Gastroesophageal reflux disease and heartburn
Highlights
Overview
- Gastroesophageal reflux disease (GERD) is a condition in which acids from the stomach flow back up into the esophagus.
- The hallmark symptoms of GERD are:
- Heartburn: a burning sensation in the chest and throat
- Regurgitation: a sensation of acid backed up in the esophagus
- Patients with GERD have abnormal nerve or muscle function in the stomach.
- Many patients with GERD do not have heartburn or regurgitation. Instead, symptoms may occur in the mouth or lungs.
Risk Factors for GERD
- Several studies suggest that obesity contributes to GERD and may increase the risk for erosive esophagitis (severe inflammation in the esophagus) in GERD patients.
- The likelihood of GERD increases in postmenopausal women who receive hormone replacement therapy.
- Pregnant women are particularly vulnerable to GERD in their third trimester, as the growing uterus puts increasing pressure on the stomach.
Trends
- Hospitalizations with a primary or secondary diagnosis of GERD rose by 216% between 1998 and 2005.
Treatment
- Most cases of gastroesophageal reflux are mild and can be managed with lifestyle changes, over-the-counter medications, and antacids.
- Patients with moderate-to-severe symptoms that do not respond to lifestyle changes, or who are diagnosed at a late stage, may be started on medications of varying strength depending on their complications at diagnosis.
- Forty percent of GERD patients receiving treatment with once-daily proton pump inhibitors (PPIs) have some breakthrough symptoms.
Introduction
Gastroesophageal reflux disease (GERD) is a condition in which acids from the stomach flow back up into the esophagus (an action called reflux). Reflux occurs if the muscular actions in the esophagus or other protective mechanisms fail.
Click the icon to see an animation about heartburn.
The hallmark symptoms of GERD are:
- Heartburn: a burning sensation in the chest and throat.
- Regurgitation: a sensation of acid backed up in the esophagus.
Although acid is a primary factor in damage caused by GERD, other products of the digestive tract, including pepsin and bile, can also be harmful.
The Esophagus
The esophagus, commonly called the food pipe, is a narrow muscular tube about nine-and-a-half inches long. It begins below the tongue and ends at the stomach. The esophagus is narrowest at the top and bottom; it also narrows slightly in the middle.
The esophagus consists of three basic layers:
- An outer layer of fibrous tissue.
- A middle layer containing smoother muscle.
- An inner membrane, which contains numerous tiny glands.
Click the icon to see an image of the esophagus.
When a person swallows food, the esophagus moves it into the stomach through the action of peristalsis, wave-like muscle contractions. In the stomach, the starch, fat, and protein in food are broken down by acid and various enzymes, notably hydrochloric acid and pepsin. The lining of the stomach has a thin layer of mucous that protects it from these fluids.
If acid and enzymes back up into the esophagus, however, its lining offers only a weak defense against these substances. Instead, several other factors protect the esophagus.
The most important structure protecting the esophagus may be the lower esophageal sphincter (LES). The LES is a band of muscle around the bottom of the esophagus, where it meets the stomach.
- After a person swallows, the LES opens to let food enter the stomach. It then closes immediately to prevent regurgitation of the stomach contents, including gastric acid.
- The LES maintains this pressure barrier until food is swallowed again.
Click the icon to see an image of the stomach.
If the pressure barrier is not sufficient to prevent regurgitation and acid backs-up (reflux), peristaltic action of the esophagus serves as an additional defense mechanism, pushing the backed-up contents back down into the stomach.
Causes
Anyone who eats a lot of acidic foods can have mild and temporary heartburn. This is especially true when lifting, bending over, or taking a nap after eating a large meal high in fatty, acidic foods. Persistent GERD, however, may be due to various conditions, including biological or structural problems.
Malfunction of the Lower Esophageal Sphincter (LES) Muscles
The band of muscle tissue called the LES is responsible for closing and opening the lower end of the esophagus, and is essential for maintaining a pressure barrier against contents from the stomach. It is a complex area of smooth muscles and various hormones. If it weakens and loses tone, the LES cannot close up completely after food empties into the stomach. In such cases, acid from the stomach backs up into the esophagus. Dietary substances, drugs, and nervous system factors can weaken the LES and impair its function.
Impaired Stomach Function
Patients with GERD have abnormal nerve or muscle function in the stomach. These abnormalities result prevent the stomach muscles from contracting normally, which causes delays in stomach emptying, increasing the risk for acid back-up.
Abnormalities in the Esophagus
Some studies suggest that most people with atypical GERD symptoms (such as hoarseness, chronic cough, or the feeling of having a lump in the throat) may have specific abnormalities in the esophagus. (In one study, such abnormalities appeared in 73% of patients who had atypical symptoms.)
Motility Abnormalities. Problems in spontaneous muscle action (peristalsis) in the esophagus commonly occur in GERD, although it is not clear if such occurrences are the cause of the condition, or the result of long-term effects of GERD.
Adult-Ringed Esophagus. This condition is characterized by an esophagus with multiple rings and persistent trouble with swallowing (including getting food stuck in the esophagus). It occurs mostly in men.
Hiatal Hernia
The hiatus is a small hole in the diaphragm through which the esophagus passes into the stomach. It normally fits very snugly, but it may weaken and enlarge. When this happens, part of the stomach muscles may protrude into it, producing a condition called hiatal hernia. It is very common, occurring in over half of people over 60 years old, and is rarely serious. It was believed that most cases of persistent heartburn were caused by a hiatal hernia. Hiatal hernia may impair LES muscle function. Studies have failed to confirm evidence, however, that it is a common cause of GERD, although its presence may increase GERD symptoms in patients with both conditions.
Genetic Factors
Studies indicate that 31 - 43% of reflux may be hereditary. An inherited risk exists in many cases of GERD, possibly because of inherited muscular or structural problems in the stomach or esophagus. Genetic factors may play an especially strong role in susceptibility to Barrett's esophagus, a precancerous condition caused by very severe GERD.
