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Revista Colombiana de Gastroenterologia

Print version ISSN 0120-9957

Rev Col Gastroenterol vol.31 no.2 Bogotá Apr./June 2016


Letter to the Editor

Received: 21-04-16  Accepted: 06-05-16

Bogota, April 21, 2016

Ana María Leguízamo: Honorary Profesor of Gastroenterology at the Hospital Universitario San Ignacio of the Pontificia Universidad Javeriana in Bogotá, Colombia

Albis Hani de Ardila: Professor and Chief of the Gastroenterology Unit at the Hospital Universitario San Ignacio of the Pontificia Universidad Javeriana in Bogotá, Colombia

Valeria Costa Barney: Gastroenterologist at the Hospital Universitario San Ignacio of the Pontificia Universidad Javeriana in Bogotá, Colombia

Dr. Jaime Alvarado


Colombian Journal of Gastroenterology

Dear Dr. Alvarado:

We read the article by Castillo et al. (1) with interest. It shows the impact of lifestyle interventions for treating gastroesophageal reflux disease (GERD) and makes clear that one of the most important developments in the pathophysiology of GERD has been the discovery of acid pocket in 2001 when Fletcher et al. (2) described an area of ​​low pH immediately distal to the cardia. Their hypothesis was that this was a local acid pocket near the gastroesophageal junction in which the neutralizing effect of food on pH was absent. They suggested that this was the source of acid in the postprandial period. On this basis, recently developed drugs such as alginates and baclofen (3) have been evaluated for their effects on the acid pocket. (4) Several studies have shown that reflux increases in the right lateral decubitus position. The reason for this is not entirely clear, but it may be related to increasingly frequent transient lower esophageal sphincter relaxations (TLESRs) in the right position or possibly to the fact that the gastroesophageal junction is located above the level of gastric acid in the left lateral decubitus position. (5) Specifically, total reflux time, average time necessary for clearance of acid and TLESR are significantly longer for patients lying on their right sides than for patients in left lateral decubitus position.

With regard to consumption of food before going to bed, a randomized trial that compared consumption two hours before going to bed with consumption six hours before going to bed has shown that later food intake favors more reflux episodes while a person is supine which results in more frequent disturbances of sleep.  (6) Finally, the frequency of TLESRs is directly related to the degree of proximal gastric distention. (7) Similarly, a study by El-Serag et al. has shown that diets with large amounts of fat, particularly saturated fat, are associated with an increased risk of GERD symptoms and erosive esophagitis. (8) Various physiological studies of healthy volunteers and patients with GERD have shown increased frequency of TLESRs and esophageal acid exposure associated with fat intake. (9, 10) A study by Boeckxstaens et al. (11) has confirmed that ingestion of food intake is a well-tolerated and reliable stimulus for the onset of TLESRs and reflux in patients with GERD.

A study by Castell et al. has shown that chocolate lowers basal LES pressure which explains the reason for the pathogenesis of chocolate induced reflux symptoms. The relationship between chocolate consumption and increased esophageal acid exposure was assessed by intra-esophageal pH monitoring. It is believed that chocolate's effects are due to the percentage of methylxanthines (theobromine in particular) and their influence on cyclic adenosine monophosphate (cAMP). (12) The information about the possible relationships between diet and GERD is scant which makes critical studies demonstration of the impact of changes in lifestyle on GERD fundamental.


1. Castillo R, Otero W, Trespalacios A. Impacto de las medidas generales en el tratamiento del reflujo gastroesofágico: una revisión basada en la evidencia. Revista Col Gastroenterol. 2015:30(4):431-46.         [ Links ]

2. Fletcher J, Wirz A, Young J et al. Unbuffered highly acidic gastric juice exits at the gastroesophageal junction after a meal. Gastroenterology- 2001;121:775-83.         [ Links ]

3. Scarpellini E, Boecxstaens V, Broers C, Vos R, Pauwels A, Tack J. Effect of baclofen on gastric acid pocket in subjects with gastroesophageal reflux disease symptoms. Dis Esophagus. 2015.         [ Links ]

4. Mitchell DR, Derakhshan MH, Robertson EV,McColl KEL. The role of the Acid Pocket in Gastroesophageal Reflux Disease. J Clin Gastroenterol. 2016:50:111-9.         [ Links ]

5. Kaltenbach T, Crockett S, Gerson LB. Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach. Arch Intern Med. 2006;166:965-71.         [ Links ]

6. Piesman M , Hwang I, Wong RKH. Nocturnal Reflux Episodes Following the Administration of a Standardized Meal. Does Timing Matter? Am J Gastroenterol. 2007;102:2128-34.         [ Links ]

7. Scheffer RCH, Akkermans LMA, Bais JE, Roelofs JMM, Smout AJPM et al. Elicitation of transiet lower oesophageal sphincter relaxations in response to gastric distensión and meal ingestión. Neurogastronterol Mot. 2002;14:647-55.         [ Links ]

8. El-Serag HB, Satia JA, Rabeneck L. Dietary intake and the risk of gastro-esophageal reflux disease: a cross sectional study in volunteers. Gut. 20015;54:11-17.

9. Hills JM et al. The mechanism of action of perpermint oil and gastrointestinal smooth muscle. Gastroenterology. 1991;101:55-65.         [ Links ]

10. Murphy DW, Castell DO: Chocolate and heartburn: evidence of increased esophageal acid exposure after chocolate ingestion: Am J Gastroenterol. 1988;83:633-6.         [ Links ]

11. Boeckxstaens GE, Hirsch DP, Verkleij CB et al. Reproducibility of meal- induced transient lower oesophageal sphincter relaxations in patients with gastro-oesophageal reflux disease. Neurogastroenterol Motil. 2006;17:23-228.         [ Links ]

12. Wright LE, Castell DO. The adverse effect of chocolate on lower esophageal sphincter pressure. Dig Dis. 1975;20:703.         [ Links ]