gerd iii
TRANSCRIPT
What is GERD (acid reflux)?
Gastroesophageal reflux disease, commonly referred to as GERD or acid reflux, is a
condition in which the liquid content of the stomach regurgitates (backs up or refluxes)
into the esophagus. The liquid can inflame and damage the lining (cause esophagitis) of
the esophagus although visible signs of inflammation occur in a minority of patients. The
regurgitated liquid usually contains acid and pepsin that are produced by the stomach.
The refluxed liquid also may contain bile that has backed-up into the stomach from the
duodenum. (The duodenum is the first part of the small intestine that attaches to the
stomach.) Acid is believed to be the most injurious component of the refluxed liquid.
GERD is a chronic condition. Once it begins, it usually is life-long. If there is injury to the
lining of the esophagus (esophagitis), this also is a chronic condition. Moreover, after the
esophagus has healed with treatment and treatment is stopped, the injury will return in
most patients within a few months. Once treatment for GERD is begun, therefore, it
usually will need to be continued indefinitely although it is argued that in some patients
with intermittent symptoms and no esophagitis, treatment can be intermittent and done
only during symptomatic periods.
As is often the case, the body has ways (mechanisms) to protect itself from the harmful
effects of reflux and acid. For example, most reflux occurs during the day when
individuals are upright. In the upright position, the refluxed liquid is more likely to flow
back down into the stomach due to the effect of gravity. In addition, while individuals are
awake, they repeatedly swallow, whether or not there is reflux. Each swallow carries any
refluxed liquid back into the stomach. Finally, the salivary glands in the mouth produce
saliva, which contains bicarbonate. With each swallow, bicarbonate-containing saliva
travels down the esophagus. The bicarbonate neutralizes the small amount of acid that
remains in the esophagus after gravity and swallowing have removed most of the liquid.
Gravity, swallowing, and saliva are important protective mechanisms for the esophagus,
but they are effective only when individuals are in the upright position. At night
during sleep, gravity is not in effect, swallowing stops, and the secretion of saliva is
reduced. Therefore, reflux that occurs at night is more likely to result in acid remaining in
the esophagus longer and causing greater damage to the esophagus.
Certain conditions make a person susceptible to GERD. For example, GERD can be a
serious problem during pregnancy. The elevated hormone levels of pregnancy probably
cause reflux by lowering the pressure in the lower esophageal sphincter.At the same
time, the growing fetus increases the pressure in the abdomen. Both of these effects
would be expected to increase reflux. Also, patients with diseases that weaken the
esophageal muscles, such as scleroderma or mixed connective tissue diseases, are
more prone to develop GERD.
What causes GERD?
The cause of GERD is complex. A small number of patients with GERD produce
abnormally large amounts of acid, but this is uncommon and not a contributing factor in
the vast majority of patients. The factors that contribute to GERD are lower esophageal
sphincter abnormalities, hiatal hernias, abnormal esophageal contractions, and slow or
prolonged emptying of the stomach.
Lower esophageal sphincter
The action of the lower esophageal sphincter (LES) is perhaps the most important factor
(mechanism) for preventing reflux. The esophagus is a muscular tube that extends from
the lower throat to the stomach. The LES is a specialized ring of muscle that surrounds
the lower-most end of the esophagus where it joins the stomach. The muscle that makes
up the LES is active most of the time. This means that it is contracting and closing off the
passage from the esophagus into the stomach. This closing of the passage prevents
reflux. When food or saliva is swallowed, the LES relaxes for a few seconds to allow the
food or saliva to pass from the esophagus into the stomach, and then it closes again.
Several different abnormalities of the LES have been found in patients with GERD. Two
of them involve the function of the LES. The first is abnormally weak contraction of the
LES, which reduces its ability to prevent reflux. The second is abnormal relaxations of the
LES, called transient LES relaxations. They are abnormal in that they do not accompany
swallows and they last for a long time, up to several minutes. These prolonged
relaxations allow reflux to occur more easily. The transient LES relaxations occur in
patients with GERD most commonly after meals when the stomach is distended with
food. Transient LES relaxations also occur in individuals without GERD, but they are
infrequent.
