Acid reflux 3rd trimester

Feeling the burn? Tips to manage heartburn, GERD in pregnancy | Your Pregnancy Matters

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Your Pregnancy Matters

July 30, 2019

Your Pregnancy Matters

Robyn Horsager-Boehrer, M. D. Obstetrics and Gynecology

The pregnancy hormone progesterone can increase heartburn, starting in the first trimester.

Heartburn is common in adults – especially during pregnancy. While some research suggests women who have moderate heartburn during pregnancy give birth to babies with fuller heads of hair, having symptoms more than twice a week might be a sign of gastroesophageal reflux disease (GERD), or recurrent heartburn.

According to a study of 510 pregnant women, approximately 26% have GERD symptoms during the first trimester. The rate jumps to 36% in the second trimester and 51% during the third trimester. That’s substantial compared with the 20% of adults in the U.S. who experience heartburn.

Why the increase in symptoms during pregnancy? Progesterone, a hormone that increases early in pregnancy, relaxes smooth muscle in the body. It helps your uterus stretch to accommodate the growing fetus, but also reduces the reliability of the esophageal sphincter – a ring-like structure that seals off stomach contents from the throat.

Increased pressure placed on the stomach externally from the growing uterus, especially in the third trimester, can also worsen heartburn symptoms such as:

Burning pain in the center of the chest, especially after eating
Sour or bitter taste in the mouth
Sore throat or cough

Thankfully, there are several pregnancy-safe ways to deal with acute heartburn and ongoing cases of GERD.

"Progesterone, a hormone that increases early in pregnancy, also reduces the reliability of the esophageal sphincter, which means that certain foods such as spicy dishes may trigger heartburn symptoms. "
Robyn Horsager-Boehrer, M.D.

Heartburn treatment options during pregnancy

Lifestyle changes

Consider these diet and sleep modifications to relieve or prevent heartburn:

Avoid tobacco and alcohol. These substances worsen the symptoms, and it’s already recommended for all women during pregnancy to avoid smoking, vaping, and drinking alcohol. Need to quit? We offer a free tobacco cessation program.
Shift your eating schedule. Smaller, more frequent meals fill the stomach less and may reduce symptoms. Also, avoid bending over or lying flat after meals to reduce acid reflux.
Prop yourself up in bed. Try sleeping with an extra pillow under your head or a small wedge under your pillow. The incline can help prevent stomach acid from splashing into your lower esophagus.
Skip the sauce or spice. If you notice that certain foods such as tomato sauces or spicy dishes trigger symptoms, avoid them until after the baby comes.

Oral antacids with calcium carbonate have the added benefit of supplementing calcium intake during pregnancy.

Medications

Heartburn and GERD symptoms are less severe when there is less acid in the stomach. That said, you need a certain amount of acid to properly digest food. Three types of medication can help create that balance.

Oral antacids like aluminum and magnesium hydroxide (think Maalox or Mylanta) and calcium carbonate (like TUMS) neutralize acid already present in the stomach. Calcium carbonate has the added benefit of supplementing calcium intake during pregnancy. It’s safe to follow the directions on the package – there’s no need to change the dosage or schedule due to pregnancy.

On the flip side, two types of medications actually reduce acid production before it can enter the stomach.

h3-receptor antagonists (h3-blockers) reduce h3 histamine, which stimulates cells in the stomach to produce acid. Thus, less stomach acid is produced. Examples include ranitidine (Zantac), cimetidine (Tagamet HB), and famotidine (Pepcid). All of these are available over the counter and in generic forms.

Proton pump inhibitors (PPIs) block an enzyme in stomach cells that’s needed to produce acid. These drugs are available over the counter but can take several days to provide maximum relief, so you might consider trying an antacid or h3 blocker first. Examples of PPIs include lansoprazole (Prevacid) and omeprazole (Prilosec), as well as generic versions. Both brand name and generic are considered safe during pregnancy.

Please note, because stomach acid is necessary for iron absorption, h3 blockers and PPIs can decrease the effectiveness of iron supplements. Talk to your doctor if this might be an issue for you.

Related reading: 4 common pregnancy-related GI issues

When to call the doctor

If heartburn symptoms are associated with headaches or swelling of the hands and face, talk with your provider before trying these remedies, especially if the symptoms are new and present in the last trimester of pregnancy.

