delivers patient outcomes similar to those provided by conventional Nissen procedures, but is less invasive, has fewer adverse effects, and does not limit future treatment options. Following the principles of Nissen , the TIF procedure repairs the anti - reflux barrier by reducing a hiatal hernia (≤ 2 cm), and creating a valve 2 to 4 cm in length and greater than 270 degree circumferential wrap, thus restoring the dynamics of the angle of His. This procedure c an be done with a MUSE device, http://www.medigus.com/healthcare - professional o https://www.endogas tricsolutions.com/tif - procedure/tif - vs - antireflux - surgery/ Page 4 o https://pubmed.ncbi.nlm.nih.gov/27495332/ o https://pubmed.ncbi.nlm.nih.gov/297330 15/ LINX REFLUX MANAGEMENT SYSTEM · The LINX Reflux Management System is a laparoscopic, fundic - sparing anti - reflux procedure indicated for patients diagnosed with GERD, LPR, and small hiatal hernias (Hiatal Hernia Repair can be done on large hernias) Laparoscopic placement of the LINX device is major surgery and death can occur. The LINX device is a long - term implant. Basically, it is a series of titanium beads, each with a magnetic core, connected together with titanium wires to form a ring shape. The LINX device is surgically implanted around the lower end of the esophagus. It has been reported by a surgeon that more people nowadays remove the LINX device rather than installing it. Common symptoms on the LINX device is regurgitation, as food gets stuck in the esophagus, persistent symptoms of reflux, dysphagia, or device erosion o https://www.linxforlife.com/ o https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3667475/ o https://www.researchgate.n et/publication/328681991_Removing_the_magnetic_sphincter_augm entation_device_operative_management_and_outcomes BANDED ANTI - REFLUX MUCOSECTOMY (ARMS ) · Anti - reflux mucosectomy (ARMS) is a relatively new endoscopic procedure for GERD , thus not a lot of infor mation exists The procedure involves hemi - circumferential endoscopic mucosal resection (EMR) that is performed around the gastroesophageal junction (GEJ), which then contracts and tightens during healing. o https://pubmed.ncbi.nlm.nih.gov/30734179/ o https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4052191/ STRETTA RADIOFREQUENCY TREATMENT · The Stretta system delivers low power, low temperature radiofrequency (RF) energy to the lower esophageal sphincter (LES) muscle and gastric cardia. This energy remodels the tissue, resulting in improved barrier function and fewer random relaxations that cause reflux symptoms. RF energy has been shown to thicken the musculature and increase the size and amount of smooth muscle fibers in the treatment zone. The result is a measurable strengthening of the LES and a reduction in transient LES relaxations, without stricture or fibrosis. Studies show this effect may repair the deficient sphincter and restore the natural barrier function of the EGJ. Stretta is by far the most widely studied minimally invasive treatment option for GERD – and has been proven safe and effective in more than 60 clinical studies and 25,000 procedures. Studies show that patients experience significant and lasting symptom relief fro m 4 - 10 years*, without the higher complication rates of surgery, or the higher costs. The procedure can be redone at any time if the results are not very efficient. However, recent studies show that its effects are irreversible, and it has the potential to cause serious adverse events and does not really benefit GERD. In an analysis of data from 4 randomized controlled trials, on a total of 153 patients, Lipka et al (last link) found the overall quality of evidence to be very low. Page 5 o https://www.restech.com/solutions/stretta/#:~:text=How%20Stretta%20Therapy%20Works,rel axations%20that%20cause%20reflux%20symptoms o https://pubmed.ncbi.nlm.nih.gov/24078808/ o https://www.cghjournal.org/article/S1542 - 3565(14)01504 - 3/fulltext ESOPH AGEAL VALVULOPLASTY (MODIFIED BELSEY) · Currently only done by one Dr. in the world, Dr. Farid Gharagozloo, the Esophageal Valvuloplasty is best suited for candidates with failed Nissen’s. This procedure is fairly new however, and not much data has been avai lable . The only available research done, has been conducted by Dr. Farid himself. There’s a Facebook group dedicated to this surgery. o https://pubmed.ncbi.nlm.nih.gov/30500978/ o https://www.facebook.com/groups/1647211462073684/ BELSEY MARK IV · The Belsey Mark IV repair or anti - reflux fundoplication is a classic procedure that has proven to be a successful and durable anti - reflux operation. The Belsey Mark IV is seldom performed as a primary anti - reflux operation in noncomplicated cases o https://bmcsurg.biomedcentral.com/articles/10.1186/1471 - 2482 - 13 - 24 Common Symptoms HEARTBURN · Heartburn is a painful burning feeling in your chest or throat REGURGITATION · Foods can remain in the hernia and return back into the mouth DIFFICULTY SWALLOWING · The lining in your stomach protects it from the hydrochloric acid that breaks down your meals. Your esophagus does not have any lining or protection from the acid, so when it creeps up out of the stomach, it can irritate and inflame your esophagus and throat. The irritation can cause soreness and itchiness, making it painful to swallow. PERSISTENT COUGH · As the acid flows up into the esophagus — and possibly even the throat and lungs — your body encourages you to cough up the substance to remove it from your body. This may cause hoarsness. UPSET STOMACH · An upset stomach is another common sign; this type of discomfort can occur when stomach acid inflames your esophagus. Many different things can cause indigestion, but if you find yourself feeling nauseous only after eating, it might be acid reflux. Page 6 GLOBUS SENSATION · Globus sensation is the feeling that you have something stuck in the back of your throat. The acid irritates your throat, causing the muscles to either swell or tense up, which can create the feeling of a foreign object lodged in your throat. TOOTH SENSITIVITY · When acid reaches your mouth, it can erode your tooth enamel and cause sensitivity. Damage to enamel is permanent, so if you have concerns, speak with a doctor as soon as possible. Other related side effects include bad breath and gum inflammation. ACID REFLUX · Backflow of stomach acid into the esophagus causing acidic taste in mouth. DYSPHAGIA · Hiatal hernias can cause obstruction and delay in emptying of the lower part of the esophagus and the stomach, resulting in dysphagia. LARYNGOPHARYNGEAL REFLUX (LPR) · LPR is the retrograde flow of gastric contents into the larynx, oropharynx and/or the nasopharynx. LPR causes respi ratory symptoms such as cough and wheezing and is often associated with head and neck complaints such as dysphonia, tinnitus, globus sensation , and dysphagia. TIGHTNESS OF CHEST / ANXIETY / HEART PALPITATIONS · A common symptom of GERD is the tightness of ch est and having a hard time taking a deep breath. This sometimes causes a nxiety Anxiety may be a cause of heart palpitations. Do you suspect GERD, LPR, or Hiatal Hernia? WHAT SHOULD I DO? · Consult your local gastroenterolog ist. He will likely start off wit h a simple endoscopy. If there is a hernia, keep note of the size of the hernia, and its “hill grade”. Several tests can be done to help diagnose a hiatal hernia. These include a barium swallow test, the aforementioned endoscopy procedure, esophageal manom etric studies, a pH Bravo test, and gastric emptying studies. Proton Pump Inhibitors / H2 Blockers WHAT ARE TH EY AND WHAT ARE THEIR DIFFERENCES? PPIs inhibit certain cells from "pumping" acid into the stomach. They do not stop stomach fluid from refluxing into the esophagus but they lower acid levels in the stomach fluid, which alleviates heartburn. They are generally considered safe in the short term. H2 receptor blockers are most used to treat gastritis, or inflamed stomach, and to treat peptic ulcers. Peptic ulcers are painful sores that form in the lining of the stomach, lower esophagus, or duodenum, which is the first part of the small intestine. They often develop as a result of in flammation and excess stomach acid. Doctors may also recommend H2 receptor blockers to keep peptic ulcers from returning. Both medications work by blocking and decreasing the production of stomach acid, but PPIs are considered stronger and faster in reduci ng stomach acids. However, H2 receptor blockers specifically Page 7 decrease the acid released in the evening, which is a common contributor to peptic ulcers. This is why H2 receptor blockers are specifically prescribed to people who have ulcers or who are at ris k for getting them. PPIs are more often prescribed for people who have