Other Conditions Associated with GERD
Crohn's disease is a chronic ailment that causes inflammation and injury in the colon and other parts of the gastrointestinal tract, including the esophagus. Other disorders that may affect areas that can contribute to GERD include diabetes, any gastrointestinal disorder (including peptic ulcers), lymphomas, and other types of cancer.
Click the icon to see an image of inflammatory bowel disease.
Eradication of Helicobacter Pylori
Helicobacter Pylori, also called H. pylori, is a bacterium found in the mucous membranes of the stomach, and is now known to be a major cause of peptic ulcers. Antibiotics that eradicate H. pylori are now accepted treatment for curing ulcers. Of some concern, however, are studies indicating that H. Pylori may actually protect against GERD by reducing stomach acid. Furthermore, curing ulcers by eliminating the bacteria might actually trigger GERD in some people. Studies are mixed, however, on whether patients with cured H. Pylori infections are at higher risk for GERD.
In any case, the bacteria should be eradicated in infected patients with existing GERD who are taking ongoing acid suppressing agents. There is some evidence that the combination of H. pylori and chronic acid suppression in these patients can lead to atrophic gastritis, a precancerous condition in the stomach.
Drugs that Increase the Risk for GERD
NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs), common causes of peptic ulcers, may also cause GERD or increase its severity in people who already have it. There are dozens of NSAIDs, including over-the-counter aspirin, ibuprofen (Motrin, Advil, Nuprin), and naproxen (Aleve), as well as prescription anti-inflammatory medicines. A person with GERD who takes the occasional aspirin or other NSAID will not necessarily experience adverse effects. This is especially true if there are no risk factors or indications of ulcers. Acetaminophen (Tylenol), which is NOT an NSAID, is a good alternative for those who want to relieve mild pain. It does not, however, relieve inflammation.
Other Drugs. Many other drugs can cause GERD, including but not limited to the following: calcium channel blockers (used to treat high blood pressure and angina), anticholinergics (used in the treatments of urinary tract disorders, allergies, and glaucoma), beta adrenergic agonists (used to treat asthma and obstructive lung diseases), dopamine (used in Parkinson's disease), bisphosphonates (used to treat osteoporosis), sedatives, antibiotics, potassium, or iron pills.
Click the icon to see an image of peristalsis.
Risk Factors
GERD occurs monthly in about half of American adults. People of all ages are susceptible to GERD. Elderly people with GERD tend to have a more serious condition than younger people.
Risk Factors for Heartburn and GERD
Eating Pattern. Anyone who eats a heavy meal and subsequently lies on their back or bends over from the waist is at risk for an attack of heartburn. Anyone who snacks at bedtime is at high risk for heartburn.
Pregnancy. Pregnant women are particularly vulnerable to GERD in their third trimester, as the growing uterus puts increasing pressure on the stomach. Heartburn in such cases is often resistant to dietary interventions and even to antacids.
Obesity. A number of studies suggest that obesity contributes to GERD and may increase the risk for erosive esophagitis (severe inflammation in the esophagus) in GERD patients. The Nurses' Health Study found that being overweight or obese significantly increased GERD symptoms in women. The higher a woman's body mass index (BMI), the study found, the more frequent were her symptoms. Women who lost weight in the study saw a decrease in their symptoms. Research suggests that the prevalence of GERD symptoms among obese patients has been underreported. Other researchers have reported that increased BMI is associated with a higher risk for cancer of the esophagus.
Respiratory Diseases. People with asthma are at very high risk for GERD. One study indicated that patients with chronic obstructive pulmonary diseases (such as emphysema or chronic bronchitis) were also more likely to have GERD.
Smoking. Increasing evidence indicates that smoking raises the risk for GERD. Studies suggest that smoking reduces LES muscle function, increases acid secretion, impairs muscle reflexes in the throat, and damages protective mucous membranes. Smoking reduces salivation, which helps neutralize acid. It is unknown whether the smoke, nicotine, or both trigger GERD. Some people who use nicotine patches to quit smoking, for example, have heartburn, but it is not clear if the nicotine or stress produces the acid back-up. In addition, smoking can lead to emphysema, in itself a risk factor for GERD.
Alcohol Use. Alcohol has mixed effects on GERD. It relaxes the LES muscles and, in high amounts, may irritate the mucous membrane of the esophagus. (Small amounts of alcohol, however, may actually protect the mucosal layer.) All alcoholic beverages increase stomach acid levels. A combination of heavy alcohol use and smoking increases the risk for esophageal cancer.
Hiatal Hernia. People with hiatal hernia may be at risk for some of the complications of gastroesophageal reflux.
Hormone Replacement Therapy. An analysis of results from the Nurses' Health Study shows that symptoms of GERD are more likely to occur in postmenopausal women who receive hormone replacement therapy. The risk increases with larger estrogen doses and longer duration of therapy.
Symptoms
Heartburn. Heartburn is the primary symptom of GERD. It is a burning sensation that spreads up from the stomach to the chest and throat. Heartburn is most likely to occur in connection with the following activities:
- Eating a heavy meal
- Bending over
- Lifting
- Lying down, particularly on the back
Patients with nighttime GERD, a common problem, tend to feel more severe pain than those whose symptoms occur at other times.
The severity of heartburn does not necessarily indicate actual injury to the esophagus. For example, Barrett's esophagus, which causes precancerous changes in the esophagus, may only trigger a few symptoms, especially in elderly people. On the other hand, people can have severe heartburn but suffer no damage in their esophagus.
Dyspepsia. Up to half of GERD patients have dyspepsia, a syndrome that consists of the following:
- Pain and discomfort in the upper abdomen
- A feeling of fullness in the stomach
- Nausea after eating
People without GERD can have dyspepsia .
Regurgitation. Regurgitation is the feeling of acid backing up in the throat. Sometimes acid regurgitates as far as the mouth and can be experienced as a "wet burp." Uncommonly, it may come out forcefully as vomit.
Less Common Symptoms
Many patients with GERD do not have heartburn or regurgitation. Elderly patients with GERD often have less typical symptoms than do younger people. Instead, symptoms may occur in the mouth or lungs.