Heartburn-like pain can be a symptom of preeclampsia, or dangerously high blood pressure during pregnancy. Preeclampsia puts mothers and babies at risk, and further evaluation may be necessary.

As mentioned, heartburn is very common in pregnancy. If your symptoms don’t resolve with diet changes or medication, let your provider know so you can find an effective treatment.

Tired of feeling the burn? Call 214-645-8300 or request an appointment online.

Heartburn, Acid Reflux, and GERD During Pregnancy

It’s called heartburn, although that burning feeling in your chest has nothing to do with the heart. Uncomfortable and frustrating, it bothers many women, particularly during pregnancy.

The first question you may have is how to make it stop. You may also wonder if treatments are safe for your baby. Learn what causes heartburn during pregnancy and what you can do about it.

During normal digestion, food travels down the esophagus (the tube between your mouth and stomach), through a muscular valve called the lower esophageal sphincter (LES), and into the stomach.

The LES is part of the doorway between your esophagus and your stomach. It opens to allow food through and closes to stop stomach acids from coming back up.

When you have heartburn, or acid reflux, the LES relaxes enough to allow stomach acid to rise up into the esophagus. This can cause pain and burning in the chest area.

During pregnancy, hormone changes can allow the muscles in the esophagus, including the LES, to relax more frequently. The result is that more acids may seep back up, particularly when you’re lying down or after you’ve eaten a large meal.

In addition, as your fetus grows during the second and third trimesters and your uterus expands to accommodate that growth, your stomach is under more pressure. This can also result in food and acid being pushed back up into your esophagus.

Heartburn is a common occurrence for most people at one time or another, but it doesn’t necessarily mean you’re pregnant. However, if you also experience other symptoms, such as a missed period or nausea, these could be signs that you need to take a pregnancy test.

Pregnancy increases your risk of heartburn or acid reflux. During the first trimester, muscles in your esophagus push food more slowly into the stomach and your stomach takes longer to empty.

This gives your body more time to absorb nutrients for the fetus, but it can also result in heartburn.

During the third trimester, the growth of your baby can push your stomach out of its normal position, which can lead to heartburn.

However, each woman is different. Being pregnant doesn’t necessarily mean you’ll have heartburn. It depends on many factors, including your physiology, diet, daily habits, and your pregnancy.

Relieving heartburn during pregnancy typically involves some trial and error. Lifestyle habits that can reduce heartburn are often the safest methods for mother and baby. The following tips may help relieve your heartburn:

Eat smaller meals more frequently and avoid drinking while eating. Drink water in between meals instead.
Eat slowly and chew every bite thoroughly.
Avoid eating a few hours before bed.
Avoid foods and beverages that trigger your heartburn. Typical culprits include chocolate, fatty foods, spicy foods, acidic foods like citrus fruits and tomato-based items, carbonated beverages, and caffeine.
Stay upright for at least one hour after a meal. A leisurely walk may also encourage digestion.
Wear comfortable rather than tight-fitting clothing.
Maintain a healthy weight.
Use pillows or wedges to elevate your upper body while sleeping.
Sleep on your left side. Lying on your right side will position your stomach higher than your esophagus, which may lead to heartburn.
Chew a piece of sugarless gum after meals. The increased saliva may neutralize any acid coming back up into the esophagus.
Eat yogurt or drink a glass of milk to quell symptoms once they start.

Alternative medicine options include acupuncture and relaxation techniques, such as progressive muscle relaxation, yoga, or guided imagery. Always check with your doctor before trying new treatments.

Over-the-counter antacids such as Tums, Rolaids, and Maalox may help you cope with occasional heartburn symptoms. Those made of calcium carbonate or magnesium are good options.

However, it may be best to avoid magnesium during the last trimester of pregnancy. Magnesium could interfere with contractions during labor.

Most doctors recommend avoiding antacids that contain high levels of sodium. These antacids can lead to a buildup of fluid in the tissues.

You should also avoid any antacids that list aluminum on the label, as in “aluminum hydroxide” or “aluminum carbonate”. These antacids can lead to constipation.

Finally, stay away from medications like Alka-Seltzer that may contain aspirin.

Ask your doctor for the best option. If you find yourself downing bottles of antacids, your heartburn may have progressed to gastroesophageal acid reflux disease (GERD). In that case, you may need a stronger treatment.

