What is Gastroesophageal Reflux Disease (GERD)
Normally, food travels down the esophagus and stays in the stomach to be digested. If a person has gastroesophageal reflux disease (GERD), food and stomach acid move back up into the esophagus.
GERD is defined as symptoms or mucosal injury caused by the abnormal reflux of gastric contents into the esophagus. It involves typical symptoms occurring two or more times weekly, or symptoms perceived as problematic to patients, or resulting in complications.
One third of the U.S. population suffers from symptoms of Gastroesophageal Reflux Disease at least once monthly, 10% to 20% once weekly, and 4% to 7% daily.
Although there is a high prevalence of heartburn, not everyone with heartburn has GERD.
When this happens, the esophagus becomes sore and swollen (inflamed). Over time, Gastroesophageal Reflux Disease can make small holes (ulcers) in the lining of the esophagus.
Typical and atypical symptoms of GERD
The typical symptoms of Gastroesophageal Reflux Disease include heartburn, regurgitation, or water brash (in which the oral cavity suddenly fills with fluid, usually clear and perhaps acidic) or dysphagia (the blockage to the passage of food in the lower substernal area). Classic heartburn is defined as the substernal burning “rising from the stomach or lower chest towards the neck” that lasts for a few moments to several minutes, that is relieved by antacids or food, and that occurs a half hour or an hour after meals.
Atypical or extraesophageal symptoms include cough, asthma, hoarseness, laryngitis, dental erosions, and noncardiac chest pain. Atypical symptoms are the primary complaint in 20% to 25% of patients with Gastroesophageal Reflux Disease and are secondarily associated with heartburn and regurgitation in many more. Nearly 50% of patients with chest pain and negative coronary angiograms, 75% with chronic hoarseness, and up to 80% with asthma have a positive 24-hour esophageal pH test, indicating abnormal acid reflux into the esophagus.
Although many patients with atypical symptoms benefit from antireflux surgery, it is not as effective as for those patients with typical symptoms.
What is the significance of abnormal esophageal motility in patients with GERD?
Long-standing, severe Gastroesophageal Reflux Disease can lead to deterioration of esophageal body function.
Abnormalities of esophageal body function include a lack of peristalsis, severely disordered peristalsis ( more than 50% simultaneous contractions), or ineffective peristalsis (the amplitude of the contractions in one or more of the lower esophageal segments is less than 30 mm Hg ), also called ineffective esophageal motility.
Dysphagia is generally a prominent symptom in patients with defective peristalsis.
How is Gastroesophageal Reflux Disease diagnosed?
Workup of patients with suspected GERD
The four tests performed when Gastroesophageal Reflux Disease is suspected are barium swallow and upper gastrointestinal (GI) series, esophagogastroduodenoscopy (EGD), esophageal manometry, and 24-hour pH test, with the latter being the gold standard for a diagnosis of Gastroesophageal Reflux Disease.
- • Barium esophagram provides both a functional and structural information. It is most useful in assessing the size and reducibility of a hiatal hernia and presence of esophageal shortening. A large, fixed hiatal hernia or paraesophageal hernia and a short esophagus are evidence of advanced disease and may predict a long, difficult operation.
- • EGD helps to identify the presence of esophagitis and Barrett’s esophagus. It can also be used to evaluate response to treatment and to detect complications of GERD, including peptic stricture and shortened esophagus. Furthermore, endoscopy provides valuable information about the absence of other lesions in the upper GI tract that can produce symptoms identical to those of Gastroesophageal Reflux Disease.
- • Esophageal manometry evaluates the peristaltic function of the esophagus and the pressure and relaxation of the LES. It is not a diagnostic test but provides information about the severity of the underlying physiologic defects of the LES and esophageal body. Furthermore, manometry helps rule out achalasia or other esophageal motility problems . A normal manometric test includes a resting basal LES of 10 to 45 mm Hg.
- • Esophageal 24-hour pH monitoring is the most direct method for assessing the presence and severity of Gastroesophageal Reflux Disease and, because it has the highest sensitivity and specificity of all available tests, has become the gold standard for the diagnosis of Gastroesophageal Reflux Disease. It is very useful in the evaluation of patients with atypical symptoms and patients with typical symptoms but with no evidence of esophagitis on endoscopy. The test also measures the correlation between symptoms and episodes of reflux in the supine or erect position. It is also used to determine if there is adequate acid suppression when patients are on medical treatment. It should be performed in every patient before surgical repair and with patients off acid suppression. A new device, the BRAVO probe, is a miniaturized pH probe that is attached 5 cm above the lower esophagus (as determined by manometry) during EGD that transmits pH data to a recording device that the patient wears. It stays in the esophagus for 3 to 5 days and is then spontaneously excreted in the stool. The advantage of the probe is that it is much better tolerated than the standard nasoesophageal probes. Newer techniques currently being tested, use 3-hour instead of 24-hour pH monitoring.
How is Gastroesophageal Reflux Disease treated?
What are the surgical options to relieve GERD?
All of the successful surgical procedures for GERD have certain characteristics in common. All create an intraabdominal segment of esophagus, prevent recurrence of the hiatal hernia if present, and create an antireflux valve.