Chest Sensations or Pain. Patients may have the sensation that food is trapped behind the breastbone. Chest pain is a common symptom of GERD. It is very important to differentiate it from chest pain caused by heart conditions, such as angina and heart attack.
Symptoms in the Throat. Less commonly, GERD may produce symptoms that occur in the throat:
- Acid laryngitis. A condition that includes hoarseness, dry cough, the sensation of having a lump in the throat, and the need to repeatedly clear the throat.
- Trouble swallowing (dysphagia). In severe cases, patients may even choke or food may become trapped in the esophagus, causing severe chest pain. This may indicate a temporary spasm that narrows the tube, or it could also be an indication of serious esophageal damage or abnormalities.
- Chronic sore throat
- Persistent hiccups
Coughing and Respiratory Symptoms. Airway symptoms, such as coughing and wheezing, may occur.
Chronic Nausea and Vomiting. Nausea that persists for weeks or even months, and is not traced back to a common cause of stomach upset, may be a symptom of acid reflux. In rare cases, vomiting can occur as often as once a day. All other causes of chronic nausea and vomiting should be ruled out, including ulcers, stomach cancer, obstruction, and pancreas or gallbladder disorders.
Gastroesophageal Reflux Disease in Children
GERD is very common in children of all ages, but it is usually mild. Symptoms usually resolve in most infants by 12 months of age, and in nearly all of them by 24 months of age. Children with the following conditions are at higher risk for severe GERD:
- Neurological impairments
- Food allergies
- Scoliosis
- Cyclic vomiting
- Cystic fibrosis
- Problems in the lungs, ear, nose, or throat
- Any medical condition affecting the digestive tract
Symptoms in Children. Typical symptoms in infants include frequent regurgitation, irritability, arching the back, choking or gagging, resisting feedings.
A physician should examine any child who has symptoms of severe GERD as soon as possible, because these symptoms may indicate complications such as anemia, failure to gain weight, or respiratory problems. Symptoms of severe GERD in infants and small children may include:
- Failure to thrive
- Chronic coughing
- Frequent infections
- Wheezing
- Gasping or frequent cessation of breathing while asleep (a condition called sleep apnea). Sleep apnea is thought to be associated with GERD.
- Severe vomiting -- particularly if it is bilious (green colored) -- always requires a doctor's visit, since it could be a symptom of a severe obstruction.
Babies and children may experience these symptoms without having GERD. An Australian study suggested that many infants who have normal levels of irritability may be treated inappropriately for reflux disorders.
Complications
Nearly everyone has an attack of heartburn at some point in their lives. In the vast majority of cases the condition is temporary and mild, causing only transient discomfort. If patients develop persistent gastroesophageal reflux disease with frequent relapses, however, and it remains untreated, serious complications may develop over time. Complications can include:
- Erosive esophagitis
- Severe narrowing (stricture) of the esophagus
- Barrett's esophagus
- Problems in other areas, including the teeth, the throat, and the airways leading to the lungs
Older people are at higher risk for complications from persistent GERD. The following conditions also put individuals at risk for recurrent and serious GERD:
- The esophagus is very inflamed.
- Initial symptoms are severe.
- Symptoms continue in spite of treatments that successfully heal the esophagus.
- There are severe underlying muscular abnormalities.
Erosive Esophagitis and its Complications
Erosive esophagitis develops in chronic GERD patients when the levels of irritation and inflammation caused by acid result in extensive injuries to the esophagus. Some studies have suggested that overweight Caucasian males with GERD are at highest risk for this condition. In anyone, however, the longer and more severe the GERD condition, the higher the risk for developing erosive esophagitis.
Bleeding. Bleeding may occur in around 8% of patients with erosive esophagitis. In very severe cases, the patient may detect dark-colored, tarry stools (indicating the presence of blood) or may vomit blood, particularly if ulcers have developed in the esophagus. This is a sign of severe damage and requires immediate attention.
Sometimes long-term bleeding can result in iron-deficiency anemia and may even require emergency transfusions. This condition can occur without heartburn or other warning symptoms, or even without obvious blood in the stools.
Barrett's Esophagus and Esophageal Cancer
Barrett's esophagus. Barrett's esophagus (BE) results in abnormal cellular changes in the esophagus that, in turn, put a patient at risk for esophageal cancer. There are many issues involved with BE, including its prevalence and true severity, that are currently unresolved.
About 10% of patients with symptomatic GERD have BE. In some cases, BE develops as an advanced stage of erosive esophagitis. While obesity, alcohol use, and smoking have all been implicated as risk factors for Barrett's esophagus, their role remains unclear. Only the persistence of GERD symptoms indicates a higher risk for BE. Nevertheless, not all patients with BE have either esophagitis or symptoms of GERD. In fact, studies suggest that more than half of the people with BE have no GERD symptoms at all. BE, then, is likely to be much more prevalent and probably less harmful than is currently believed. (BE that occurs without symptoms can only be identified in clinical trials or in autopsies, so it is difficult to determine the true prevalence of this condition.) Some evidence suggests that the presence of specific immune factors may be involved in determining the development of BE.
The incidence of esophageal cancer is clearly increased in patients with Barrett's esophagus. Most cases of esophageal cancer start with BE, and symptoms are present in less than half of these cases. However, only a minority of BE patients develop cancer. When BE patients develop abnormalities of the mucous membrane cells lining the esophagus (a condition called dysplasia), the risk of cancer rises significantly. There is some evidence that acid reflux may contribute to the development of cancer in BE.
Complications of Stricture
If the esophagus becomes severely injured over time, narrowed regions called strictures can develop, which may impair swallowing (a condition known as dysphagia). Stretching procedures or surgery may be required to restore normal swallowing. Paradoxically, strictures may actually prevent other GERD symptoms, by helping to keep acid from traveling up the esophagus.
Asthma and Other Respiratory Disorders
Asthma. Asthma and GERD often occur together. Studies report that reflux disorder coincides with 32 - 80% of asthma cases. Some theories for the causal connection between GERD and asthma are as follows:
- Acid leaking from the lower esophagus in GERD stimulates the vagus nerves, which run through the gastrointestinal tract. These stimulated nerves cause the nearby airways in the lung to constrict, producing asthma symptoms.