The most recently-described abnormality in patients with GERD is laxity of the LES.
Specifically, similar distending pressures open the LES more in patients with GERD than
in individuals without GERD. At least theoretically, this would allow easier opening of the
LES and/or greater backward flow of acid into the esophagus when the LES is open.
Hiatal hernia
Hiatal hernias contribute to reflux, although the way in which they contribute is not clear.
A majority of patients with GERD have hiatal hernias, but many do not. Therefore, it is
not necessary to have a hiatal hernia in order to have GERD. Moreover, many people
have hiatal hernias but do not have GERD. It is not known for certain how or why hiatal
hernias develop.
Normally, the LES is located at the same level where the esophagus passes from the
chest through the diaphragm and into the abdomen. When there is a hiatal hernia, a
small part of the upper stomach that attaches to the esophagus pushes up through the
diaphragm. As a result, a small part of the stomach and the LES come to lie in the chest,
and the LES is no longer at the level of the diaphragm.
It appears that the diaphragm that surrounds the LES is important in preventing reflux.
That is, in individuals without hiatal hernias, the diaphragm surrounding the esophagus is
continuously contracted, but then relaxes with swallows, just like the LES. Note that the
effects of the LES and diaphragm occur at the same location in patients without hiatal
hernias. Therefore, the barrier to reflux is equal to the sum of the pressures generated by
the LES and the diaphragm. When the LES moves into the chest with a hiatal hernia, the
diaphragm and the LES continue to exert their pressures and barrier effect. However,
they now do so at different locations. Consequently, the pressures are no longer additive.
Instead, a single, high-pressure barrier to reflux is replaced by two barriers of lower
pressure, and reflux thus occurs more easily. So, decreasing the pressure barrier is one
way that a hiatal hernia can contribute to reflux.
There is a second way in which hiatal hernias might contribute to reflux. When a hiatal
hernia is present, there is a hernial sac, which is a small pouch of stomach above the
diaphragm. The sac is pinched off from the esophagus above by the LES and from the
stomach below by the diaphragm. What's important about this situation is that the sac
can trap acid that comes from the stomach. This trap keeps the acid close to the
esophagus. As a result, it is easier for the acid to reflux when the LES relaxes with a
swallow or a transient relaxation.
Finally, there is a third way in which hiatal hernias might contribute to reflux. The
esophagus normally joins the stomach obliquely due to which a flap of tissue is formed
between the stomach and esophagus. This flap of tissue is believed to act like a valve,
shutting off the esophagus from the stomach and preventing reflux. When there is a
hiatal hernia, the entry of the esophagus into the stomach is pulled up into the chest.
Therefore, the valve-like flap is distorted or disappears and it no longer can help prevent
reflux.
Esophageal contractions
As previously mentioned, swallows are important in eliminating acid in the esophagus.
Swallowing causes a ring-like wave of contraction of the esophageal muscles, which
narrows the lumen (inner cavity) of the esophagus. The contraction, referred to as
peristalsis, begins in the upper esophagus and travels to the lower esophagus. It pushes
food, saliva, and whatever else is in the esophagus into the stomach.
When the wave of contraction is defective, refluxed acid is not pushed back into the
stomach. In patients with GERD, several abnormalities of contraction have been
described. For example, waves of contraction may not begin after each swallow or the
waves of contraction may die out before they reach the stomach. Also, the pressure
generated by the contractions may be too weak to push the acid back into the stomach.
The effects of abnormal esophageal contractions would be expected to be worse at night
when gravity is not helping to return refluxed acid to the stomach. Note that smoking also
substantially reduces the clearance of acid from the esophagus. This effect continues for
at least 6 hours after the last cigarette.