If you have heartburn that often wakes you up at night, returns as soon as your antacid wears off, or creates other symptoms (such as difficulty swallowing, coughing, weight loss, or black stools), you may have a more serious problem that requires attention.

Your doctor may diagnose you with GERD. This means that your heartburn needs to be controlled to protect you from complications such as damage to the esophagus.

Your doctor may prescribe certain acid-reducing medications to reduce your symptoms. Research indicates that medications called h3 blockers, which help block the production of acid, appear to be safe.

Another type of medication, called proton pump inhibitors, is used for people with heartburn that doesn’t respond to other treatments.

If you’re concerned about the effects of medications, be sure to talk to your doctor. Doctors can help you control your symptoms while keeping your unborn child safe.

Acid related diseases in pregnancy | Rassvet Clinic

Heartburn during pregnancy is a very common complaint. It is known that up to 80% of pregnant women experience symptoms characteristic of gastroesophageal reflux disease (GERD) (heartburn, dysphagia, belching, and others), and the frequency of heartburn in the first trimester is 7.2%, in the second - 18.2%, in the third - 40%.

The main factors behind this high prevalence of GERD in pregnancy include hormonal changes such as hyperprogesteronemia (increased levels of the hormone progesterone) and hyperestrogenemia (increased levels of estrogen hormones), as well as increased intra-abdominal pressure due to uterine and fetal growth.

The action of gestational hormones in the first trimester of pregnancy is due to the fact that they, without affecting the basal tone of the lower esophageal sphincter (LES), reduce the increase in pressure of this sphincter in response to a variety of physiological stimuli, including food intake. In the second and third trimesters of pregnancy, progesterone and estrogen reduce the basal tone of the LES to 50% of the initial level, the maximum decrease occurs at 36 weeks of gestation. After a successful delivery, the tone of the LES in women who did not suffer from GERD before pregnancy, as a rule, returns to normal - in connection with this, this condition is called "pregnancy heartburn."

Pregnancy heartburn usually does not lead to the development of esophagitis, complications of GERD (strictures, ulcers, bleeding) and does not require serious medical treatment.

If a woman had GERD before pregnancy, the complaints may worsen during pregnancy and require examination and medication.

The diagnosis of GERD during pregnancy is established primarily on the basis of complaints, anamnesis data and objective examination. X-ray examination in pregnant women - due to possible damaging effects on the fetus - is not used, pH-metry and manometry can be used, but the need for its use is doubtful.

Esophagogastroduodenoscopy (EGD) is the method of choice for diagnosing GERD in pregnant women, but it should only be used for strict indications, such as a history of complications of GERD and the ineffectiveness of ongoing drug therapy.

Treatment of GERD in pregnant women should be based on changes in lifestyle and nutrition: exclusion of a horizontal position of the body immediately after meals, sleeping with the head end of the bed elevated (by 15 cm), exclusion of physical activity that increases intra-abdominal pressure (including wearing corsets, tight belts, bandages). The last meal should take place no later than 3 hours before bedtime, you need to eat in small portions, pay special attention to the normalization of the stool.

First-line drugs for the treatment of GERD in pregnant women include antacids and alginates. With the ineffectiveness of these drugs, it is permissible to prescribe prokinetics (metoclopramide), blockers of histamine h3 receptors and (according to strict indications) proton pump inhibitors (PPIs).

H2-histamine blockers are the most commonly prescribed group of drugs for pregnant women. They are classified as risk category B by the US Food and Drug Administration (FDA) ( "drugs taken by a limited number of pregnant women without evidence of their effect on the incidence of congenital anomalies or damaging effects on the fetus") . In Russian instructions, only cimetidine and ranitidine are allowed with a caveat: use during pregnancy is possible only if the expected effect of therapy outweighs the potential risk to the fetus. Famotidine and nizatidine in the Russian Federation are contraindicated for pregnant women.

Although most PPIs are also classified by the FDA as risk category B, in Russia there are more stringent restrictions on the use of this group of drugs in pregnant women. So, lansoprazole is contraindicated in the first trimester, in the second and third trimesters it can be used only if the expected benefit of therapy outweighs the potential risk to the fetus. The use of pantoprazole and esomeprazole is possible only under strict indications, when the benefit to the mother outweighs the potential risk to the fetus. Rabeprazole during pregnancy is contraindicated.

