Heartburn and Reflux Consortium
Overview of Gastro-Esophageal Reflux Disease “GERD”
Normal Swallowing Function
Normally when we swallow the chewed up food is transferred from the mouth to the esophagus. The esophagus is positioned in the chest and moves the food down to the stomach using a wave-like pumping method called peristalsis. At the very bottom of the esophagus is the lower esophageal sphincter, the “LES”. This is a region of esophageal muscle approximately 2-3 inches long, that typically remains closed at rest. When a food bolus reaches the LES it relaxes to allow the food to pass into the stomach. After the food passes through, the LES shuts closed to prevent too much stomach juice from coming back up the esophagus. A little bit of stomach juice might normally reflux back up, but if too much comes up it becomes a problem.
What is Gastro-Esophageal Reflux Disease, aka GERD?
GERD involves reflux of stomach juices backwards up into the esophagus. Most commonly the juice will irritate the esophagus and cause the burning pain in the mid chest we call “heartburn”. However, not all patients actually feel the heartburn. In some people the reflux causes the esophagus to go into spasm causing severe chest pain that can mimic a heart attack. Some people have reflux that irritates the back of the throat, and can even cause asthma and erosions of the teeth. Eating a large meal late at night, then lying down can make all the symptoms worse. In severe cases, the reflux can cause significant irritation to the esophagus, called “esophagitis”. Esophagitis can cause bleeding, scarring, and even increase the risk of developing cancer of the esophagus.
Not every patient who has “heartburn” has reflux. Also, “normal” people have reflux upon occasion. Other diseases of the esophagus, throat, lungs, and heart can all cause symptoms similar to reflux. A formal evaluation is needed to determine how much reflux a patient is having.
Treatment is based first on lifestyle changes, adding medications if needed, and adding surgery in some cases.
Initial treatment involves lifestyle changes such as eating dinner earlier, learning how much and which type of foods cause more discomfort, and perhaps sleeping on more pillows to elevate the head. Overweight patients can get often get significant relief with even modest weight loss.
If lifestyle measures are not adequate, then medicines are added to the treatment plan. There are three basic categories of medicines; antacids, H2 blockers, and proton pump inhibitors (“PPIs”). Antacids directly neutralize stomach acid, and examples include Maalox ™, Tums ™, Rolaids ™, and others. H2 blockers help indirectly block the ability of the stomach cells to produce acid, and include pepcid ™, tagamet ™, and zantac(tm). Proton pump inhibitors directly block the stomach cells from producing acid and include prilosec ™, prevacid ™, nexium ™, and others. These medicines all decrease the acid load in the stomach so that the patient does not sense the stomach juice as much. Irritation of the esophagus, called “esophagitis” can improve. However, even though there is less acid, the reflux is often still occurring. Additionally, the U.S. Food and Drug Administration has issued a warning that long term use of some of the medications are associated with fractures of the hips, and other bones.
If lifestyle and medical treatment is inadequate then surgery is recommended. Surgery carries risks that are balanced against the patient’s condition, and the risks of long term daily use of the medications. The type of surgery is called a “fundoplication”. The fundoplication involves using the floppy upper part of the stomach to wrap it around the lower esophagus to gently squeeze and support the lower esophageal sphincter (LES). This decreases the amount of stomach fluid from refluxing up. Many patients get enough relief to “relax” some of the lifestyle changes, and lower the need for medicines.
There are two methods to create a fundoplication, “natural orifice surgery” and “laparoscopic” surgery. It is very rare nowadays to need the large “open” incision, but this technique is still available. Natural orifice surgery involves passing a scope with instruments down through the mouth, and creating the fundoplication from the “inside-out”. Laparoscopic surgery involves using several small incisions passed through the skin and abdominal wall to create the fundoplication from the “outside-in”. There are pros and cons of these approaches, and not every patient is eligible for each. A formal consultation is needed to determine which one is appropriate.
Philosophy of our Group
We believe that GERD is a chronic disorder that requires a multi-disciplinary approach for successful treatment. We bring together physicians with expertise in the medical and surgical management of GERD, along with professional lifestyle educators. Our team will help you and your primary physician put together an orderly evaluation and long term treatment plan.