GERD or acid reflux. Doctors usually do not recommend taking both a PPI and an H2 receptor blocker at the same time. H2 receptor blockers can interfere with the effectiveness of PPIs. I f your GERD symptoms do not improve with the use of a PPI, your doctor may recommend an H2 receptor blocker instead. WHAT ARE THE NAMES OF COMMON PPI’S AND H2 BLOCKERS? PPI’s: · M meprazole (Prilosec, Prilosec OTC, Zegerid) · L ansoprazole (Prevacid) · P antoprazo le (Protonix) · R abeprazole (Aciphex) · E someprazole (Nexium) · D exlansoprazole (Dexilant) H2 Blockers: · Famotidine (Pepcid AC, Pepcid Oral) · Cimetidine (Tagamet, Tagamet HB) · Ranitidine (Zantac, Zantac 75, Zantac Efferdose, Zantac injection, and Zantac Syrup) · Nizatidine Capsules (Axid AR, Axid Capsules, Nizatidine Capsules) ARE THERE ANY SIDE EFFECTS? PPI’s: Unfortunately, PPI’s have serious side effects, the most common ones reported include headache, diarrhea, nausea, and vomiting. Reports of more ser ious side effects include kidney disease, infections, reduced level of vitamin B12, reduced magnesium levels, reduced calcium absorption, an increased risk of hip fractures, and an increased risk of pneumonia and other life - threatening infections , but thes e are very rare and are generally associated with long - term use (using these products for more than a year ). Currently there is a lawsuit against companies producing PPI’s because they have been linked to an excess risk of death ( https://pubmed.ncbi.nlm.nih.gov/28676480/ ) ( https://www.drugwatch.com/proton - pump - inhibitors/lawsuits/ ) H2 Blockers: Side effects of H2 receptor blockers include constipation, diarrhea, difficulty sleeping, dry mouth, dry skin, headaches, ringing in the ears, a runny nose, and trouble urinating. In more serious cases, H2 blockers can cause side effects like blistered, bu rning, or scaling skin, changes in vision, confusion, agitation, difficulty breathing, wheezing, chest tightness, irregular heartbeat, hallucinations and suicidal thoughts. WHICH IS SAFER THAN THE OTHER? H2 blockers are considered safer than PPI’s in long - term use. ( https://www.sciencedaily.com/releases/2017/07/170705113546.htm#:~:text=Further %2C%20the%2 0risk%20rose%20steadily,that%20of%20H2%20blocker%20users ) among people taking the drugs for one to two years, the risk to PPI users was nearly 50 percent higher than that of H2 blocker users. Page 8 Natural Remedies / Dietary Supplements PROBIOTICS · P robiotic supplements containing Lactobacillus acidophilus are commonly used for heartburn and reflux symptoms. Probiotics or “friendly” bacteria may help maintain a balance in the digestive system between good and harmful bacteria. o https://pubmed.ncbi.nlm.nih.gov/31906573/ MELATONIN · Recent studies found that melatonin up to 6 mg at bedtime may be an effective treatment for GERD with fewer and less serious adverse effects. o https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2821302/ o https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6506578/ o https://pubmed.ncbi.nlm.nih.gov/18616070/ AMINO ACIDS / VITAMINS · A recent study shows the regression of GERD symptoms whilst using amino acids and vitamins. o https://pubmed.ncbi.nlm.nih.gov/16948779/ GINGER · Some GERD patients reported that small doses of ginger may relieve gastrointestinal irritation. Ginger can reduce the likelihood of stomach acid flowing up into the esophagus. Ginger can also reduce inflammation. This may relieve symptoms of acid reflux. o https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6341159/ APPLE CIDER VINEGAR · While this may seem a little strange, fighting acid with acid, apple cider vinegar has been used for centuries as a natural alternative to medicine due to its many health benefits. With only 3 calories per tablespoon, this vinegar contains several healthy antioxidants and amino acids and helps balance your stomach pH by neutralizing stomach acid Although there is no research to support the claim, people have reported positive results. ALOE VERA · Recent research suggests that decolorized and purified aloe vera juice may be a safe and effective treatment for r educing reflux symptoms. The study found that the juice effectively reduced the symptoms of acid reflux as well as certain traditional medication without any reported side effects. Aloe vera has anti - inflammatory properties. The juice is loaded with vitami