Emptying of the stomach
Most reflux during the day occurs after meals. This reflux probably is due to transient
LES relaxations that are caused by distention of the stomach with food. A minority of
patients with GERD, about 20%, has been found to have stomachs that empty
abnormally slowly after a meal. The slower emptying of the stomach prolongs the
distention of the stomach with food after meals. Therefore, the slower emptying prolongs
the period of time during which reflux is more likely to occur.
In addition to the above, some medications may cause or worsen GERD. Some common
medications that may have this effect include anticholinergics, antihypertensives such
as beta blockers or calcium channel blockers, bronchodilators, dopamine-active drugs,
progestin, sedatives, and tricyclic antidepressants. Individuals should not stop taking
these or any drugs that are prescribed until the prescribing doctor has discussed the
potential GERD situation with them.
Symptoms of GERD
More common symptoms are:
Feeling that food may be left trapped behind the breastbone
Heartburn or a burning pain in the chest (under the breastbone)
Increased by bending, stooping, lying down, or eating
More likely or worse at night
Relieved by antacids
Nausea after eating
Less common symptoms are:
Cough or wheezing
Difficulty swallowing
Hiccups
Hoarseness or change in voice
Regurgitation of food
Sore throat
Complications of GERD
Barrett's oesophagus (a change in the lining of the oesophagus that can increase the risk of cancer)
Bronchospasm (irritation and spasm of the airways due to acid)
Chronic cough or hoarseness
Dental problems
Oesophageal ulcer
Inflammation of the oesophagus
Stricture (a narrowing of the oesophagus due to scarring from the inflammation)
Diagnosis
Symptoms and response to treatment (therapeutic trial)
The usual way that GERD is diagnosed—or at least suspected—is by its characteristic
symptom, heartburn. To confirm the diagnosis, physicians often treat patients with
medications to suppress the production of acid by the stomach. If the heartburn then is
diminished to a large extent, the diagnosis of GERD is considered confirmed. This
approach of making a diagnosis on the basis of a response of the symptoms to treatment
is commonly called a therapeutic trial.
There are problems with this approach, however, primarily because it does not include
diagnostic tests. For instance, patients who have conditions that can mimic GERD,
specifically duodenal or gastric (stomach) ulcers, also can actually respond to such
treatment. In this situation, if the physician assumes that the problem is GERD, he or she
will not look for the cause of the ulcer disease. For example, a type of infection
called Helicobacter pylori, or non-steroidal anti-inflammatory drugs (for
example, ibuprofen), can also cause ulcers and these conditions would be treated
differently from GERD.
Endoscopy
Upper gastrointestinal endoscopy (also known as esophago-gastro-duodenoscopy or
EGD) is a common way of diagnosing GERD. EGD is a procedure in which a tube
containing an optical system for visualization is swallowed. As the tube progresses down
the gastrointestinal tract, the lining of the oesophagus, stomach, and duodenum can be
examined.
The oesophagus of most patients with symptoms of reflux looks normal. Therefore, in
most patients, endoscopy will not help in the diagnosis of GERD. However, sometimes
the lining of the oesophagus appears inflamed (esophagitis). Moreover, if erosions
(superficial breaks in the esophageal lining) or ulcers (deeper breaks in the lining) are
seen, a diagnosis of GERD can be made confidently. Endoscopy will also identify several
of the complications of GERD, specifically, ulcers, strictures, and Barrett's esophagus.
Biopsies also may be obtained.
Finally, other common problems that may be causing GERD like symptoms can be
diagnosed (for example ulcers, inflammation, or cancers of the stomach or duodenum)
with EGD.
Biopsies
Biopsies of the esophagus that are obtained through the endoscope are not considered
very useful for diagnosing GERD. They are useful, however, in diagnosing cancers or
causes of esophageal inflammation other than acid reflux, particularly infections.
