Gastroesophageal reflux disease (GERD) also referred to as heartburn or indigestion is very common in the United States, affecting up to 36% of the population. It occurs when acid from the stomach enters the esophagus.
Etiology and Risk Factors for Gastroesophageal Reflux
This is made possible when the lower esophageal sphincter (the valve between the stomach and esophagus) does not function properly. A hiatal hernia (A in the figure below) is usually present in patients with severe reflux which contributes to deforming and making incompetent the valve mechanism. It does this in two ways by deforming the flap valve mechanism between the stomach and esophagus and by placing the valve in the chest (a negative pressure environment) which acts to “suck” the acid up into the esophagus.
There are factors that can increase the incidence and/or severity of the reflux
Foods – these tend to weaken the sphincter pressure allowing reflux
- Cigarette smoke
- Carbonated Beverages
- Alcoholic Beverages
- Hiatal Hernia – as described above deforms the sphincter mechanism
- Obesity – increases the intra-abdominal pressure overcoming the valve pressure and forces acid into the esophagus
- Pregnancy – same mechanism as seen in obesity
- Scleroderma – a connective tissue disorder that destroys the muscle of the esophagus
- Cardiac medications – Beta Blockers and Calcium Channel blockers
- Sedatives – i.e. valium
- Bronchodilators – used to treat asthma
Symptoms of Gastroesophageal Reflux
- Heartburn – 80%
- Regurgitation -54 % (food returning to the mouth)
- ABD pain -29%
- Cough -27%
- Dysphagia – 23% (solid food getting “stuck” in esophagus)
- Hoarseness -21%
- Belching – 15%
- Bloating – 15%
- Aspiration -14% (acid/food entering the windpipe)
- Wheezing -7%
Some of these symptoms when they occur can be indicative of more severe disease and may require additional work-up. These include dysphagia and regurgitation. Regurgitation may indicate a more severely affected valve and dysphagia may be caused by chronic damage to the esophagus which can lead to a stricture. A stricture is a narrowing of the esophagus which may be caused by scarring secondary to the damage the acid produces in the esophagus or cancer of esophagus from repeated injury.
Diagnosis of Gastroesophageal Reflux
For mild disease, those with minimal symptoms, diagnosis may be made by assessing the effectiveness of treatment and placing the patient on ant-acid therapy. If their symptoms are relieved then you have the diagnosis.
For patients whose symptoms are not or only partially relived or have had symptoms for a long time, the initial study of choice is an upper endoscopy or EGD. This involves sedating the patient and placing a video camera connected to a long tube into the esophagus. This gives the physician a lot of information including if there is inflammation, stricture or scarring, a hiatal hernia, Barrett’s Esophagus (will be discussed later), or even cancer. The physician will also be able to evaluate the stomach and duodenum (first portion of the small intestine) during this procedure.
This study is not routinely performed but allows the physician to assess the motor function of the esophagus. A pressure probe is placed in the esophagus and the patient allowed to swallow water. The pressures in the esophagus are then recorded at different levels within the esophagus as well as the pressure at the lower esophageal sphincter. If the pressure is low then esophageal reflux is more likely. This test is mostly reserved for patients in whom the diagnosis is unclear or another disease is suspected to be responsible for the symptoms experienced by the patient.
This study helps to quantify the extent of the reflux and correlate it to the patient’s symptoms. This test usually is done in patients with no damage seen in the esophagus on upper endoscopy (EGD) to determine the amount of acid exposure in the esophagus. The patient also carries a log book and documents the time when reflux is experienced and this can be compared to the pH probe to determine if acid is the cause of the symptoms. Some reflux on this study is normal and a score has therefore been developed based on many parameters to predict abnormal exposure that may respond to more aggressive treatment.
This study is done in the radiology department and consists of drinking barium while watching under x-ray guidance. The barium will outline the esophagus and stomach and demonstrate if a hiatal hernia is present and if reflux is occurring. This study is not done routinely. It is usually done if a large hiatal hernia is suspected and also if a patient has had prior surgery on the esophagus.
Gastric Emptying Study
This is typically done only in very rare circumstances to determine if the reflux is actually occurring because the stomach fails to empty. It may be suggested if the patient’s main complaint is one of vomiting or if a large amount of food is seen in the stomach on upper endoscopy (EGD) after an overnight fast. Treatment
Medical Treatment for Gastroesophageal Reflux
Initial treatment is typically with medications and lifestyle modifications. Over the counter antacids can be used but most physicians will start the patients on a proton pump inhibitor (PPI – i.e. Prilosec). This medications turns off the majority of acid produced by the stomach. Lifestyle modifications include eating smaller meals, avoiding the foods listed above or others that aggravate symptoms, and not eating late at night or within 2 hours of lying down. Other treatments suggested would be elevating the head of the bed 30 degrees or losing weight to prevent reflux.
Gastroesophageal Reflux Surgery (GERD Surgery)
Indications for surgical treatment are failure of medical therapy. This would include recurrent or persistent symptoms or complications from reflux despite reflux symptoms. This includes non-healing esophagitis (esophageal inflammation), strictures (narrowing of esophagus secondary to scar tissue), or Barrett’s esophagus.
