Treatment Advances for GERD -- December 17, 2012 -- Dr. Andrew K - NewsChannel5.com | Nashville News, Weather & Sports

Treatment Advances for GERD -- December 17, 2012 -- Dr. Andrew Kastello

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SAINT THOMAS HEALTH MEDICAL MONDAYS
Monday, December 17, 2012
TOPIC: Treatment Advances for GERD
Andrew Kastello, MD: General Surgeon|Riverpark Hospital
CAPELLA –SAINT THOMAS HEALTH

 One in 10 Americans experiences heartburn symptoms at least once a week. Heartburn has different triggers, including certain foods, medications, obesity, or even stress. Knowing your triggers will help you design a prevention strategy. If you suffer from heartburn it's important to find effective heartburn remedies to prevent the acid reflux from worsening. Heartburn treatment may include medications, home remedies, or diet changes.

Gastroesophageal Reflux Disease (GERD)

Gastroesophageal reflux disease, or GERD, is a digestive disorder that affects the lower esophageal sphincter (LES), the ring of muscle between the esophagus and stomach. Many people, including pregnant women, suffer from heartburn or acid indigestion caused by GERD. Doctors believe that some people suffer from GERD due to a condition called hiatal hernia. In most cases, heartburn can be relieved through diet and lifestyle changes; however, some people may require medication or surgery.

What Is Gastroesophageal Reflux?

Gastroesophageal refers to the stomach and esophagus. Reflux means to flow back or return. Therefore, gastroesophageal reflux is the return of the stomach's contents back up into the esophagus.

In normal digestion, the LES opens to allow food to pass into the stomach and closes to prevent food and acidic stomach juices from flowing back into the esophagus. Gastroesophageal reflux occurs when the LES is weak or relaxes inappropriately, allowing the stomach's contents to flow up into the esophagus.

The severity of GERD depends on LES dysfunction as well as the type and amount of fluid brought up from the stomach and the neutralizing effect of saliva.

What Is the Role of Hiatal Hernia in GERD?

Some doctors believe a hiatal hernia may weaken the LES and increase the risk for gastroesophageal reflux. Hiatal hernia occurs when the upper part of the stomach moves up into the chest through a small opening in the diaphragm (diaphragmatic hiatus). The diaphragm is the muscle separating the abdomen from the chest. Recent studies show that the opening in the diaphragm helps the support lower end of the esophagus. Many people with a hiatal hernia will not have problems with heartburn or reflux. But having a hiatal hernia may allow stomach contents to reflux more easily into the esophagus.

Coughing, vomiting, straining, or sudden physical exertion can cause increased pressure in the abdomen resulting in hiatal hernia. Obesity and pregnancy also contribute to this condition. Many otherwise healthy people age 50 and over have a small hiatal hernia. Although considered a condition of middle age, hiatal hernias affect people of all ages.

Hiatal hernias usually do not require treatment. However, treatment may be necessary if the hernia is in danger of becoming strangulated (twisted in a way that cuts off blood supply, called a paraesophageal hernia) or is complicated by severe GERD or esophagitis (inflammation of the esophagus). The doctor may perform surgery to reduce the size of the hernia or to prevent strangulation.

What Other Factors Contribute to GERD?

Dietary and lifestyle choices may contribute to GERD. Certain foods and beverages, including chocolate, peppermint, fried or fatty foods, coffee, or alcoholic beverages, may trigger reflux and heartburn. Studies show that cigarette smoking relaxes the LES. Obesity and pregnancy can also play a role in GERD symptoms.

What Are the Symptoms of Heartburn?

Heartburn, also called acid indigestion, is the most common symptom of GERD and usually feels like a burning chest pain beginning behind the breastbone and moving upward to the neck and throat. Many people say it feels like food is coming back into the mouth leaving an acid or bitter taste.

The burning, pressure, or pain of heartburn can last as long as 2 hours and is often worse after eating. Lying down or bending over can also result in heartburn. Many people obtain relief by standing upright or by taking an antacid that clears acid out of the esophagus.