X-rays
Before the introduction of endoscopy, an X-ray of the esophagus (called an esophagram)
was the only means of diagnosing GERD. Patients swallowed barium (contrast material),
and X-rays of the barium-filled esophagus were then taken. The problem with the
esophagram was that it was an insensitive test for diagnosing GERD. That is, it failed to
find signs of GERD in many patients who had GERD because the patients had little or no
damage to the lining of the esophagus. The X-rays were able to show only the infrequent
complications of GERD, for example, ulcers and strictures.
Examination of the throat and larynx
When GERD affects the throat or larynx and causes symptoms of cough, hoarseness, or
sore throat, patients often visit an ear, nose, and throat (ENT) specialist. The ENT
specialist frequently finds signs of inflammation of the throat or larynx. Although diseases
of the throat or larynx usually are the cause of the inflammation, sometimes GERD can
be the cause. Accordingly, ENT specialists often try acid-suppressing treatment to
confirm the diagnosis of GERD.
Esophageal acid testing
Esophageal acid testing is considered a "gold standard" for diagnosing GERD. As
discussed previously, the reflux of acid is common in the general population. However,
patients with the symptoms or complications of GERD have reflux of more acid than
individuals without the symptoms or complications of GERD. Moreover, normal
individuals and patients with GERD can be distinguished moderately well from each other
by the amount of time that the esophagus contains acid.
The amount of time that the esophagus contains acid is determined by a test called a 24-
hour esophageal pH test. (pH is a mathematical way of expressing the amount of acidity.)
For this test, a small tube (catheter) is passed through the nose and positioned in the
esophagus. On the tip of the catheter is a sensor that senses acid. The other end of the
catheter exits from the nose, wraps back over the ear, and travels down to the waist,
where it is attached to a recorder. Each time acid refluxes back into the esophagus from
the stomach, it stimulates the sensor and the recorder records the episode of reflux. After
a 20 to 24 hour period of time, the catheter is removed and the record of reflux from the
recorder is analyzed.
Typical symptoms, response to treatment, or the presence of complications of GERD in
combination with pH testing are required for the correct diagnosis of GERD. GERD also
may be confidently diagnosed when episodes of heartburn correlate with acid reflux as
shown by acid testing.
A newer method for prolonged measurement (48 hours) of acid exposure in the
esophagus utilizes a small, wireless capsule that is attached to the esophagus just above
the LES. The capsule is passed to the lower esophagus by a tube inserted through either
the mouth or the nose. After the capsule is attached to the esophagus, the tube is
removed. The capsule measures the acid refluxing into the esophagus and transmits this
information to a receiver that is worn at the waist. After the study, usually after 48 hours,
the information from the receiver is downloaded into a computer and analyzed. The
capsule falls off of the esophagus after 3-5 days and is passed in the stool. (The capsule
is not reused.)
The advantage of the capsule over standard pH testing is that there is no discomfort from
a catheter that passes through the throat and nose. Moreover, with the capsule, patients
look normal (they don't have a catheter protruding from their noses) and are more likely
to go about their daily activities, for example, go to work, without feeling self-conscious.
Because the capsule records for a longer period than the catheter (48 versus 24 hours),
more data on acid reflux and symptoms are obtained.
Capsule pH testing is expensive. Sometimes the capsule does not attach to the
esophagus or falls off prematurely. For periods of time the receiver may not receive
signals from the capsule, and some of the information about reflux of acid may be lost.
Occasionally there is pain with swallowing after the capsule has been placed.
Esophageal motility testing
Esophageal motility testing determines how well the muscles of the esophagus are
working. For motility testing, a thin tube (catheter) is passed through a nostril, down the
back of the throat, and into the esophagus. On the part of the catheter that is inside the
esophagus are sensors that sense pressure. A pressure is generated within the
esophagus that is detected by the sensors on the catheter when the muscle of the
esophagus contracts. The end of the catheter that protrudes from the nostril is attached
to a recorder that records the pressure. During the test, the pressure at rest and the
relaxation of the lower esophageal sphincter are evaluated. The patient then swallows
sips of water to evaluate the contractions of the esophagus.
