Gastroesophageal Reflux Disease

Gastroesophageal Reflux Disease, (GERD)
Heartburn and Hiatus Hernia

BACKGROUND

In recent years there has been a profound increase in both the number of people suffering from heartburn and the severity and duration of their suffering. Why this has happened is unknown. That the phenomenon exists is unquestioned and the extensive drug industry advertising for "over the counter medications" to treat heartburn is an indication of how big a problem this is.

Heartburn is a common term. What does it mean? Usually it is used to describe a burning sensation in the middle of the chest just behind the sternum or breastbone. This is where the heart is located but heartburn has nothing to do with the heart. The burning or pain originates in the esophagus which is behind the heart. The esophagus is a long muscular tube which propels food from the mouth to the stomach. This requires coordinated sequential tightening and relaxing of segments of the esophagus (peristalsis). Normally there is an area at the junction of the esophagus and stomach where the muscles are generally tight, relaxing only temporarily to allow swallowed food to pass into the stomach. This are is called the lower esophageal sphincter (LES). The LES prevents acid, which is produced in the stomach to help digest food, from being pushed, or refluxing, into the esophagus. Human stomachs have a special lining which is resistant to the acid produced in the stomach. On the other hand, the lining of the esophagus has no special resistance and is easily "burned" by this acid. The scientific, or medical term, for heartburn is gastroesophageal reflux disease (GERD).

Anyone might have occasional brief episodes of heartburn. This is considered normal. It is abnormal when it happens several times during 24 hours, when it happens many times a month, and when it begins to cause swallowing difficulties, hoarseness, coughing episodes, or bleeding. When the acid only goes as high as the middle of the esophagus it usually is felt as heartburn. It can however go as high as the mouth where some people will get a sour or acid taste. If the acid does get as high as the mouth it can flow into the larynx or voice box or even further down into the trachea or wind pipe. Frequent irritation of the larynx by acid may cause laryngitis or hoarseness and irritation of the trachea may cause a nagging cough. Generally the hoarseness or cough develop without any pain.

In some people the LES becomes weak. Why this happens is not known. When it happens the normal barrier preventing stomach acid from getting into the esophagus is lost. As acid continues to irritate or burn the lower esophagus there is less peristalsis in that portion of the esophagus. This allows the acid to stay in contact longer with the lining of the esophagus causing more severe burning. Eventually scarring develops where the lining has been repeatedly burned. The scarring may affect nerves in the area and the pain or heartburn may be felt less. Continued scarring leads to narrowing of the lower esophagus known as a stricture. Once a stricture develops food begins to stick in the lower esophagus. Initially, strictures can be widened by passing increasingly larger diameter dilators through them. As time goes on the strictures may become strong and it becomes more dangerous to dilate them. Sometimes the burning of the lining is so severe that ulceration of the lining develops and this may lead to immediate bleeding as well as later scarring.

Most patients with GERD also have a hiatus hernia. That is when a portion of the stomach, normally totally within the abdomen or belly, slides up into the chest. Having a hiatus hernia does not mean you will also have GERD. Most people with hiatus hernias do not have GERD. Unlike inguinal or groin hernias, hiatal hernias often do not have to be repaired.

INITIAL TREATMENT

The first treatment of serious heartburn or GERD should be simple lifestyle changes. Diet modification is first. Some foods increase stomach acid and/or decrease LES pressure and should be avoided. These are:

foods with caffeine such as coffee, tea, cola drinks and chocolate
fried and fatty foods, spicy foods and acidic foods such as citrus fruits and tomatoes
onions
peppermint

Small meals are better than large meals, and, after eating it is best not to bend over, lie down or go to sleep for at least three hours.

Both smoking and drinking alcohol will substantially increase stomach production of acid; LES pressure is lowered by alcohol. Smoking and drinking alcohol should be stopped. Check medications to be sure they do not contain alcohol or caffeine like substances.

Excess weight, particularly in and on the abdomen or belly increases pressure on the stomach and causes more reflux of acid. Tight clothing and frequent bending over may also cause more reflux. Sleeping with the head of the bead elevated about 6 inches may also help to keep acid from refluxing at night.

If symptoms persist despite these life style modifications then it is best to see your doctor. Gallbladder attacks, stomach or duodenal ulcers or merely irritation (gastritis) and narrowing of the arteries to the heart (coronary arteriosclerosis or spasm) may cause symptoms similar to heartburn.

Your doctor might prescribe medications that reduce the production of acid by the stomach and medications that increase peristalsis in the esophagus; or your doctor might refer you to a gastroenterologist.

MEDICAL EVALUATION

Gastroenterologists are doctors that specialize in problems of the digestive system. The tests they use to diagnose GERD are:

barium upper GI. You swallow a chalk like drink that allows the inside of your esophagus and stomach to be seen by xray.
esophagogastric duodenoscopy. A flexible scope is put into your mouth and directed through the esophagus, stomach, and duodenum. It allows the doctor to see directly if there is irritation of the lining of the esophagus and of the stomach and duodenum and how bad that irritation is. The gastroenterologist may also remove a small sample of the irritated lining (biopsy). Most patients are in a semi sleep when this is done.
esophageal manometry. A tube similar to the endoscope is passed down the esophagus until it reaches the stomach. You will be asked to swallow. Pressure measurements will be taken. This is how peristalsis throughout the esophagus is evaluated.
pH probe. A thin tube is passed down your nose until the end reaches your stomach. The tube stays there 24 hours during which it records how frequently acid refluxes into the esophagus and how long it stays there when it does.

MEDICAL TREATMENT

When lifestyle changes do not relieve the symptoms of GERD then medications are usually prescribed. The first medications used are H-2 blockers. These drugs suppress stomach production of acid. Their common names are Axid, Pepcid, Tagamet, and Zantac. Some of these are sold over the counter. If these are not sufficient then drugs that increase peristalsis and perhaps tighten the LES are added. The common name for these drugs are Propulsid and Reglan. In those situations when symptoms still persist a stronger inhibitor of stomach acid production, Prilosec, is used in place of the H-2 blockers.

SURGICAL TREATMENT

Those people who have continuing symptoms despite lifestyle modification and the prescribed use of appropriate medication should consider an operation to cure their GERD. The operation, called a fundoplication, involves wrapping the top of the stomach around the esophagus. This is like wrapping a scarf around your neck. The fundoplication creates normal LES pressure. It does not have to be tight to do this. For almost all people having this operation heartburn ends immediately. Most people do have some difficulty swallowing afterwards. This usually lasts for about 1 - 3 weeks. The best way to do this operation is by video endoscopic laparoscopy. Patients get general anesthesia and are fully asleep. In our hands the operations average about 2 hours. Our patients are usually in the hospital 1 - 3 days afterward. Like patients having laparoscopic gallbladder operations, they are back to their usual activity in less than a week. Because the operation is done laparoscopically the 5 incisions are tiny (about 1/2 inch) and rarely painful. The risks of the operation are injury to the spleen, liver, esophagus, or stomach which might result in bleeding or infection. Those injuries are usually correctable. Sometimes the spleen may have to be removed (splenectomy). There is also the risk that the operation might not completely eliminate GERD, that swallowing difficulties might be prolonged, or that you may not be able to vomit when you have to.

We, at Guild Surgical Specialists, have done nearly 200 of these operations in the past seven years. Only 1 patient has had to be "opened". Approximately 95% of our patients have been cured of their GERD.