Parkinson disease is the most common neurodegenerative disorder characterized by the loss of dopaminergic neurones in the Nigrostriatal region of the brain. The dopaminergic neurons are predominantly responsible for the control of bodily movements and posture. Their deficiency leads to muscular imbalance and loss of control and coordination in the elderly patients.
Acid reflux, gastroesophageal reflux disease (GERD) or just simple heartburn occurs quite frequently in many people, but Parkinson’s disease patients seem to be more prone to developing this condition. It is one of the most common non motor features of the Parkinson’s disease. In clinical practice the disappearance of these symptoms after the treatment of proton pump inhibitors allows the treating doctor to conclude that the patient had acid related dyspepsia, which is usually defined as the upper abdominal pain, retrosternal pain, discomfort, nausea, vomiting and heartburn. There are a number of reasons why this is so.
How Does Acid Reflux Occur?
When food is swallowed, it moves down through the esophagus (food pipe) into the stomach. The esophageal sphincter, situated between the esophagus and the stomach, opens to allow this action to take place and closes back again so that the food does not go back into the esophagus. In this way, the esophageal sphincter acts as a one way-valve.
In certain situations, the lower esophageal sphincter (LES) becomes weak, so that the stomach contents push against it and give rise to a feeling of fullness, or the stomach acids may regurgitate or flow back into the esophagus through the weakened sphincter and cause a burning sensation in the throat. If the condition is mild, the patient may suffer from heartburn once in a while, but if this acid reflux occurs frequently, the patient is said to be suffering from GERD.
The delicate lining of throat and oesophagus is destroyed or scarred by the powerful stomach acid, which gets regurgitated due to the Gastroesophageal Reflux Disease. The continuous and permanent scarring can lead to precancerous condition and the patient will eventually have difficulty with swallowing, which manifests as nutritional deficiencies with the passage of time.
Night time reflux v/s daytime reflux.
Human body has protective mechanisms against the harmful effects of acid reflux. Most of the patients develop episodes during the day when they are upright, in this case the reflux liquid flows back into the stomach, owing to the gravity. Also, when the patient is awake he repeatedly swallows, which carries any refluxed liquid back into the stomach. At last, the saliva produced by salivary glands contains bicarbonate ions which neutralizes the small amount of acid that remains in the oesophagus after the gravity and swallowing reflex have taken care of most of the regurgitated fluid. It could hence be effectively concluded that the gravity, swallow reflex and saliva are important protective mechanisms for the oesophagus.
However, they are effective only when the patient is upright or awake. While sleeping at night, gravity is eliminated, swallowing ceases and the secretion of saliva is reduced. Thus, the reflux that occurs at night, causes more damage to to the esophageal lining as compared to the daytime reflux.
Why are Parkinson’s Disease Patients more Prone to Acid Reflux?
- There is slower action of the nerves supplying the gastrointestinal tract in people suffering from Parkinson’s disease, so that movement of food during the process of digestion is slowed down. Food remaining in the stomach for long causes acid and gas build-up.
- The esophageal sphincter is frequently weakened in a Parkinson’s patient and it becomes harder for it to stay closed properly. This causes the stomach acids, gas and, the diluted food to be pushed upwards against the sphincter to cause the feeling of fullness. If the sphincter becomes too weak, it could easily be pulled open, which allows the acid to come up into the throat, thereby producing a burning feeling called as Acid Reflux.
- It is believed that the dopaminergic agents induce the gastrointestinal problems by stimulating the peripheral dopaminergic receptors. Parkinson’s disease drugs (anticholinergics and dopamine) can cause or aggravate acid reflux.
- Also, the helicobacter pylori infection can induce motor fluctuations by interrupting the absorption of levodopa in Parkinson’s disease patients.
Symptoms of Acid Reflux
Heartburn – a burning sensation in the chest, under the sternum (breast bone), usually after a meal. This may be worse at night or on lying down. It can also be aggravated by a heavy meal or on bending or lifting a heavy weight after a meal.
Belching or burping.
Regurgitation of food.
Nausea or vomiting.
Diagnosis of Acid Reflux in Parkinson’s Disease
Diagnosis can usually be made on the basis of signs and symptoms. If necessary, the following investigations may be done :
- 24 hour esophageal pH monitoring combined with the proton pump inhibitor test.
- Esophageal gastroduodenoscopy – to detect signs of acid reflux and changes in the esophagus.
- Barium swallow – to detect signs of regurgitation.
- Manometry – to measure pressure of the sphincter muscle.
Treatment of Acid Reflux in Parkinson’s Disease
Treatment of esophageal problems in Parkinson’s disease remains difficult, but the symptoms manifested due to the reflux can be treated with suitable antireflux measures.
- Certain foods are more likely to trigger the acid reflux, Avoiding these foods through certain dietary and lifestyle changes can help. Foods that can trigger the reflux include alcohol, citrus fruits like lemon, oranges, tomatoes, caffeine, chocolate and peppermint.
- Avoid rich, spicy or acidic food and caffeinated drinks.
- Avoid eating anything for several hours before bedtime.
- Large meals contribute to the bloating and eventually to acid reflux as the stomach requires a comparatively greater time to process bulky food. A larger meal is more likely to stay in the stomach for a longer time and the resultant gas production will cause the upward pressure against the weakened esophageal sphincter to cause reflux. It is thus advised for the Parkinson’s patients with GERD to have smaller and frequent meals.
- Avoid alcohol and tobacco.
- Avoid lying down, bending or lifting weights after a meal.
- Lose weight if obese.
- Avoid wearing tight clothes or belts.
- Raise head-end of the bed.
- A change in Parkinson’s disease drug therapy if the symptoms are severe.
- Medication such as antacids, histamine H2 blockers, proton pump inhibitors or a prokinetic drug like metoclopramide may help. Always speak to your doctor about drug interactions before starting any medication.
- Medications like Proton pump inhibitors might increase the risk of osteoporosis related fractures which is already a problem from which the patients of Parkinson’s disease suffer. For this reason many patients would like to find natural remedies for GERD. Alternative therapies, including homeopathy and herbal treatment should be done only after consulting with the supervising doctor.
- Surgery – a procedure called fundoplication may be done if the symptoms are severe and all other treatments fail.