Gastroesophageal Reflux Disease, (GERD)
(Heartburn and Hiatus Hernia)
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 has become.
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 area 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.
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
- 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.
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 x-ray.
Esophagogastric duodenoscopy. A flexible scope is put into your mouth and directed through the esophagus, stomach, and duodenum. It allows the doctor to view any 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.
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 a drug that increases peristalsis and perhaps tightens the LES is added. The common name for this drug is Reglan. In those situations when symptoms still persist stronger inhibitors of stomach acid production, proton pump inhibitors such as Prevacid or Prilosec are used instead of H-2 blockers.
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 most common operation performed, 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 a higher 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 3 - 6 weeks. Essentially all of these procedures are performed laparoscopically today. Patients receive general anesthesia and are fully asleep. The operations typically last about 1 and 1/2 hours. My patients are usually in the hospital 1 - 2 days afterwards. Like patients having laparoscopic gallbladder operations, they are back to their usual activity in less than a week. The risks of the operation are injury to the spleen, liver, esophagus, or stomach, which might result in bleeding or infection. Those injuries are very uncommon and usually correctable. Remotely, 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. A full 360-degree wrap is performed in the majority of cases; however, selected patients sometimes have a partial, 270-degree wrap (Toupet Fundoplication), if the esophagus is weaker than normal.
Dr. Lydon has been performing laparoscopic fundoplications since 1992 and was involved in the first procedures done in the region. He has also been a leader in the field and has trained and proctored several surgeons in this procedure. He has been involved in hundreds of cases with a rate of conversion to the "open" procedure of well under 1%. Approximately 90 to 95% of these patients have been cured of their GERD.
Other surgical options now include a Transoral Incisionless Fundoplication (TIF) using the Esophyx TM device and implantation of a Linx device, made by Torax Medical TM, to augment the lower esophageal sphincter. The TIF procedure involves placement of polypropylene fasteners at the GE junction via an endoscope to create a new valve within the stomach. The Linx device was FDA approved in March of 2012 and is unique in that a functioning LES is recreated by using a specially designed weak magnetic chain around the LES. This is accomplished laparoscopically in a procedure that takes under an hour and requires, on average, a 24-hour hospital stay. No other antireflux procedure can accomplish the recreation of a functioning valve the way the Linx device does. Early results have been excellent with 90% of patients off proton pump inhibitors at 24 months post-op. Both of these procedures allow patient to consume a regular diet within days of surgery. Dr. Lydon now offers the implantation of the Linx device to selected patients with GERD.