Discussion
In this study we had a selective group of patients who had supine reflux on esophageal pH test with associated nocturnal reflux symptoms. Bed head elevation was done during the night-time from 22.00 hours to 05.00 hours. Patients who were upright or combined refluxers were excluded from the study as no bed head elevation was done during the daytime. We aimed to see the effect of bed head elevation on the symptoms of heartburn and esophageal pH parameters by using a 24-h esophageal pH test. In order to see the independent effect of bed head elevation, patients were kept off drugs for a period of 1 week before pH study and 1 week during the study period, which included proton pump inhibitors, H2 blockers, and antacids.
The majority of our patients had non-erosive reflux disease (NERD), despite having supine acid reflux, where esophagitis is seen more commonly. NERD is seen more commonly among the Asian population with symptoms which respond sub-optimally to proton pump inhibitors. There may be a role for simultaneous non-acid reflux in producing symptoms or hypersensitive esophageal mucosa to gastric contents explaining poor correlation between acid reflux and symptoms.[15,16] Bed head elevation could be effective in rapidly clearing both acid and non-acid reflux.
We raised the entire bed frame at the head end with wooden blocks of 20 cm in height. None of our patients had any problems in sleeping on the bed with the head end elevated on blocks. These patients were in hospital for 2 days and their position on the bed was monitored by the nurse and the attendant of the patient during the night-time. Three patients had insomnia, which they attributed to the hospital environment. Subsequently these patients practiced the same method at home under natural home conditions. The head of the bed can be elevated by plastic or wooden bed risers that support bed posts or legs, a therapeutic bed wedge pillow, or an inflatable mattress lifter that fits in between the mattress and the box spring or a hospital bed with an elevation feature. The height of the bed head elevation is critical and must be at least 6–8 inches (15–20 cm) to be at least minimally effective to prevent reflux of gastric contents. Raising the whole frame of the bed head is better than using multiple pillows as the latter can put the head at an angle that can increase pressure on the stomach and make reflux worse. Multiple pillows or a wedge elevate the head portion only, rather than the upper torso of the body so it does not give any advantage of gravity in clearing the reflux and further may cause neck pain. Patients also have a tendency to slide down from pillows.[17]
The present study showed that bed head elevation significantly reduced esophageal acid exposure and acid clearance time during the supine period besides reduction in symptom grade, although total resolution of heartburn and sleep disturbance was not seen. A meta-analysis of previous non-randomized studies revealed that bed head elevation is an effective therapy in relieving the symptoms of reflux.[9] Elevation of the upper body at night is generally recommended for all patients with GERD, nevertheless most patients with GERD have reflux only during the day and elevation at night is of little benefit. It is not possible to know for certain which patients will benefit from elevation at night unless acid testing clearly demonstrates night reflux. Most reflux is postprandial, however a small subgroup with major nocturnal reflux may benefit from bed head elevation; although the beneficial effect seems to be small when compared with proton pump inhibitor treatment.[18]
Improvement in symptoms and reflux parameters is likely due to the effect of gravity in causing increased clearance of refluxed stomach contents (not only acidic contents but also non-acidic contents). Reflux of acid is more injurious at night than during the day. At night, in a supine position it is easier for reflux to occur because gravity is not opposing the reflux as it does in the upright position during the day. In addition, lack of effect of gravity allows the refluxed liquid to travel further up the esophagus and remain in the esophagus longer.[9,19] There may be other factors which could have some influence on esophageal pH which we could not evaluate in this study, like sleeping on the left lateral decubitus position, and the frequency of salivation in the elevated head end position which has some role in acid clearance.[20,21]
Proton pump inhibitors, like esomeprazole, have been shown to relieve night-time heartburn in 53.1% of patients along with improvement in sleep-related disturbances.[12] Despite continued pharmacologic advancement in medical therapy for GERD, a high percentage of patients require continuous acid suppressive therapy and about 10% will require anti-reflux surgery for control of their symptoms or complications. The expense and potential side-effects of long-term pharmacologic therapy underscores the importance of phase 1 therapies as components in the medical approach to this disorder. Our study reveals a significant reduction in nocturnal acid exposure and acid clearance time with improvement of symptoms and sleep disturbances. Therefore lifestyle modification that involves bed head elevation could be helpful in patients of symptomatic nocturnal reflux by reducing the severity of symptoms and may give a synergistic effect along with proton pump inhibitors.
J Gastroenterol Hepatol. 2012;27(6):1078-1082. © 2012 Blackwell Publishing
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