- Acid back-up that reaches the mouth may be inhaled (aspirated) into the airways. Here, the acid triggers a reaction in the airways that causes asthma symptoms.
There is some evidence that asthma causes GERD. In contrast, some evidence suggests that GERD causes asthma. Some clinical trials report that treating GERD in patients who also have asthma reduces symptoms of both conditions. Not all such patients report improved asthma symptoms with GERD treatments, and these treatments do not appear to have much effect on actual lung function. One study suggested that this approach works in people with asthma who tend to be overweight and have severe GERD in the lower part of the esophagus.
Other Respiratory and Airway Conditions. Studies indicate an association between GERD and various upper respiratory problems that occur in the sinuses, ear and nasal passages, and airways of the lung. People with GERD appear to have an above-average risk for chronic bronchitis, chronic sinusitis, emphysema, pulmonary fibrosis (lung scarring), and recurrent pneumonia. If a person inhales fluid from the esophagus into the lungs, serious pneumonia can occur. It is not yet known whether treatment of GERD would also reduce the risk for these respiratory conditions.
Dental Problems
Dental erosion (the loss of the tooth's enamel coating) is a very common problem among GERD patients, including children. It results from the acid backing up into the mouth and eroding the enamel.
Chronic Throat Conditions
An estimated 20 - 60% of patients with GERD have atypical symptoms in the throat (hoarseness, sore throat) without any significant heartburn. A failure to diagnose and treat GERD may lead to persistent throat conditions, such as chronic laryngitis, hoarseness, difficulty speaking, sore throat, cough, constant throat clearing, and granulomas (soft, pink bumps) on the vocal cords.
Sleep Apnea
GERD commonly occurs with obstructive sleep apnea, a condition in which breathing stops temporarily but repeatedly during sleep. It is not clear which condition is responsible for the other, but GERD is particularly severe when both conditions occur together. Both conditions may also have risk factors in common, such as sleeping on the back. Studies suggest that in such patients GERD can be markedly improved with a continuous positive airway pressure (CPAP) device, which opens the airways and is the standard treatment for severe sleep apnea.
Complications in Infants and Children
Feeding Problems. Children with GERD tend to refuse food and may be late in eating solids. Such behaviors may negatively affect the mothers as well.
Associations with Asthma and Infections in the Upper Airways. In addition to asthma, GERD is associated with other upper airway problems, including ear infections and sinusitis. Some experts argue that the association with common childhood infections and asthma is unfounded.
Dental Erosion. Chronic severe GERD can cause irreversible loss of tooth enamel.
Rare Complications in Infants. Although GERD is very common, the following complications may occur. These complications are very rare and only occur in certain cases:
- Failure to thrive
- Anemia resulting from feeding problems and severe vomiting
- Acid back-up may be inhaled into the airways and cause pneumonia
The infant's life may be in danger if acid reflux causes spasms in the larynx severe enough to block the airways. In fact, some experts believe this chain of events may contribute to sudden infant death syndrome (SIDS). More research is needed to determine whether this association is valid.
Diagnosis
If a patient suffers from chronic heartburn, chances are good the patient also has GERD. (Occasional heartburn does not necessarily indicate the presence of GERD.) The following is the general diagnostic approach:
- A physician can usually make an easy diagnosis of GERD if the patient finds relief from persistent heartburn and acid regurgitation after taking antacids for short periods.
- If the diagnosis is uncertain but the physician still suspects GERD, a drug trial using a proton-pump inhibitor medication, such as omeprazole (Prilosec) identifies 80 - 90% of people with the conditions. This class of medication blocks stomach acid secretion.
Laboratory or more invasive tests, including endoscopy, may be required in the following cases:
- If the diagnosis is still uncertain
- If atypical symptoms are present
- If Barrett's esophagus is suspected
- If complications, such as signs of bleeding or difficulty in swallowing, are present
Some of these tests are described below.
Barium-Swallow Radiograph
A barium swallow radiograph (x-ray) is useful for identifying structural abnormalities and erosive esophagitis. For this test, the patient drinks a solution containing barium, and then x-rays of the digestive tract are taken. This test can show stricture, active ulcer craters, hiatal hernia, erosion, or other abnormalities. The test cannot reveal mild irritation.
Upper Endoscopy
Upper endoscopy, also called esophagogastroduodenoscopy or panendoscopy, is more accurate than a barium-swallow radiograph. It is also more invasive and expensive. It is widely used in GERD, for purposes that include identifying and grading severe esophagitis, periodic monitoring of patients with Barrett's esophagus, screening people at high risk for BE, or when other complications of GERD are suspected. Upper endoscopy is also used as part of various surgical techniques.
Endoscopy to Diagnose GERD. Endoscopy may be performed either in a hospital or in a doctor's office:
- The patient should eat nothing for at least 6 hours before the procedure.
- The doctor administers a local anesthetic using an oral spray and an intravenous sedative to suppress the gag reflex and to relax the patient.
- Next, the physician places an endoscope (a thin flexible plastic tube containing a tiny camera) into the patient's mouth and down the esophagus. The procedure does not interfere with breathing. It may be slightly uncomfortable for some patients; others are able to sleep through it.
- Once the endoscope is in place, the camera allows the physician to see the surface of the esophagus and to look for abnormalities, including hiatal hernia and damage to the mucous lining.
- The physician performs a biopsy (the removal and microscopic examination of small tissue sections). The biopsy may detect tissue injury indicative of GERD. It may also be used to detect cancer or other conditions, such as yeast (Candida albicans) or viral infections (such as herpes simplex and cytomegalovirus). Such infections are more likely to occur in people with impaired immune systems.
Complications from the procedure are uncommon. If they occur, complications are almost always mild and typically include minor bleeding from the biopsy site or irritation where medications were injected.
If a patient has moderate-to-severe GERD symptoms and the procedure reveals injury in the esophagus, usually no further tests are needed to confirm a diagnosis. The test is not foolproof, however. A visual view misses about half of all esophageal abnormalities.