Pregnancy has a beneficial effect on the course of peptic ulcer disease: 75-80% of women experience remission of the disease, and it does not have a noticeable effect on its outcome. However, some patients may experience an exacerbation. This is most often observed in the first trimester of pregnancy (14.8%) and the third trimester (10.2%), as well as 2-4 weeks before the due date or in the early postpartum period. Uncomplicated peptic ulcer does not adversely affect the development of the fetus.

Treatment of peptic ulcer in pregnant women includes adherence to generally accepted "regime" measures and diet; taking in the usual therapeutic doses of non-absorbable antacids (1 sachet 3 times a day 1 hour after meals and adsorbents 1 sachet 3 times a day 1 hour after meals). If there is no effect, h3-blockers are prescribed (ranitidine 150/300 mg once a night), in case of their insufficient effectiveness, as well as with the development of complications, we can take PPIs (omeprazole 20-40 mg, lansoprazole 30-60 mg, pantoprazole 40 mg). mg in the morning before the first meal). Bismuth preparations are contraindicated for pregnant women. Eradication therapy for H. pylori infection in pregnant women is not carried out.

Author:

Kaibysheva Valeria Olegovna
Gastroenterologist Ph.D.

GERD during pregnancy - causes, symptoms, diagnosis and treatment

GERD during pregnancy is an acid-dependent disease of the esophagus caused by damage to the mucosa during reflux of stomach contents, which has arisen or aggravated under the influence of gestational factors. Manifested by heartburn, sour eructation, odynophagia, less often - nausea, vomiting, dysphagia, epigastric pain, cough, dysphonia, hypersalivation in sleep, taste perversions, depressed mood. It is diagnosed using alkaline and omeprazole tests, esophagoscopy, pH-metry, manometry. For treatment, alginates, antacids, selective histamine blockers, drugs that inhibit the proton pump, prokinetics are used.

General information

GERD (gastroesophageal reflux disease, gastroesophageal reflux) is one of the most common diseases of the gastrointestinal tract, contributing to such a common symptom as pregnancy heartburn. According to the observations of specialists in the field of obstetrics and gynecology, from 30 to 95% of patients during the period of bearing a child experience heartburn, which some experts even consider a natural manifestation of pregnancy. In 21-80% of patients suffering from GERD, the disease debuted precisely in connection with gestation.

Women who have given birth more than once are more susceptible to the disease. The relevance of timely detection of gastroesophageal reflux is due to a significant deterioration in the quality of life of a pregnant woman and the need to prescribe pharmacotherapy to almost half of the patients.

GERD during pregnancy

Causes

Gastroesophageal reflux of acidic gastric contents develops when the cardiac sphincter is weakened, the motility of the esophagus and stomach is impaired, gastric secretion is increased, and the protective properties of the esophageal mucosa are reduced. The occurrence of GERD is promoted by congenital and acquired hernia of the esophageal opening of the diaphragm with displacement into the posterior mediastinum of the abdominal esophagus, part or all of the stomach, smoking, dietary errors, and obesity.

Nitrates, antidepressants, progestins, anticholinergics, calcium channel blockers, and other medications that cause transient relaxation of the esophageal sphincter play a role. Specialists in the field of modern gastroenterology consider pregnancy as a separate prerequisite for the development of gastroesophageal reflux disease. The high incidence of GERD during gestation is associated with the action of factors such as:

Progesterone increase . Under the action of progestins, the lower esophageal sphincter relaxes, the tone of which is restored only in the postpartum period. By reducing the tone of smooth muscle fibers and reducing the sensitivity of intestinal receptors to histamine and serotonin, physiological hyperprogesteronemia slows down gastrointestinal motility and impairs gastric emptying. As a result, reflux occurs more frequently.
Increased intra-abdominal pressure . During pregnancy, the relative position of the internal organs of the abdominal cavity is disturbed, which is associated with the development of the fetus and the growth of the uterus. When the stomach is displaced towards the diaphragm, evacuation stagnation of its contents is formed faster and the risk of diaphragmatic hernia formation increases. The factor of increasing intra-abdominal pressure is most significant in carrying multiple pregnancies and large fetuses.

