Heartburn (GERD)

What is GERD?

Acid reflux or gastroesophageal reflux disease (GERD) is a very common condition that is characterized by repeated bouts of heartburn, a burning sensation in the chest and throat. Roughly 50% of the population will suffer from heartburn at some point throughout their life. Symptoms of GERD include frequent heartburn, regurgitation of food, burping, bloating and pain with swallowing. Atypical symptoms of GERD include bad breath and dental erosion, asthma, dry cough, hoarseness, pneumonia, and chest pain.

What Causes GERD?

65% of GERD occurs when there is a weak or dysfunctional lower esophageal sphincter (LES) that allows backflow of acidic stomach contents into the esophagus (the tube that connects the mouth to the stomach). In some cases, patients have a defect called a hiatal hernia where part of the stomach protrudes through a weak spot in the diaphragm. This type of hernia may limit the LES from working properly.

50% of GERD is due to impaired esophageal motility, meaning the contents in the esophagus is inadequately cleared from your mouth to your stomach due to dysfunction in the motility mechanism.

5% of GERD is the result of delayed gastric emptying, meaning your stomach is slow to empty which causes bloating and pressure back towards your esophagus.

What are the complications of GERD?

Each time a patient experiences heartburn or reflux, the lining of the esophagus is exposed to the harsh acidity of the stomach contents. Long standing GERD and repeat exposure can lead to more serious conditions of the esophagus including:

• Esophagitis (inflammation of the esophagus)
• Ulcers or erosion with or without bleeding
• Esophageal strictures (narrowing)
• Barrett’s esophagus (pre-cancerous changes in the cells of the esophagus)

How is GERD Treated?

Most patients with GERD manage their symptoms conservatively with lifestyle modifications as well as anti-reflux medications (examples listed below). The goals of treatment are to reduce symptoms, allow for esophageal healing, and prevent further recurrence and complications.

Medications

• Antacids
  • Tums, Alka-Seltzer
• Proton-Pump Inhibitors
  • Pantoprazole, Omeprazole, Lansoprazole, etc
• Histamine (H2) Blockers
  • Ranitidine, Famotidine, Cimetidine, etc
• Gastric Motility Agents
  • Metoclopramide

Side Effects of Long Term Anti-Reflux Medication
Use

Proton-pump inhibitors, or PPIs, are medications (listed above) that alter the acid production in the stomach. They are commonly prescribed medications to help manage reflux symptoms, and are relatively safe when taken for short periods of time. However, studies have shown that long-term use of PPIs has led to an increased risk in the following conditions:

• Kidney disease (interstitial nephritis)
• Osteoporosis (including increased risk of hip, wrist and spine fractures)
• Nutritional/vitamin/mineral deficiencies
• Increased risk of stomach infections including: C. dif, Salmonella and Campylobacter
• Dementia
• Early Death

Tests Used to Diagnose GERD

Prior to surgical management of GERD, some of the following tests may be necessary to further assess your condition.

• Upper Endoscopy or esophagogastroduodenoscopy (EGD)- with the patient
  under light anesthesia, the surgeon inserts a long, flexible camera and light down
  the patient’s throat to evaluate the lining of the esophagus, stomach and first part
  of the small intestine.
• pH Testing (Bravo)- during an EGD, the surgeon will attach a small capsule to
  the lining of the lower esophagus. The capsule measures the acid level in the
  esophagus throughout the day and then transmits this information to a portable
  monitor worn by the patient for 48 hrs.
• Manometry- a thin, pressure-sensitive tube is passed through the patient’s nose
  and down throat. Through a series of swallowing tests, the function and
  coordination of the esophagus is assessed.
• Marshmallow Bagel Swallow- the patient will eat pieces of marshmallow and
  bagel followed by barium while the examiner takes x-rays of the esophagus to
  assess for good esophageal motility.
• Upper GI XR Series- the patient drinks a barium contrast mixture which helps
  the examiner better visualize the upper gastrointestinal tract during a series of
  radiographic images.
• Gastric Emptying Study- before the scan the patient will eat something solid,
  something liquid and a small amount of tasteless radioactive material. The
  radioactive material allows the examiner to see how quickly the stomach is
  emptying through a series of timed images (3-5 hours).

Surgical Management

Once the surgeon has the results from the pre-operative testing listed above, you will then have a thorough discussion to decide which surgical option may be best for you.

LINX Procedure- laparoscopic, placement of an adjustable magnet around the esophagus to mimic the function of the lower esophageal sphincter (LES), allowing food to enter the stomach while prohibiting acid from back flowing into the esophagus. This is performed under general anesthesia and typically takes about an hour. Patients stay overnight in the hospital and go home the next day. For more information about the LINX system please visit www.linxforlife.com

Fundoplication- (sometimes called a Nissen fundoplication or a partial fundoplication) is a laparoscopic procedure to reinforce the lower esophageal sphincter (LES) by
wrapping a portion of the stomach around the sphincter and stitching it in place. This is usually a surgery best suited for patients with a hiatal hernia >2cm. This is performed under general anesthesia and typically takes about two hours. Patients typically stay overnight in the hospital and go home in a day or two. Watch here.

Combined Transoral Intra-gastric Fundoplication (c-TIF):
This is when the surgeon and specialized gastroenterologist do a combined surgery when your surgeon will make small incisions laparoscopically and repair your hiatal hernia, then the gastroenterologist will use an endoscopic fastening device to re-create your lower esophageal sphincter (LES)/valve from inside your esophagus. This is
usually a better option for those patients with a hiatal hernia <2cm or a very weak valve. This is performed under general anesthesia and typically takes 90 minutes. Patient’s typically stay one night overnight in the hospital afterwards. See more information here.