ns, minerals, and amino acids. It may also boost digestion and remove toxins from the body. DEGLYCYRRHIZINATED LICORICE (DGL) · It is widely believed that chewing on DGL tablets 6 - 8 times a day will alleviate acid reflux symptoms at least ½ hour before, or 2 hours after meals. However, not much scientific data exists to back up such claim. Page 9 ENDEFEN · Endefen is a powder that dissolves in water, creating a gloppy mix that coats the esophageal lining Endefen s upports the integrity of the gastric lining by promoti ng the growth of gastric mucosal cells. GAVISCON (ADVANCE) · With its main component alginate, a polymer derived from brown seaweed that is GRAS (Generally Regarded As Safe) and used widely in the food and pharmaceutical industries, has been found to be effective to prevent acid reflux in what I would call a "hybrid - mechanical" mechanism of action. The alginate binds gastric acid to polymerize and form a gel that acts as a protective layer floating above the contents of the stomach. It is recommended to t ake Gaviscon after meals, and before sleeping. o https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6836317/ CHAMOMILE TEA · Some people have reported good results drinking chamomile tea. The tea helps balance the acidity levels in your stomac h, and can also reduce stress levels, which can contribute to heartburn. o https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4756774/ IBEROGAST · A popular German formulation used extensively in Europe for treatment of dyspepsia (indigestion), Iberogast is a liquid combination of the herbs Iberis amara, Angelica, Chamomile, Caraway Fruit, St. Mary’s Thistle, Balm Leaves, Peppermint Leaves, Celandine, and Licorice Root. Together, they exert anti - inflammatory, anti - spasmodic, anti - bacterial and pro - motility effects. The latter makes Iberogast particularly helpful for GERD. By including certain herbal bitters which are traditional digestive aids, Iberogas t promotes optimal gastric emptying and intestinal transit, alleviating the stuck feeling that many GERD sufferers experience. Due to its dual anti - bacterial and pro - motility effects, Iberogast is ideal for sufferers of SIBO (small intestine bacteria overg rowth), a frequent contributor to the reflux and sour eructations of heartburn sufferers. WARNING: Contains peppermint, which is thought to provoke GERD in some individuals. o https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4928719/ SLIPPERY ELM · Slippery elm may be helpful for treating occasional heartburn , Slippery elm is available in various forms, such as capsules, powder, and lozenges. If you’re taking powdered bark, a typical dosage is about one tablespoon up to three times per day. You can m ix it with tea or water. Adding too much slippery elm to the water may cause it to become too thick to ingest. You can add sugar and honey to the drink to make it more palatable. If you prefer capsules, it’s common to take 400 - to 500 - milligram capsules up to three times per day. It’s generally safe to take daily capsules for up to eight weeks. o https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5605819/ Lifestyle Changes EAT SPARINGLY AND SLOWL Y · When the stomach is very full, there can be more reflux into the esophagus. If it fits into your schedule, you may want to try what is sometimes called "grazing" — eating small meals more frequently rather than three large meals daily. Page 10 AVOID CERTAIN FOODS · People with acid reflux were once instructed to eliminate all but the blandest foods from their diets. But that is no longer the case. "We've evolved from the days when you couldn't eat anything," Dr. Wolf says. But there are still some foods that are more likely than others to trigger reflux, including mint, fatty foods, spicy foods, tomatoes, onions, garlic, coffee, tea, chocolate, and alcohol. If you eat any of these foods regularly, you might try eliminating them to see if doing so controls your reflux, and then try adding them back one by one. The Foodicine Health website at www.foodicinehealth.org has diet tips for people with acid reflux and GERD as well as for other gastrointestinal disorders. DON'T DRINK CARBONATED BEVERAGES · They make you burp, whi ch sends acid into the esophagus. Drink flat water instead of sparkling water. STAY UP AFTER EATING · When you are standing, or even sitting, gravity alone helps