Capsule Endoscopy. Capsule endoscopy was first approved for use in 2000. In this test, the patient swallows a small capsule containing a tiny camera. An esophagus-specific capsule device was approved in 2004. After the patient swallows the capsule, a series of color pictures are transmitted to a recording device where they can be downloaded and interpreted by a doctor. The entire procedure takes 20 minutes. The capsule is naturally passed through the digestive system within 24 hours. A newer technique has a string attached to the capsule for retrieval. Capsule endoscopy may provide a more attractive and less invasive alternative for patients than traditional endoscopy. However, while capsule endoscopy is useful as a screening device for diagnosing esophageal conditions such as GERD and Barrett's esophagus, traditional endoscopy is still required for gathering tissue samples or removing polyps.
Monitoring for Barrett's Esophagus and Cancer
Barrett's esophagus is diagnosed using endoscopy, a procedure that involves inserting a tube down the throat so that the physician can view the esophagus.
Monitoring High-Risk GERD Patients. Some experts recommend a one-time screening test for BE using endoscopy in high-risk patients (such as Caucasian overweight men) with chronic GERD.
Monitoring Patients with Barrett's Esophagus for Cancer. Periodic endoscopy is recommended for detecting early cancer in patients who have been diagnosed with Barrett's esophagus. When Barrett's esophagus is diagnosed, multiple biopsies are generally taken. The biopsy results (show no dysplasia, low-grade dysplasia, or high-grade dysplasia) will determine the frequency of future monitoring.
PH Monitor Examination
The (ambulatory) pH monitor examination may be employed to determine acid back-up. It is useful when endoscopy has not detected damage to the mucous lining in the esophagus, but GERD symptoms are present. pH monitoring may be used when patients have not found relief from medicine or surgery. The traditional trans-nasal catheter diagnostic procedure involved inserting a tubular probe through the nose and down to the esophagus. The tube was left in place for 24 hours. This test was irritating to the throat, and uncomfortable and awkward for most patients.
A new method, known as the Bravo pH test uses a small capsule-sized data transmitter that is temporarily attached to the wall of the esophagus during endoscopy. The capsule records pH levels and transmits these data to a pager-sized receiver worn by the patient. Patients can maintain their usual diet and activity schedule during the 24 - 48-hour monitoring period. After a few days, the capsule detaches from the esophagus, passes through the digestive tract, and is eliminated through a bowel movement.
Manometry
Manometry is a technique that measures muscular pressure. It employs a tube containing various openings, which is placed through the esophagus. As the muscular action of the esophagus exerts pressure on the tube in various locations, a computer connected to the tube measures this pressure. Manometry is useful for the following situations:
- To determine if a GERD patient would benefit from surgery, by measuring pressure exerted by the lower esophageal sphincter muscles.
- To detect impaired stomach motility (an inability of the muscles to contract normally), which cannot be surgically corrected with standard procedures.
- To determine if impaired peristalsis or other motor abnormalities are causing chest pain in people with GERD who have these symptoms.
Other Tests
Blood and Stool Tests. Stool tests may show traces of blood that are not visible without a microscope. Blood tests for anemia should be performed if bleeding is suspected.
Bernstein Test. For patients with chest pain in which the diagnosis is uncertain, a procedure called the Bernstein test may be useful, although it is rarely used. A tube is inserted through the patient's nasal passage. Solutions of hydrochloric acid and saline are administered separately into the esophagus. A diagnosis of GERD is established if the acid infusion causes symptoms and the saline solution does not.
Ruling out Other Disorders
Because many illnesses share similar symptoms, careful analysis and consideration of the patient's history is key to an accurate diagnosis. The following are only a few of the conditions that could accompany or resemble GERD.
Dyspepsia. The most common disorder confused with GERD is dyspepsia, pain or discomfort in the upper abdomen without heartburn. Specific symptoms may include a feeling of fullness (particularly early in the meal), bloating, and nausea. Dyspepsia can be a symptom of GERD, but does not always occur with GERD. The drug metoclopramide (Reglan) helps stomach emptying and may be helpful for this condition.
Angina and Chest Pain. About 600,000 people come to emergency rooms each year with chest pains. More than 100,000 of these people are believed to actually have GERD. Chest pain from both GERD and severe angina can occur after a heavy meal. In general, a heart problem is probably not responsible for the pain if it is worse at night and does not occur after exercise. It should be noted that the two conditions often coexist. In fact, there is some theory that in patients with coronary artery disease, acid reflux may actually trigger angina. In such cases, experts believe that acid in the esophagus may activate nerves that temporarily impair blood flow to the heart.
Other Diseases. Many gastrointestinal diseases (such as inflammatory bowel disease, ulcers, and intestinal cancers) can cause GERD, but they are often easily identified, since they have other symptoms and affect different areas of the intestinal tract.
Treatment
Acid suppression continues to be the mainstay for treating GERD. The aim of drug therapy is to reduce the amount of acid present and improve any abnormalities in muscle function of the lower esophageal sphincter, the esophagus, or the stomach.
Most cases of gastroesophageal reflux are mild and can be managed with lifestyle changes, over-the-counter medications, and antacids.
Drug Treatments
Patients with moderate-to-severe symptoms that do not respond to lifestyle changes, or who are diagnosed at a late stage, may be started on medications of varying strength depending on their complications at diagnosis. Experts argue, however, about the best way to initiate drug treatment for GERD in most of these patients. The two major treatment options are known as the step-up and step-down approaches:
- Step-up. With a step-up drug approach the patient first tries an H2 blocker drug, which is available over the counter. These drugs include famotidine (Pepcid AC), cimetidine (Tagamet HB), ranitidine (Zantac 75), and nizatidine (Axid AR). If the condition fails to improve, therapy is "stepped up" to the more powerful proton-pump inhibitors, usually omeprazole (Prilosec).
- Step-down. A step-down approach first uses a more potent agent, most often a proton-pump inhibitor (PPI), such as omeprazole (Prilosec). When patients have been symptom-free for 2 months or longer, they are then "stepped down" to a half-dose. If symptoms do not recur, the drug is withdrawn. If symptoms recur, the patient is put on high-dose H2 blockers. In one study using this step-down approach, 58% of patients remained symptom-free after a year, with 27% not using any medications at all. Some physicians argue that the step-down approach should be used for most patients with moderate-to-severe GERD.