Barrett’s is a precancerous condition felt to attributed to persistent partially treated reflux. It is a change of the normal flat cells of the esophagus to tall columnar cells in an effort to protect itself from the chronic irritation. The incidence of Barrett’s is reported to be 10% of patients with reflux with cancer developing at a rate of 1% per year beginning 10 years after diagnosis. There are some studies that suggest preventing reflux with surgery can halt the progression of Barrett’s esophagus and prevent the development of cancer.
Surgery is typically done laparoscopically and takes about 1 hour to complete. It entails reducing the hiatal hernia, (pulling the stomach back into the abdomen), closing the diaphragmatic hole (decreasing the likelihood of the stomach returning to the chest), and wrapping the stomach around the esophagus (to recreate the one way flap valve and prevent acid from leaving the stomach and entering the esophagus).
The effects of surgery are immediate with most patients waking up from anesthesia noticing a marked improvement in symptoms. The patients typically go home the day after surgery on a liquid/soft diet for a couple of weeks. It is important not to eat heavy solid foods too soon as swelling at the surgery site will cause the food to “hang up” leading to discomfort and vomiting.
Advantages of the laparoscopic when compared to traditional surgery approach include, less postoperative pain, shorter hospital stay, faster return to work, and improved cosmetic result. Most patients are candidates for this approach, but prior abdominal surgery may increase risks to be converted to an “open” or traditional surgical method through a large midline incision. The risk of this occurring in our hands is less than 1%.
After Gastroesophageal Reflux Surgery
Post-operatively the patient will be able to return to light duty work in a week but will require four weeks off of manual labor. Routine activity and light exercise is encouraged soon after surgery, limiting lifting to less than 20 pounds. This hastens recovery from surgery, allows for healing, and reduces the risk of disrupting the repair. It is a longer process for eating to return to normal and may take up to 3-4 months. The key is to eat slowly and chew food well. Results of Surgery After surgery 90% of patients are no longer taking any antacid when surveyed at 10 years. Five to 8% take some type of antacid occasionally, and 2% are still taking medications daily. Complications from Surgery Complications can occur with any surgical procedure. Bleeding, infection and damage to surrounding organs are all possible but very rare with this procedure. The more common complications are listed below.
- Dysphagia – Most patients will experience this to some degree after surgery. It is the feeling that food is “sticking” in the esophagus after swallowing. It is usually secondary to swelling after surgery and will resolve with time. Less than 2% of patients need any intervention such as dilatation of the esophagus or repeat surgery.
- Gas Bloat – This is the feeling of “bloating” of the stomach. Because the valve to prevent reflux has been created it is difficult to belch. Many patients who experience reflux reflexively swallow to clear the esophagus of acid and relieve their symptoms. Air is also swallowed with this maneuver. Prior to surgery the gas pressure could be relieved with belching; after surgery it cannot in most patients. Time and a conscious effort to overcome this habit will lead to resolution of these symptoms.
- GI dysfunction – This occurs in many forms and cannot be adequately explained based on the surgery performed. It can present as constipation, diarrhea or a combination of the two. It can be abdominal cramping or other discomfort. Typically extensive testing does not reveal a cause for the symptoms, but studies show in over 95% of patients they resolve over time.
Pre and Post-Operative Instructions for Anti-Reflux Surgery
- Discuss with your surgeon treatment options and ask any questions you might have with regards to that treatment.
- Sign a consent for surgery confirming that you understand the potential risks and benefits of surgery and agree to proceed.
- Complete pre-operative testing including blood work, EKG or other tests your physician may order
- After lunch the day before surgery eat only a liquid diet and take 1 bottle of Magnesium Citrate at 2:00pm or after work. This will empty your colon making your surgery safer and decreasing issues with constipation post operatively.
- Shower with Hibiclense (anti-bacterial soap) the night before and morning of surgery to help decrease risk of wound infection. (It can be purchased at any pharmacy or may be given to you by hospital staff)
- Do NOT eat or drink anything after midnight before surgery. The stomach needs to be completely empty prior to surgery.
- Stop Aspirin 1 week prior, Plavix 10 days prior, and Coumadin (Wafarin) 5 days prior to surgery. Notify your surgeon if taking any other blood thinners for instruction on when to stop them.
- Stop Smoking 1 week prior to surgery.
Day of Surgery
- Arrive at hospital at time instructed by office staff. A minimum of 2 hours prior to scheduled surgery time
- Nurses will prepare you for surgery with an IV and any pre-op medications that have been ordered.
- The anesthesiologist will talk to you about putting you to sleep in a room just outside the operating room.
- After surgery you will go to the recovery room for about 1 hour where you will be watched closely as you continue to wake up. Family members are not allowed in at this time.
- You will spend at least 1 night in the hospital.
After Discharge from the Hospital
- You are encouraged to walk and resume light activity when you return home
- No lifting over 20 pounds until you see your surgeon.
- Take pain medications as needed to allow increased mobility.
- Prevent constipation by drinking lots of fluid and if necessary taking a stool softener (Colace) or Milk of Magnesia as needed.
- Schedule a post-operative appointment for 2 weeks after surgery. Do this the day you get home or soon thereafter for ease of scheduling.
Call Your Doctor If:
- Persistent fever over 101 degrees F
- Significant bleeding
- Pain not relieved by medications or that is getting more severe
- Persistent nausea and vomiting
- Increasing redness or drainage from the incisions
- If unable to eat or drink liquids
- Constipation not relieved by stool softeners or Milk of Magnesia of 3 days duration
- Persistent cough or increasing shortness of breath