Heartburn pain can be mistaken for the pain associated with heart disease or a heart attack, but there are differences. Exercise may aggravate pain resulting from heart disease, and rest may relieve the pain. Heartburn pain is less likely to be associated with physical activity.

How Common Is Heartburn and GERD?

More than 60 million American adults experience heartburn at least once a month, and about 25 million adults suffer daily from heartburn. Twenty-five percent of pregnant women experience daily heartburn. Recent studies show that GERD in infants and children is more common than previously recognized and may produce recurrent vomiting, coughing, and other respiratory problems.

What Is the Treatment for GERD?

Doctors recommend lifestyle and dietary changes for most people needing treatment for GERD. Treatment aims at decreasing the amount of reflux or reducing damage to the lining of the esophagus from refluxed materials.

Avoiding foods and beverages that can weaken the LES is recommended. These foods include chocolate, peppermint, fatty foods, coffee, and alcoholic beverages. Foods and beverages that can irritate a damaged esophageal lining, such as citrus fruits and juices, tomato products, and pepper, should also be avoided.

Decreasing the size of portions at mealtime may also help control symptoms. Eating meals at least 2 to 3 hours before bedtime may lessen reflux by allowing the acid in the stomach to decrease and the stomach to empty partially. In addition, being overweight often worsens symptoms. Many overweight people find relief when they lose weight.

Cigarette smoking weakens the LES. Stopping smoking is important to reduce GERD symptoms.

Elevating the head of the bed on 6-inch blocks or sleeping on a specially designed wedge reduces heartburn by allowing gravity to minimize reflux of stomach contents into the esophagus. Do not use pillows to prop yourself up which only increases pressure on the stomach.

Along with lifestyle and diet changes, your doctor may recommend over-the-counter or prescription treatments. 

Antacids taken can help neutralize acid in the esophagus and stomach and stop heartburn. Many people find that nonprescription antacids provide temporary or partial relief. An antacid combined with a foaming agent helps some people. These compounds are believed to form a foam barrier on top of the stomach that prevents acid reflux from occurring.

Long-term use of antacids, however, can result in side effects, including diarrhea, altered calcium metabolism (a change in the way the body breaks down and uses calcium), and buildup of magnesium in the body. Too much magnesium can be serious for patients with kidney disease. If antacids are needed for more than 3 weeks, a doctor should be consulted.

For chronic reflux and heartburn, the doctor may recommend medications to reduce acid in the stomach. These medicines include H2 blockers, which inhibit acid secretion in the stomach. H2 blockers include: cimetidine (Tagamet), famotidine (Pepcid), nizatidine (Axid), and ranitidine (Zantac).

Another type of drug, the proton pump (or acid pump) inhibitor inhibits an enzyme (a protein in the acid-producing cells of the stomach) necessary for acid secretion. Some proton pump inhibitors include esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix), and rabeprazole (Aciphex).

Other approaches to therapy will increase the strength of the LES and quicken emptying of stomach contents with motility drugs that act on the upper gastrointestinal (GI) tract. These drugs include bethanechol (Urecholine) and metoclopramide (Reglan).

What If Heartburn or GERD Symptoms Persist?

People with severe, chronic esophageal reflux or with symptoms not relieved by the treatment described above may need more complete diagnostic evaluation. Doctors use a variety of tests and procedures to examine a patient with chronic heartburn.

An upper GI series may be performed during the early phase of testing. This test is a special X-ray that shows the esophagus, stomach, and duodenum (the upper part of the small intestine). While an upper GI series provides limited information about possible reflux, it is used to rule out other diagnoses, such as peptic ulcers.

Endoscopy is an important procedure for individuals with chronic GERD. By placing a small lighted tube with a tiny video camera on the end (endoscope) into the esophagus, the doctor may see inflammation or irritation of the tissue lining the esophagus (esophagitis). If the findings of the endoscopy are abnormal or questionable, biopsy (removing a small sample of tissue) from the lining of the esophagus may be helpful.

Esophageal manometric studies -- pressure measurements of the esophagus -- occasionally help identify low pressure in the LES or abnormalities in esophageal muscle contraction.