Recent guidelines indicate that PPIs should be the first drug treatment, given once a day for about 8 weeks. Even when symptoms are completely relieved by medication, they usually return within a few months after drug treatment has stopped. Long-term maintenance may be necessary.
If neither approach relieves symptoms, the physician should look for other conditions. Endoscopy and other tests might be used to confirm GERD and rule out other disorders. In some cases, bile, not acid, may be responsible for symptoms, so acid-reducing or blocking agents would not be helpful. (Bile is a fluid that is present in the small intestine and gallbladder.)
Treatments for Barrett's Esophagus
To date, no treatments can reverse the cellular damage done after Barrett's esophagus has developed, although some procedures are showing promise.
Medications. If a patient is diagnosed with Barrett's esophagus, the doctor will prescribe proton pump inhibitors to suppres acid. Use of these medications may help slow progression of the abnormal changes in the esophagus.
Surgery: Surgical treatment of Barrett's esophagus is a consideration when patients develop high-grade dysplasia of the cells lining the esophagus. See "Surgery" section.
Managing GERD in Infancy and Childhood
Here are some hints on managing GERD in infants:
- During and after feeding, infants should be positioned vertically and burped frequently.
- If a baby with GERD is fed formula, the mother should ask the doctor how to thicken it in order to prevent splashing up from the stomach.
- Parents of infants with GERD should discuss the baby's sleeping position with their pediatrician. Seated position should be avoided, if possible. Experts strongly recommend that all healthy infants sleep on their backs to help prevent sudden infant death syndrome (SIDS). For babies with GERD, however, lying on the back may obstruct the airways. In one study, infants with gastroesophageal reflux who spent prolonged periods of time in infant seats, including car seats, had more reflux than those who spent waking time on their stomachs. If the physician recommends that babies with GERD sleep on their stomachs, parents should be sure that their infant's mattress is very firm, possibly tilted up at the head, and that there are no pillows. The baby's head should be turned so that the mouth and nose are completely unobstructed. Observe children placed on their stomach.
- Because food allergies may trigger GERD in children, parents may want to discuss a dietary plan with their physician that starts the child on formulas using non-allergenic proteins, and then incrementally adds other foods until symptoms are triggered.
Managing GERD in Children. The same drugs used in adults may be tried in children with chronic GERD. While some drugs are available over the counter, do not give them to children without physician supervision.
- Changes in diet can include eliminating foods that are acidic or possibly associated with reflux, such as tomatoes, chocolate, mint, juices, and carbonated or caffeinated drinks.
- Weight reduction for obese patients is important.
- Milder medications, such as antacids, are used first. However, long-term use of these drugs is generally not recommended due to the occurrence of either diarrhea or constipation, depending on which antacids are used.
- H2 blockers may be tried next. They are available over the counter and include famotidine (Pepcid AC), cimetidine (Tagamet HB), ranitidine (Zantac 75), and nizatidine (Axid AR). The FDA has issued a warning on Pepcid AC for people with kidney problems.
- Proton-pump inhibitors (PPIs), such as omeprazole (Prilosec) and lansoprazole (Prevacid), are even more powerful agents that suppress the production of stomach acid. Delayed-release esomeprazole (Nexium) capsules have been approved for use in children ages 12 - 17 for the short-term treatment of GERD. PPIs appear to be safe and effective even for children as young as 1 year old who fail the less intensive therapies. However, a 2006 study found that otherwise healthy children who were treated with H2 blockers and PPIs had an increased risk of developing respiratory and intestinal infections.
Surgical fundoplication involves wrapping the upper curve of the stomach (fundus) around the esophagus. The goal of this surgical technique is to strengthen the LES. Until recently, surgery was the primary treatment for children with severe complications from GERD because older drug therapies had severe side effects, were ineffective, or had not been designed for children. However, with the introduction of proton-pump inhibitor drugs, some children may be able to avoid surgery. Surgical fundoplication can be performed laparoscopically through small incisions. Weakening of the LES over the long-term occurs with children as well as adults.
Surgery
Surgery may be indicated under certain circumstances:
- If lifestyle changes and drug treatments have failed
- In patients with other medical complications
- In younger people with chronic GERD, who face a lifetime of expense and inconvenience with maintenance drug treatment
Some physicians are recommending surgery as the treatment of choice for many more patients with chronic GERD, particularly since minimally invasive surgical procedures are becoming more widely available, and since only surgery improves regurgitation. Furthermore, persistent GERD appears to be much more serious than was previously believed, and the long-term safety of acid suppression using medication is still uncertain.
Nevertheless, anti-GERD procedures have many complications and high failure rates (ranging from 30% at 5 years to 63% at 10 years) and, as with medications, current surgical procedures cannot cure GERD. About 15% of patients still require anti-GERD medications after surgery. Furthermore, about 40% of surgical patients are at risk for new symptoms after surgery (such as gas, bloating, and trouble swallowing), with most occurring more than a year after surgery. Finally, evidence now suggests that surgery does not reduce the risk for esophageal cancer in high-risk patients, such as those with Barrett's esophagus. New procedures may improve current results, but at this time patients should consider surgical options very carefully with both a surgeon and their primary doctor.
Surgical Management Of Barrett's Esophagus
Procedures to Remove the Mucous Lining. Various techniques or devices have been developed to remove the mucous lining of the esophagus. The intention is to remove early cancerous or precancerous tissue (high-grade dysplasia, or severe abnormalities in the cells) and allow regrowth of new and hopefully healthy tissue in the esophagus. Such techniques include photodynamic therapy (PDT), surgical removal of the abnormal lining, or ablation techniques, such as the use of laser, to destroy the abnormal lining.