- • Dor fundoplication: partial 270-degree anterior fundoplication
- • Belsey Mark IV: partial 270-degree anterior fundoplication via thoracic approach
- • Toupet fundoplication: partial 270-degree posterior fundoplication
- • Nissen fundoplication: total 360-degree fundoplication
- • Thal fundoplication: 90-degree anterior fundoplication
- • Watson: 120-degree anterolateral fundoplication
The approach to the repair can be abdominal (open or laparoscopic), thoracic (open or video-assisted thoracic surgery), and even thoracoabdominal. None of the operations or approaches is perfect for all patients. If the esophagus is shortened, consider approaching from the chest and performing a Collis gastroplasty in which a portion of the lesser curvature is stapled and divided to create extra esophageal length. If esophageal motility is an issue, consider a partial wrap so as not to produce severe dysphagia. Additionally, robot-assisted Nissen has been widely performed with similar outcomes to conventional laparoscopic Nissen repair.
What are the indications for an antireflux operation?
The introduction of minimally invasive procedures to surgically treat Gastroesophageal Reflux Disease has increased the frequency of these operations. The ability to permanently stop GE reflux and rid patients of dependence on expensive medications has prompted gastroenterologists to refer patients for surgical therapy more readily. Indications for surgery include:
- • Patient’s wish to control symptoms without medication
- • Persistent symptoms despite maximal medical therapy (most common)
- • Gastroesophageal Reflux Disease with prominent regurgitation component
- • Paraeshopageal hiatal hernia
- • Reflux complications (esophagitis, Barrett’s esophagus, bleeding, stricture, mucosal ulceration, Cameron ulcer—chronic iron-deficiency anemia caused by slow bleeding from the point where the herniated stomach rubs against the diaphragm)
Surgery may be the treatment of choice in patients who are at high risk of progression despite medical therapy. The risk factors for progression include:
- • Nocturnal reflux on 24-hour esophageal pH study
- • Structurally deficient LES (pressure less than 6 mm Hg)
- • Mixed reflux of gastric and duodenal juice
- • Mucosal injury at presentation
GERD in lung transplant patients is associated with decreased survival and attenuated allograft function. Early Nissen fundoplication has been safely performed in this subset of patients with improved outcomes from a lung transplant standpoint, as evidenced by 1-year forced expiratory volume in the first second of expiration measurements.
What are the predictors of successful antireflux surgery?
Predictors of successful antireflux surgery include typical symptoms of GERD (heartburn and regurgitation), an abnormal score on 24-hour esophageal pH monitor, and symptomatic improvement in response to acid suppression therapy before surgery.
What are the predictors of poor outcome after antireflux surgery?
The presence of GI symptoms other than typical GERD symptoms predicts less than optimal results. A large hiatal hernia, stricture with persistent dysphagia, and Barrett are characteristics of advanced GERD and may predict less than ideal results.
Benefits of surgical treatment of GERD
Antireflux procedures performed by experienced esophageal surgeons provide several benefits that cannot be accomplished with antacid medications. A successful operation augments the LES and repairs the hiatal hernia if present. It prevents the reflux of both gastric and duodenal juice, thus preventing aspiration. Antireflux operations also improve esophageal body motility and speed gastric emptying, which is often subclinically delayed in patients with GERD. More than 90% of patients are relieved of symptoms, eat unrestricted diets, and are satisfied with the surgical outcome.
Follow these instructions at home:
- Follow a diet as told by your doctor. You may need to avoid foods and drinks such as:
- Coffee and tea (with or without caffeine).
- Drinks that contain alcohol.
- Energy drinks and sports drinks.
- Carbonated drinks or sodas.
- Chocolate and cocoa.
- Peppermint and mint flavorings.
- Garlic and onions.
- Spicy and acidic foods, such as peppers, chili powder, curry powder, vinegar, hot sauces, and BBQ sauce.
- Citrus fruit juices and citrus fruits, such as oranges, lemons, and limes.
- Tomato-based foods, such as red sauce, chili, salsa, and pizza with red sauce.
- Fried and fatty foods, such as donuts, french fries, potato chips, and high-fat dressings.
- High-fat meats, such as hot dogs, rib eye steak, sausage, ham, and bacon.
- High-fat dairy items, such as whole milk, butter, and cream cheese.
- Eat small meals often. Avoid eating large meals.
- Avoid drinking large amounts of liquid with your meals.
- Avoid eating meals during the 2–3 hours before bedtime.
- Avoid lying down right after you eat.
- Do not exercise right after you eat.
- Pay attention to any changes in your symptoms.
- Take over-the-counter and prescription medicines only as told by your doctor. Do not take aspirin, ibuprofen, or other NSAIDs unless your doctor says it is okay.
- Do not use any tobacco products, including cigarettes, chewing tobacco, and e-cigarettes. If you need help quitting, ask your doctor.
- Wear loose clothes. Do not wear anything tight around your waist.
- Raise (elevate) the head of your bed about 6 inches (15 cm).
- Try to lower your stress. If you need help doing this, ask your doctor.
- If you are overweight, lose an amount of weight that is healthy for you. Ask your doctor about a safe weight loss goal.
- Keep all follow-up visits as told by your doctor. This is important.
Contact a doctor if:
- You have new symptoms.
- You lose weight and you do not know why it is happening.
- You have trouble swallowing, or it hurts to swallow.
- You have wheezing or a cough that keeps happening.
- Your symptoms do not get better with treatment.
- You have a hoarse voice.
Get help right away if:
- You have pain in your arms, neck, jaw, teeth, or back.
- You feel sweaty, dizzy, or light-headed.
- You have chest pain or shortness of breath.
- You throw up (vomit) and your throw up looks like blood or coffee grounds.
- You pass out (faint).
- Your poop (stool) is bloody or black.
- You cannot swallow, drink, or eat.