For patients in whom diagnosis is difficult, doctors may measure the acid levels inside the esophagus through pH testing. Testing pH monitors the acidity level of the esophagus and symptoms during meals, activity, and sleep. Newer techniques of long-term pH monitoring are improving diagnostic capability in this area.

Does GERD Require Surgery?

A small number of people with GERD may need surgery because of severe reflux and poor response to medical treatment. Fundoplication is a surgical procedure that increases pressure in the lower esophagus. However, surgery should not be considered until all other measures have been tried. Endoscopic procedures that involve placing stitches in the LES or using electrodes to promote scarring of the LES are newer options in treatment.

What Are the Complications of Long-Term GERD?

Sometimes GERD results in serious complications. Esophagitis can occur as a result of too much stomach acid in the esophagus. Esophagitis may cause esophageal bleeding or ulcers. In addition, a narrowing or stricture of the esophagus may occur from chronic scarring. Some people develop a condition known as Barrett's esophagus. Doctors believe this condition may be a precursor to esophageal cancer.

How Can I Prevent GERD?

Lifestyle changes sometimes help prevent symptoms of gastroesophageal reflux disease, or GERD, a chronic form of heartburn. The major cause of GERD is that the lower esophageal sphincter, located where the esophagus joins the stomach, is weak or relaxes inappropriately.

Because fatty foods, mints, chocolates, alcohol, nicotine, and caffeinated beverages, such as coffee or colas, relax the lower esophageal sphincter, you may be able to reduce the amount of acid reflux you experience by avoiding these foods. Carbonated drinks, citrus fruits and juices, spicy foods, and tomato sauce may irritate the lining of your esophagus and make the effects of GERD more severe. Cutting out these foods helps some people who have GERD.

You may help reduce reflux by quitting smoking, wearing loose clothing, eating smaller meals, not lying down for at least three hours after you eat, and losing weight if you are overweight. Some people are able to prevent symptoms at night by raising the head of their bed with 6-inch blocks or by sleeping on a special wedge-shaped pillow that elevates the upper part of the body. Sleeping on your left side may also lessen symptoms.

Some medications, such as birth control pills and drugs for osteoporosis, may cause reflux and heartburn as a side effect. If medications you are taking seem to be the cause of your heartburn, talk with your doctor about other medications you might be able to use instead. Do not stop taking a prescription medication until you talk with your doctor.

Complications of Untreated Heartburn and GERD

If it's not controlled, acid reflux or GERD can result in serious problems, including esophagitis, esophageal bleeding and ulcers, Barrett's esophagus, strictures, and an increased risk of esophageal cancer.

What Is Esophagitis?

Too much stomach acid backwash in the esophagus can cause a painful and irritating inflammation of the esophagus called esophagitis. It occurs when stomach acid repeatedly comes into contact with the lining of the esophagus. Esophagitis may lead to esophageal bleeding or ulcers and scarring.What Is Barrett's Esophagus?

 

Barrett's esophagus is a serious condition that develops in some people who have chronic GERD. Most people with GERD, however, do not develop Barrett's esophagus. GERD is a major risk factor, but people without GERD may develop Barrett's esophagus.

In Barrett's esophagus, damage to the lining of the esophagus -- for example, by acid reflux from GERD -- can cause abnormal changes in the cells that line the esophagus. The normal cells that line the esophagus are damaged and replaced by a type of cell not usually found in the esophagus. People with Barrett's esophagus may be at risk of developing cancer of the esophagus, but most people with Barrett's esophagus do not develop cancer of the esophagus.

What Are the Symptoms of Barrett's Esophagus?

Symptoms may be similar to those of GERD, although some people have no symptoms at all.

How Is Barrett's Esophagus Diagnosed?

Barrett's esophagus is diagnosed with a test called an upper endoscopy to look at inside of the esophagus and obtain a biopsy to examine a sample of tissue.

How Is Barrett's Esophagus Treated?