Studies on the use of ablation techniques combined with aggressive use of proton-pump inhibitors or surgical treatments are very encouraging. Some of these techniques may eventually offer cures. At this time, they can be very effective in removing harmful tissue, although the benefits do not last in all patients. In one study, only a third of patients showed no evidence of renewed precancerous cell growth an average of 5.6 years after anti-GERD surgery and laser treatment. These procedures also carry potential complications, such as possible problems swallowing, which patients should discuss with their physician.
Esophagectomy. Esophagectomy is the surgical removal of all or part of the esophagus. Patients with Barrett's esophagus, who are otherwise healthy, are candidates for this procedure if biopsies show high-grade dysplasia or an actual cancer. After esophageal removal, in total or in part, a new conduit for foods and fluids must be established to replace the absent esophagus. Alternatives include the stomach, colon, and part of the small intestine called the jejunum. The stomach is the optimal choice.
Prevention
People with heartburn should first try lifestyle and dietary changes. Some suggestions are:
- Avoid or reduce consumption of foods and beverages that contain caffeine, chocolate, peppermint, spearmint, and alcohol. Both caffeinated and decaffeinated coffees increase acid secretion.
- Avoid all carbonated drinks, because they increase the risk for GERD.
- Although doctors often advise patients with GERD to cut down on fatty foods, many studies have found no evidence that a low-fat or high-fat meal makes any difference in symptom exacerbation. Better studies are needed to confirm this. In any case, as a rule, it is always wise to avoid saturated fats (which are from animal products), and cut down on all fats if one is overweight.
- Choose low-fat or skim dairy products, poultry, or fish. Increasing protein intake may help strengthen muscles in the muscle valve.
- Eat a diet rich in fruits and vegetables, although it's best to avoid acidic vegetables and fruits (such as oranges, lemons, grapefruit, pineapple, tomatoes).
Patients who have trouble swallowing should avoid tough meats, vegetables with skins, doughy bread, and pasta.
Prevention of Nighttime GERD
Nearly three-quarters of patients with frequent GERD symptoms have them at night. Patients with nighttime GERD also tend to experience severe pain. It is very important to take preventive measures before going to sleep. Some suggestions for preventing acid reflux at night include:
- After meals, take a walk or, at the very least, remain upright.
- Avoid bedtime snacks. In general, avoid eating for at least 2 hours prior to bedtime.
- When going to bed, try lying on the left side rather than on the right. The stomach is located higher than the esophagus when a person sleeps on the right side, which can put pressure on the lower esophageal sphincter (LES), increasing the risk for fluid back-up.
- Sleep in a tilted position to help keep acid in the stomach at night. To do this, raise the bed at an angle using 4- to 6-inch blocks at the head of the bed and use a wedge-support to elevate the top half of the body. (Extra pillows that only raise the head actually increase the risk for reflux.)
Other Preventive Measures
- Quitting smoking is essential.
- People who are overweight should try to reduce food intake and exercise to lose weight.
- People with GERD should avoid tight clothing, particularly around the abdomen.
- If possible, GERD patients should avoid nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Motrin, Advil), or naproxen (Aleve), among others. Tylenol (acetaminophen) is a good alternative pain reliever.
Although gum chewing is commonly believed to increase the risk for GERD symptoms, one study reported it might be helpful. Because saliva helps neutralize acid and contains a number of other factors that protect the esophagus, chewing gum 30 minutes after a meal has been found to help relieve heartburn and even protect against damage caused by GERD. Chewing on anything at all can help since it stimulates saliva production.
Medications
Antacids
Antacids neutralize digestive acids and are the drugs of choice for mild GERD symptoms. They are best used alone for relief of occasional and unpredictable episodes of heartburn. They all work by neutralizing the acid in the stomach. They may also stimulate the defensive systems in the stomach by increasing bicarbonate and mucous secretion. Many antacids are available without a prescription. Despite the many brands, they all rely on various combinations of three basic ingredients: magnesium, calcium, or aluminum.
Magnesium. Magnesium salts are available in the form of magnesium carbonate, magnesium trisilicate, and most commonly, magnesium hydroxide (Milk of Magnesia). The major side effect of magnesium salts is diarrhea. Magnesium salts offered in combination products with aluminum (Mylanta and Maalox) balance the side effects of diarrhea and constipation.
Calcium. Calcium carbonate (Tums, Titralac, and Alka-2) is a potent and rapid acting antacid that can cause constipation. These antacids are actually sources of calcium. There have been rare cases of hypercalcemia (elevated levels of calcium in the blood) in people taking large doses of calcium carbonate for long periods of time. This can lead to kidney failure and is very dangerous. None of the other antacids has this potential side effect.
Aluminum. Aluminum salts (Amphogel, Alternagel) are also available. The most common side effect of antacids containing aluminum salts is constipation. People who take large amounts of antacids that contain aluminum may also be at risk for calcium loss, which can lead to osteoporosis.
It is generally believed that liquid antacids work faster and are more potent than tablets, although evidence suggests that they all work equally well. Antacids can interact with a number of drugs in the intestines by reducing their absorption. These drugs include tetracycline, ciprofloxacin (Cipro), propranolol (Inderal), captopril (Capoten), and H2 blockers. Interactions can be avoided by taking the drugs 1 hour before or 3 hours after taking the antacid. Long-term use of nearly any antacid increases the risk for kidney stones.
H2 Blockers
H2 blockers impede acid production by blocking or antagonizing the actions of histamine, a chemical found in the body. Histamine encourages acid secretion in the stomach. H2 blockers are available over the counter and provide symptom relief in about half of GERD patients. It takes 30 - 90 minutes for them to work, but the benefits last for hours. People usually take the drugs at bedtime. Some people may need to take them twice a day.
H2 blockers inhibit acid secretion for 6 - 24 hours and are very useful for people who need persistent acid suppression. They may also prevent heartburn episodes in people who are able to predict its occurrence. In some studies, H2 blockers improved asthmatic symptoms in people who have both conditions. One study suggested, however, that they rarely provide complete symptom relief for chronic heartburn and dyspepsia, and that they have done little to reduce office visits to physicians for GERD.