keeps acid in the stomach, where it belongs. Finish eating three hours before you go to bed. This means no naps after lunch, and no late suppers or midnight snacks. DON'T MOVE TOO FAST · Avoid vigorous exercise for a couple of hours after eating. An after - dinner stroll is fine, but a more strenuous workout, especially if it involves bending over, ca n send acid into your esophagus. SLEEP ON AN INCLINE · Ideally, your head should be 6 to 8 inches higher than your feet. You can achieve this by using "extra - tall" bed risers on the legs supporting the head of your bed. If your sleeping partner objects to th is change, try using a foam wedge support for your upper body. Do no t try to create a wedge by stacking pillows. They w ill no t provide the uniform support you need. QUIT SMOKING · Nicotine may relax the lower esophageal sphincter and inhibits metalloproteina ses and the cross linking of collagen. Exercises · While there is no definite guaranteed way to strengthen the LES , some people report improvements following Pam Fox’s videos on YouTube to alleviate the symptoms caused by Hiatal Hernia’s ( https:// youtube.com /playlist?list=PLtyLvPHeKYToUNGtfz9lwowWEIcIKGQLZ ) HEEL DROPS · Heel drops are a common technique used by many to bring down the hiatal hernia: o Drink a glass of room temperature or slightly warm water when you get out of bed in the morning. (Skip the coffee , tea, juice, and cold water — just drink warm water.) o While standing, bring your arms straight out from your sides and bend your elbows so your hands are touching your chest. o Stand up on your toes as high as possible and drop down. You should get a pretty g ood jolt. Drop down like this 10 times continuously. Page 11 o Then, while standing with your arms up in the air, breathe short quick breaths with your mouth open for about 15 seconds. That is it. ▪ https://w ww.youtube.com/watch?v=Qs5xGSIB7pw MASSAGES · Certain massages like Dr. Dahlman’s massage has been reported to be successful ( youtube.com/watch?v=0DtwjUuqQow ) IQORO · IQoro is a neuromuscular training device that naturally treats the root cause of, reflux, snoring, sleep apnoea and swallowing difficulties . Some people have reported success by using the device long term (more than 6 months) o https://www.iqoro.com/hiatal - hernia/acid - reflux - and - heartburn/ Diets The most effective diet is trial and error. COMMON CAUSES OF FLARE - UPS · alcohol, particularly red wine · black pe pper, garlic, raw onions, and other spicy foods · chocolate · citrus fruits and products, such as lemons, oranges and orange juice · coffee and caffeinated drinks, including tea and soda · peppermint · tomatoes However, unless these foods are causing you heartburn y ou do not have to avoid them. KETO DIET · Many people have reported success stories using Keto diet. Essentially, a Keto is a low - carb, high - fat diet. It lowers blood sugar and insulin levels and shifts the body’s metabolism away from carbs and towards fat and ketones. ACID WATCHER DIET · This diet, developed by Dr. Aviv, is a 28 - d ay r eflux p revention and h ealing p rogramme . This book is the most recommended diet book for reflux sufferers and has lots of success stories with a high rate of satisfied GERD suffer ers. DR. KOUFMANN’S ACID REFLUX DIET / DROPPING ACID · This is another book for a diet specifically targeted at acid reflux sufferers. This book promises 111 different recipes including vegan and gluten - free ones. This is the second most recommended book for acid reflux sufferers and has equally helped many recover and pursue a healthy normal life. Page 12 General Important Information ( GII ) · GERD causes lots of symptoms that are usually associated with other diseases or imbalances, so it is always good to not brush o ff symptoms as GERD/LPR symptoms, it is still best to investigate symptoms even if they are caused by GERD/LPR. If you experience issues with bowel movements, do a hydrogen breath test to check for SIBO. · It is always recommended to seek different GI’s ( gastroenterolog ists) instead of one, other GI’s sometimes have different opinions. · If you take PPI’s it is recommended you do a CBC every few months, it has been reported that chronic use of PPI’s will cause malabsorption of key minerals in the body, namel y calcium and magnesium The loss of these minerals could lead to bone fractures or cardiac abnormalities. ·