Esophageal motility testing has two important uses in evaluating GERD. The first is in
evaluating symptoms that do not respond to treatment for GERD. The abnormal function
of the esophageal muscle sometimes causes symptoms that resemble the symptoms of
GERD. Motility testing can identify some of these abnormalities and lead to a diagnosis
of an esophageal motility disorder. The second use is evaluation prior to surgical or
endoscopic treatment for GERD. In this situation, the purpose is to identify patients who
also have motility disorders of the esophageal muscle. The reason for this is that in
patients with motility disorders, some surgeons will modify the type of surgery they
perform for GERD.
Gastric emptying studies
Gastric emptying studies are studies that determine how well food empties from the
stomach. As discussed above, about 20 % of patients with GERD have slow emptying of
the stomach that may be contributing to the reflux of acid. For gastric emptying studies,
the patient eats a meal that is labeled with a radioactive substance. A sensor that is
similar to a Geiger counter is placed over the stomach to measure how quickly the
radioactive substance in the meal empties from the stomach.
Information from the emptying study can be useful for managing patients with GERD. For
example, if a patient with GERD continues to have symptoms despite treatment with the
usual medications, doctors might prescribe other medications that speed-up emptying of
the stomach. Alternatively, in conjunction with GERD surgery, they might do a surgical
procedure that promotes a more rapid emptying of the stomach.
Symptoms of nausea, vomiting, and regurgitation may be due either to abnormal gastric
emptying or GERD. An evaluation of gastric emptying, therefore, may be useful in
identifying patients whose symptoms are due to abnormal emptying of the stomach
rather than to GERD.
Acid perfusion test
The acid perfusion (Bernstein) test is used to determine if chest pain is caused by acid
reflux. For the test, a thin tube is passed through one nostril, down the back of the throat,
and into the middle of the esophagus. A dilute, acid solution and a physiologic (normal)
salt solution are alternately poured (perfused) through the catheter and into the
esophagus. The patient is unaware of which solution is being infused. If the perfusion
with acid provokes the patient's usual pain and perfusion of the salt solution produces no
pain, it is likely that the patient's pain is caused by acid reflux.
GERD treatment
Lifestyle changes
To prevent heartburn, avoid foods and beverages that may trigger your symptoms. For many people, these include:
Alcohol
Caffeine
Carbonated beverages
Chocolate
Citrus fruits and juices
Tomatoes
Tomato sauces
Spicy or fatty foods
Full-fat dairy products
Peppermint
Spearmint
If other foods regularly give you heartburn, avoid those foods, too.
Also, try the following changes to your eating habits and lifestyle:
Avoid bending over or exercising just after eating
Avoid garments or belts that fit tightly around your waist
Do not lie down with a full stomach. For example, avoid eating within 2 - 3 hours of bedtime.
Do not smoke.
Eat smaller meals.
Lose weight if you are overweight.
Reduce stress.
Sleep with your head raised about 6 inches. Do this by tilting your entire bed, or by using a wedge under your body, not just with normal pillows.
One novel approach to the treatment of GERD is chewing gum. Chewing gum stimulates
the production of more bicarbonate-containing saliva and increases the rate of
swallowing. After the saliva is swallowed, it neutralizes acid in the esophagus. In effect,
chewing gum exaggerates one of the normal processes that neutralize acid in the
esophagus. Nevertheless, chewing gum after meals is certainly worth a try.
Antacids
Despite the development of potent medications for the treatment of GERD, antacids
remain a mainstay of treatment. Antacids neutralize the acid in the stomach so that there
is no acid to reflux. The problem with antacids is that their action is brief. They are
emptied from the empty stomach quickly, in less than an hour, and the acid then re-
accumulates. The best way to take antacids, therefore, is approximately one hour after
meals, which is just before the symptoms of reflux begin after a meal. Since the food
from meals slows the emptying from the stomach, an antacid taken after a meal stays in
the stomach longer and is effective longer. For the same reason, a second dose of
antacids approximately two hours after a meal takes advantage of the continuing post-
meal slower emptying of the stomach and replenishes the acid-neutralizing capacity
within the stomach.