Pathogenesis

The mechanism of GERD development during pregnancy is based on the reflux of aggressive stomach contents into the lower esophagus. Gastroesophageal reflux usually occurs when the pressure of the cardiac sphincter is less than 2 mm Hg. Art. or an increase in intragastric pressure of more than 5 mm Hg. Art. Both of these factors are found in pregnant women. Refluxate containing hydrochloric acid, pepsin, and in some cases bile acids, has an irritating effect on the epithelium of the esophagus, causes a local inflammatory reaction, and in some patients provokes the onset of erosive processes.

Classification

When systematizing the forms of GERD in pregnant women, the same criteria are taken into account as outside the gestational period - the nature of the course of the disease and the condition of the esophageal mucosa. This approach makes it possible to develop optimal medical tactics aimed at eliminating clinical symptoms and the morphological basis of their occurrence without the risk of negative effects on the fetus. Depending on the time of existence of the disorder, acute gastroesophageal reflux disease is distinguished, lasting up to 3 months, and a chronic process that exists for 3 months or more. Taking into account the characteristics of damage to the mucosa of the esophagus, such forms of GERD are distinguished as:

Gastroesophageal reflux without esophagitis . With a non-erosive variant of the disorder, detected in 55-70% of patients, there are no endoscopic signs of damage to the epithelium. Although the likelihood of complications in this case is lower, the patient's quality of life deteriorates in the same way as in the presence of erosions.
Reflux esophagitis . In 30-45% of pregnant women with GERD during endoscopy, visible signs of esophagitis caused by the aggressive action of the contents of the stomach are determined. In the erosive form of gastroesophageal reflux, acute and long-term consequences of the disease are more often observed.

When predicting the outcome of GERD in a pregnant woman, the severity of the endoscopically positive variant of the disease according to the Los Angeles classification is also taken into account. The most favorable during pregnancy is reflux esophagitis A and B degrees, in which the defects extend to 1-2 folds of the mucosa, and their sizes, respectively, are up to or more than 5 mm. With C degree of GERD, less than 75% of the esophageal circumference is affected, and with D - 75% or more, which significantly increases the likelihood of a complicated course.

Symptoms of GERD during pregnancy

75% of patients with gastroesophageal reflux complain of heartburn, which gradually increases as labor approaches. Discomfort and burning behind the sternum often occur after eating spicy, fatty, fried foods, overeating, exercise, lying down and bending over. Heartburn attacks can recur several times a day and last from minutes to several hours. Pregnant women suffering from GERD may experience sour or bitter belching, sensation of a lump in the throat, retrosternal pain when swallowing with irradiation to the precordial region, neck, lower jaw, interscapular space.

Sometimes in the II-III trimesters, nausea and vomiting are noted, it is extremely rare to swallow solid and then liquid food. Extra-esophageal manifestations of reflux disease during pregnancy are a feeling of fullness in the epigastrium, rapid satiety, repeated attacks of coughing and suffocation, a hoarse voice, sore throat, increased salivation during sleep, burning cheeks and tongue, taste perversion, bad breath. Often, pregnant women experience a sad, depressed mood. Rarely, GERD is asymptomatic.

Complications

Usually, gastroesophageal reflux does not cause any obstetric complications, however, with extensive erosive damage to the esophagus, more severe anemia in pregnant women may develop. In two thirds of patients, GERD worsens during pregnancy: in 10-11% of cases, a relapse occurs in the 1st trimester, aggravated by early toxicosis, in 33-34% - in the 2nd trimester, and in more than half of pregnant women - in the 3rd.

Rare specific complications that occur against the background of physiological immunodeficiency during pregnancy are acute esophagitis caused by candidal and herpes infections. There is a risk of ulceration of the mucosa with the development of esophageal bleeding. Long-term consequences of reflux disease are narrowing (strictures) of the esophagus, dysplasia and metaplasia of the epithelium (Barrett's esophagus) and esophageal adenocarcinoma.

