Gastroesophageal Reflux Disease
The esophagus is the tube that carries food from a person’s mouth to the stomach. At the junction of the two, there is a specialized area of muscle called the lower esophageal sphincther (LES) which acts as a valve allowing food to move into the stomach but at the same preventing it from refluxing back into the esophagus.
In some people, the LES does not function properly and stomach contents may move upwards into the esophagus. When this phenomenon occurs, it is called gastroesophageal reflux or acid reflux. As a consequence, the esophagus may become irritated causing symptoms such as heart- burn. While everyone experiences occasional reflux, people who experience it more than twice a week are considered to have gastroesophageal reflux disease, or GERD, and should to seek medical attention to prevent long term health problems.
Symptoms of GERD Include:
- Heartburn/Acid Indigestion
- Constant belching
- Difficulty swallowing
- Regurgitation of food
How is GERD Diagnosed?
In order to determine if you have GERD, your physician may order one or more tests that assess the mechanics of swallowing. These may include the following:
- Barium Upper GI – series of x-rays that shows the anatomy of the digestive tract
- 24 Hour pH Monitoring – a tiny probe is placed through the nose into the esophagus to record the amount of acid that refluxes back into the esophagus during regular everyday activities
- Esophageal Endoscopy – a small, flexible tube with a camera is passed through the mouth into the stomach. The camera then projects real-time images onto a screen so the doctor can see your esophagus and stomach
- Esophageal Manometry – records the function of the entire esophagus, to determine how well the esophagus propels food from the mouth into the stomach
Treatment for GERD
People with GERD should first change their lifestyle in a number of ways including:
- Losing weight
- Avoiding alcohol and tobacco
- Sleeping with the head of the bed elevated
- Eating small, frequent meals
- Not lying down for a few hours after a meal
- Avoiding certain foods including chocolate, peppermint, onions, citrus, caffeine and tomato based foods
Most people experience relief of symptoms from medications that either counteract acidity or reduce the amount of acid produced in the stomach. These may be over-the-counter or prescribed medications. You should always see your physician before starting any medication.
Types of Medications
- Antacids are OTC drugs that neutralize acid in the stomach and should only be used to relieve sporadic heartburn.
- H2 blockers (i.e. ranitidine) are somewhat weak suppressors of acid production in the stomach.
- Proton pump inhibitors (i.e. omeprazole) are much stronger suppressors of acid production and are more effective at healing ulcers in the esophagus and stomach.
- Prokinetic medications may help the LES become “tighter” and also increase emptying of the stomach.
There are several indications for surgery in the treatment of GERD. The most compelling ones are related to severe complications of reflux, such as strictures, bleeding or Barrett’s esophagus.
Barrett’s esophagus is a condition related to long term reflux in which changes in the cells lining the lower esophagus occur. Its importance lies on the fact that it can progress to esophageal cancer, a highly lethal condition. As a consequence, the diagnosis of Barrett’s esophagus demands a thoughtful and diligent treatment strategy. Reflux needs to be well controlled, either by surgery or medications, and patients need repeat follow up endoscopies to monitor the progression of these cellular changes to allow intervention before cancer develops.
Other common reasons for surgery include patients who do not have adequate relief of symptoms on medication or those who prefer not to take life-long medication. Little information is known about the long term use of acid suppressor drugs, such as proton pump inhibitors, but significant data is accumulating showing that they might not be as innocuous as once thought.
The surgical procedure most commonly performed for GERD is called Nissen Fundoplication. The goal of the surgery is to create a new, stronger valve that can properly pass food and liquids into the stomach and prevent them from returning to the esophagus.
To do this, a surgeon takes the upper part of the stomach, wraps it around the bottom of the esophagus and sews it there to hold it in place. With this new anatomy, the esophagus passes through a small tunnel of stomach muscle such that when the stomach contracts, it closes off the esophagus. This prevents food and acids from moving back into the esophagus.
Nissen Fundoplication is performed in one of two ways: through a traditional open incision or using minimally invasive techniques called laparoscopic surgery. In an open incision approach, the surgeon makes a 6-8 inch incision and directly visualizes the esophagus and stomach. In the minimally invasive approach, the surgeon makes 4-5 tiny incisions and using a camera and specially designed instruments the operation is completed in the same matter as in the open technique.
Both open and minimally invasive approaches have the same results. Patients who undergo a minimally invasive procedure experience a faster recovery time with less pain. Your surgeon will talk with you about which approach is best for you, a decision usually made based on your anatomy and disease process.