The goal of treatment is to prevent further damage to the esophagus due to acid coming up from the stomach. Proton-pump inhibitor medications like Aciphex, Nexium, Prevacid, Prilosec, Protonix, and Zegerid are the mainstay of treatment. These drugs reduce the amount of acid produced by the stomach. If these medications do not work, surgery to tighten the sphincter or "valve" between the esophagus and stomach may be necessary.

Doctors may remove or use laser therapy to destroy abnormal tissue. These procedures are usually reserved for those patients at high risk of developing esophageal cancer.

Does Barrett's Esophagus Cause Cancer?

Barrett's esophagus may lead to the development of a type of esophageal cancer (adenocarcinoma) in some people. Up to 0.5% of people with Barrett's esophagus will develop esophageal adenocarcinoma each year. Because of the cancer risk, people with Barrett's esophagus need regular checkups of the esophagus.

What Are Strictures of the Esophagus?

Sometimes the damaged lining of the esophagus becomes scarred, causing narrowing of the esophagus, called strictures. These strictures can interfere with eating and drinking by preventing food and liquid from reaching the stomach. Strictures are treated by dilation, in which an instrument gently stretches the strictures and expands the narrowing in the esophagus.

What Is Esophageal Cancer?

Cancer of the esophagus is a disease in which cancer is found in the tissues of the esophagus. This cancer is more common in men and in people 65 years old and older.

The risk factors for esophageal cancer include GERD, Barrett's esophagus, cigarette smoking, and drinking alcohol. The risk increases with greater use of cigarettes or alcohol. Being overweight or obese is another risk factor. Lower risk for esophageal cancer has been linked to a having a diet that is rich in vegetables and fruits. 

Treating Heartburn with Surgery

For most people, heartburn is a treatable symptom. Frequent heartburn may indicate acid reflux or gastroesophageal reflux disease, also known as GERD. When treatment doesn't work and heartburn is severe despite lifestyle changes, surgery may be an option. It may also be an option if GERD causes other medical problems. Minimally invasive procedures using endoscopy are also available to treat acid reflux.

The vast majority of people with GERD can control heartburn symptoms adequately without surgery. A few people, though, still have acid reflux symptoms even after treating them with medications, lifestyle, and diet changes. For these people, surgery helps.

Heartburn that doesn't go away despite maximum non-surgical treatment is the most common reason to consider surgery for GERD. Other situations where surgery may be an option include:

  • Severe inflammation of the esophagus, called esophagitis.
  • A narrowing, known as a stricture, of the esophagus that's not caused by cancer.
  • Barrett's esophagus, which is a change in the cells of the esophagus because of acid reflux.

All surgical procedures carry risk. So generally, GERD surgery should be considered only after other treatment has not worked and tests suggest there's a good chance surgery will succeed.

Most people, if not everyone, considering surgery for GERD will first undergo endoscopy. Many will also have tests to check the muscle function of the esophagus. These tests can include esophageal manometry and esophageal motility studies.

Types of Surgery for GERD

The main surgery performed for persistent heartburn is called fundoplication. The surgery involves several steps:

  • The surgeon first cuts into the abdomen. He or she will either make one large incision for open surgery or a few small incisions for laparoscopic surgery.
  • In laparoscopic fundoplication, the surgeon operates from outside the body using tools inserted into the abdomen. During open fundoplication, he or she operates directly using his or her hands.
  • The surgeon wraps the top part of the stomach around the lower part of the esophagus and sews it in place.
  • This tightens the lower esophagus. That helps prevent acid from moving from the stomach into the esophagus and causing acid reflux.

In most cases, the top part of the stomach is wrapped all the way around the esophagus. People with other problems in the esophagus besides reflux may undergo a modified surgery with only a partial wrap.

Laparoscopic surgery requires a shorter recovery time with less pain than open surgery. Plus it leaves no large scar. When performed by an experienced surgeon, laparoscopic surgery works at least as well as traditional open surgery. For this reason, laparoscopic fundoplication is usually the best option for GERD surgery if an experienced surgeon is available.

In some cases, symptoms may return or develop and additional surgery may be needed.

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