Antacids may be aluminum, magnesium, or calcium based. Calcium-based antacids
(usually calcium carbonate), unlike other antacids, stimulate the release of gastrin from
the stomach and duodenum. Gastrin is the hormone that is primarily responsible for the
stimulation of acid secretion by the stomach. Therefore, the secretion of acid rebounds
after the direct acid-neutralizing effect of the calcium carbonate is exhausted. The
rebound is due to the release of gastrin, which results in an overproduction of acid.
Theoretically at least, this increased acid is not good for GERD.
Though, treatment with calcium carbonate has not been shown to be less effective or
safe than treatment with antacids not containing calcium carbonate. Nevertheless, the
phenomenon of acid rebound is theoretically harmful. In practice, therefore, calcium-
containing antacids such as Tums and Rolaids are not recommended.
Aluminum-containing antacids have a tendency to cause constipation, while magnesium-
containing antacids tend to cause diarrhea. If diarrhea or constipation becomes a
problem, it may be necessary to switch antacids or alternately use antacids containing
aluminum and magnesium.
Histamine antagonists
Although antacids can neutralize acid, they do so for only a short period of time. For
substantial neutralization of acid throughout the day, antacids would need to be given
frequently, at least every hour.
The first medication developed for more effective and convenient treatment of acid-
related diseases, including GERD, was a histamine antagonist,
specifically cimetidine (Tagamet). Histamine is an important chemical because it
stimulates acid production by the stomach. Released within the wall of the stomach,
histamine attaches to receptors (binders) on the stomach's acid-producing cells and
stimulates the cells to produce acid. Histamine antagonists work by blocking the receptor
for histamine and thereby preventing histamine from stimulating the acid-producing cells.
Because histamine is particularly important for the stimulation of acid after meals, H2
antagonists are best taken 30 minutes before meals. The reason for this timing is so that
the H2 antagonists will be at peak levels in the body after the meal when the stomach is
actively producing acid. H2 antagonists also can be taken at bedtime to suppress night-
time production of acid.
H2 antagonists are very good for relieving the symptoms of GERD, particularly heartburn.
However, they are not very good for healing the inflammation (esophagitis) that may
accompany GERD. In fact, they are used primarily for the treatment of heartburn in
GERD that is not associated with inflammation or complications, such as erosions or
ulcers, strictures, or Barrett's esophagus.
Four different H2 antagonists are available by prescription, including
cimetidine (Tagamet), ranitidine (Zantac), nizatidine (Axid), and famotidine, (Pepcid).
Proton pump inhibitors
The second type of drug developed specifically for acid-related diseases, such as GERD,
was a proton pump inhibitor (PPI), specifically, omeprazole (Prilosec). A PPI blocks the
secretion of acid into the stomach by the acid-secreting cells. The advantage of a PPI
over an H2 antagonist is that the PPI shuts off acid production more completely and for a
longer period of time. Not only is the PPI good for treating the symptom of heartburn, but
it also is good for protecting the esophagus from acid so that esophageal inflammation
can heal.
PPIs are used when H2 antagonists do not relieve symptoms adequately or when
complications of GERD such as erosions or ulcers, strictures, or Barrett's esophagus
exist. Five different PPIs are approved for the treatment of GERD,
including omeprazole (Prilosec,
Dexilant), lansoprazole (Prevacid),rabeprazole (Aciphex), pantoprazole (Protonix),
and esomeprazole (Nexium). A sixth PPI product consists of a combination of
omeprazole and sodium bicarbonate (Zegerid). PPIs (except for Zegarid) are best taken
an hour before meals. The reason for this timing is that the PPIs work best when the
stomach is most actively producing acid, which occurs after meals. If the PPI is taken
before the meal, it is at peak levels in the body after the meal when the acid is being
made.