Diagnosis

During pregnancy, the diagnosis of GERD is usually made on the basis of typical clinical symptoms with daily occurrence of heartburn. An obstetrician-gynecologist and a gastroenterologist are involved in the diagnosis. Instrumental methods traditionally used in the diagnosis of the disease are used to a limited extent in pregnant women due to the possible provocation of preterm labor and the aggravation of other complications (nephropathy, early toxicosis, preeclampsia, eclampsia). Recommended for diagnostic purposes:

Alkaline test . Reception of absorbable antacids quickly stops an attack of heartburn. The positive effect of alkaline preparations is associated with the neutralization of hydrochloric acid coming from the stomach into the esophagus. In the presence of extraesophageal manifestations, the study is supplemented with an omeprazole test aimed at eliminating symptoms by inhibiting gastric secretion.
Esophageal Endoscopy . Esophagoscopy is performed if extensive erosion, ulceration, esophageal bleeding, strictures are suspected, and neoplasia can be ruled out. In endoscopic examination, GERD is manifested by swelling and slight vulnerability of the esophageal mucosa, it is possible to identify areas of damaged epithelium. In some cases, it is possible to visualize the reflux of gastric juice.
Intraesophageal pH-metry. The method is effective in non-erosive forms of gastroesophageal reflux. Electrometric determination of the acidity of the contents of the esophagus is carried out using a flexible intraesophageal probe attached to an acidogastrometer. pH-metry allows you to identify episodes of reflux of gastric juice and determine the conditions for their occurrence.
Manometry . Registration of pressure in different parts of the gastrointestinal tract using special catheters with strain gauges verifies the weakening of the cardiac sphincter and dysmotility. A manometric study also provides an objective assessment of elasticity, tone, contractile activity of the esophageal wall, and pressure profiling in the esophagus.

If necessary, the examination is supplemented with gastrocardiomonitoring, gastrointestinal impedancemetry, bilemetry. X-ray studies of the esophagus during pregnancy are not performed. GERD is differentiated from functional dyspepsia, gastric and duodenal ulcers, acute infectious esophagitis, benign tumors and esophageal cancer. If extraesophageal symptoms are detected, differential diagnosis with angina pectoris, bronchial asthma may be required.

Treatment of GERD during pregnancy

Therapeutic tactics are aimed at the rapid elimination of clinical symptoms, restoration of the esophageal mucosa, prevention of complications and relapses. In 25% of cases, the condition can be improved by non-drug methods. Pregnant women with mild GERD are recommended to stop smoking, correct diet and diet with frequent small meals, reduce the amount of high-protein and low-lipid foods, and exclude citrus juices, chocolate, caffeine-containing drinks, spices, mint, and alcohol.

Caution is required when using drugs that transiently reduce cardiac tone. Efficient sleep with a raised headboard, chewing chewing gum with calcium carbonate. Identification of severe clinical symptoms requires the appointment of special drug therapy. During pregnancy, some of the drugs used in standard treatment regimens for gastroesophageal reflux are used with caution due to possible effects on the fetus or the occurrence of obstetric complications. Patients with severe GERD are shown:

Nonabsorbable antacids and alginates . Considered 1st line drugs for the treatment of gastroesophageal reflux disease in pregnant women. By neutralizing hydrochloric acid, reducing the digestive capacity of pepsin, adsorbing lysolecithin, bile acids, improving the evacuation of stomach contents, stimulating the secretion of prostaglandins, antacids reduce the damaging effect of refluxate. Alginates have a protective effect on the esophageal mucosa.
Histamine 2-receptor blockers H . They are used when antacid therapy for GERD is ineffective. The antisecretory activity of selective histamine blockers is due to the action on the receptors of the parietal cells of the stomach. Due to inhibition of secretion, the acidity and volume of gastric contents decrease, which helps to reduce its aggressiveness and pressure on the cardiac sphincter. The effect of h3-histamine blockers on the fetus is not well understood, which limits their use.
Proton pump inhibitors . High efficiency and rapid achievement of therapeutic results in the appointment of PPIs are based on blocking the secretion of hydrochloric acid at the level of the secretory tubules of parietal cells. The limited use of pump inhibitors is due to a decrease in the bactericidal properties of gastric juice, which, against the background of natural suppression of immunity, contributes to the development of food infections and impaired calcium absorption, which is necessary for the normal course of gestation.

Gastrointestinal motility prokinetics and herbal coating preparations can be used as adjunctive agents. During gestation, surgical treatment of severe and complicated forms of GERD is not performed. Pregnancy is recommended to be completed by natural childbirth at a physiological time. Caesarean section is performed when obstetric indications are identified.

Prognosis and prevention

When adequate treatment is prescribed, the damaged esophageal mucosa usually fully recovers in 4-12 weeks, with non-erosive variants of the disease, improvement occurs within 4-10 days.