Pro-motility drugs
Pro-motility drugs work by stimulating the muscles of the gastrointestinal tract, including
the esophagus, stomach, small intestine, and/or colon. One pro-motility
drug, metoclopramide (Reglan), is approved for GERD. Pro-motility drugs increase the
pressure in the lower esophageal sphincter and strengthen the contractions (peristalsis)
of the esophagus. Both effects would be expected to reduce reflux of acid. However,
these effects on the sphincter and esophagus are small. Therefore, it is believed that the
primary effect of metoclopramide may be to speed up emptying of the stomach, which
also would be expected to reduce reflux.
Pro-motility drugs are most effective when taken 30 minutes before meals and again at
bedtime. They are not very effective for treating either the symptoms or complications of
GERD. Therefore, the pro-motility agents are reserved either for patients who do not
respond to other treatments or are added to enhance other treatments for GERD.
Foam barriers
Foam barriers provide a unique form of treatment for GERD. Foam barriers are tablets
that are composed of an antacid and a foaming agent. As the tablet disintegrates and
reaches the stomach, it turns into foam that floats on the top of the liquid contents of the
stomach. The foam forms a physical barrier to the reflux of liquid. At the same time, the
antacid bound to the foam neutralizes acid that comes in contact with the foam. The
tablets are best taken after meals (when the stomach is distended) and when lying down,
both times when reflux is more likely to occur. Foam barriers are not often used as the
first or only treatment for GERD. Rather, they are added to other drugs for GERD when
the other drugs are not adequately effective in relieving symptoms. There is only one
foam barrier, which is a combination of aluminum hydroxide gel, magnesium trisilicate,
and alginate (Gaviscon).
Surgery
The drugs described above usually are effective in treating the symptoms and
complications of GERD. Nevertheless, sometimes they are not. For example, despite
adequate suppression of acid and relief from heartburn, regurgitation, with its potential for
complications in the lungs, may still occur. Moreover, the amounts and/or numbers of
drugs that are required for satisfactory treatment are sometimes so great that drug
treatment is unreasonable. In such situations, surgery can effectively stop reflux.
The surgical procedure that is done to prevent reflux is technically known as
fundoplication and is called reflux surgery or anti-reflux surgery. During fundoplication,
any hiatal hernial sac is pulled below the diaphragm and stitched there. In addition, the
opening in the diaphragm through which the esophagus passes is tightened around the
esophagus. Finally, the upper part of the stomach next to the opening of the esophagus
into the stomach is wrapped around the lower esophagus to make an artificial lower
esophageal sphincter. All of this surgery can be done through an incision in the abdomen
(laparotomy) or using a technique called laparoscopy. During laparoscopy, a small
viewing device and surgical instruments are passed through several small puncture sites
in the abdomen. This procedure avoids the need for a major abdominal incision.
Surgery is very effective at relieving symptoms and treating the complications of GERD.
The most common complication of fundoplication is swallowed food that sticks at the
artificial sphincter. Fortunately, the sticking usually is temporary. If it is not transient,
endoscopic treatment to stretch (dilate) the artificial sphincter usually will relieve the
problem.
Endoscopy
Very recently, endoscopic techniques for the treatment of GERD have been developed
and tested. One type of endoscopic treatment involves suturing (stitching) the area of the
lower esophageal sphincter, which essentially tightens the sphincter.
A second type involves the application of radio-frequency waves to the lower part of the
esophagus just above the sphincter. The waves cause damage to the tissue beneath the
esophageal lining and a scar (fibrosis) forms. The scar shrinks and pulls on the
surrounding tissue, thereby tightening the sphincter and the area above it.
A third type of endoscopic treatment involves the injection of materials into the
esophageal wall in the area of the LES. The injected material is intended to increase
pressure in the LES and thereby prevent reflux.
Endoscopic treatment has the advantage of not requiring surgery. It can be performed
without hospitalization. Experience with endoscopic techniques is limited.