Brands. Four H2 blockers are available in the U.S.:
- Famotidine (Pepcid AC, Pepcid Oral). Famotidine is the most potent H2 blocker. The most common side effect of famotidine is headache, which occurs in 4.7% of people who take it. Famotidine is virtually free of drug interactions, but the Food and Drug Administration (FDA) has issued a warning on its use in patients with kidney problems.
- Cimetidine (Tagamet, Tagamet HB). Cimetidine is the oldest H2 blocker. It has few side effects; about 1% of people taking it will have mild temporary diarrhea, dizziness, rash, or headache. Cimetidine interacts with a number of commonly used medications, such as phenytoin, theophylline, and warfarin. Long-term use of excessive doses (more than 3 grams a day) may cause impotence or breast enlargement in men. These problems resolve after the drug is discontinued.
- Ranitidine (Zantac, Zantac 75, Zantac Efferdose, Zantac injection, and Zantac Syrup). Ranitidine interacts with very few drugs. In a recent study, ranitidine provided more pain relief and healed ulcers more quickly than cimetidine in people younger than age 60, but there was no difference in older patients. A common side effect associated with ranitidine is headache, occurring in about 3% of the people who take it.
Nizatidine Capsules (Axid AR, Axid Capsules, Nizatidine Capsules). Nizatidine is nearly free of side effects and drug interactions. A controlled-release form is proving to help alleviate nighttime GERD symptoms.
Drug Combinations.
- Over-the-counter antacids and H2 blockers: This combination may be the best approach for many people who get heartburn after eating. Both classes of drugs are effective in relieving GERD, but have different timing. Antacids work within a few minutes but are short-acting, while H2 blockers take longer but have long-lasting benefits. Pepcid AC combined with an antacid (calcium carbonate and magnesium) is now available as Pepcid Complete.
- Proton-pump inhibitors and H2 blockers: Doctors sometimes recommend a nighttime dose of an H2 blocker for people who are taking proton-pump inhibitors twice a day. This is based on the belief that adding the H2 blocker will prevent a rise in acid reflux at night. An important 2002 study, however, reported no additional benefits from the nighttime H2 blocker. Some experts recommended an H2 blocker in patients who are on proton-pump inhibitors only to prevent breakthrough symptoms, such as before a heavy meal.
Long Term Complications. In most cases, these agents have good safety profiles and few side effects. H2 blockers can interact with other drugs, although some less so than others. In all cases, however, the physician should be made aware of any other drugs a patient is taking. More research is needed into the effects of long-term use of these medications. Anyone with kidney problems should use famotidine only under the direction of a doctor.
Concerns and Limitations. Some experts are concerned that the use of acid-blocking drugs in people with peptic ulcers may mask ulcer symptoms and increase the risk for serious complications.
These agents provide no protection against Barrett's esophagus. In addition, of concern are reports that long-term acid suppression with these drugs may cause cancerous changes in the stomach in patients who are infected with H. pylori. Research on this question is still ongoing.
FDA Warning for Famotidine (Pepcid AC)
Famotidine is excreted primarily by the kidney. This can pose a danger to people with kidney problems. Physicians are now being advised by the FDA and Health Canada to reduce the dose and increase the time between doses in patients with kidney failure. Use of the drug in those with impaired kidney function can affect the central nervous system and may result in anxiety, depression, insomnia or drowsiness, and mental disturbances.
Proton-Pump Inhibitors
Proton-pump inhibitors (PPIs) suppress the production of stomach acid and work by inhibiting the molecule in the stomach glands that is responsible for acid secretion (the gastric acid pump). According to recent guidelines, initial drug treatment should be with PPIs once daily for about 8 weeks.
The standard agent has been omeprazole (Prilosec), which is now available over the counter without a prescription. Newer prescription oral PPIs include esomeprazole (Nexium), lansoprazole (Prevacid), rabeprazole (AcipHex), and pantoprazole (Protonix).
Studies report significant relief from heartburn in most patients taking PPIs. PPIs are effective for healing erosive esophagitis and may also be helpful in patients with chronic laryngitis that is suspected to be caused by GERD. The newer agents provide quicker symptom relief compared to omeprazole. However, a comparison study suggested that, to date, esomeprazole is the only newer oral PPI to show any significant advantage over omeprazole.
All PPIs are more effective than H2 blockers. However, a recent study found that over 40% of people treated with PPIs still have breakthrough symptoms, especially at night. Of concern, 41% of patients experiencing these breakthrough symptoms have not spoken to their doctor about them.
In addition to relieving most common symptoms, including heartburn, proton-pump inhibitors also have the following advantages:
- They are effective in relieving chest pain and laryngitis caused by GERD.
- They may also reduce acid reflux that typically occurs during strenuous exercise.
Patients with impaired esophageal muscular action are still likely to have acid breakthrough and reflux at night. Proton-pump inhibitors also may have little or no effect on regurgitation or asthmatic symptoms. Some experts believe, however, that they should be the first drugs of choice, even for patients with milder symptoms. Currently, these drugs are recommended for patients with:
- Moderate symptoms that do not respond to H2 blockers
- Severe symptoms
- Respiratory complications
- Persistent nausea
- Esophageal injury
These agents have no affect against non-acid reflux, such as bile back-up.
Adverse Effects. Proton-pump inhibitors may pose the following concerns:
- Side effects are uncommon but may include headache, diarrhea, constipation, nausea, and itching.
- Pregnant women and nursing mothers should avoid proton-pump inhibitors should, although recent studies suggest that they do not pose an increased risk of birth defects.
- PPIs may interact with certain drugs, including anti-seizure medications (such as phenytoin), anti-anxiety drugs (such as diazepam), and blood thinners (such as warfarin).
- Long-term use of high-dose PPIs may produce vitamin B12 deficiencies, but more studies are needed to confirm whether this risk is significant. High-dose PPIs used long-term also may increase the risk of hip fracture in older adults, according to several studies.
Some evidence suggests that acid reflux may contribute to the higher risk of cancer in Barrett's esophagus, but it is not yet confirmed whether acid-blockers have any protective effects against cancer in these patients. Moreover, long-term use of proton-pump inhibitors by people with H. pylori may, in theory, reduce acid secretion enough to cause atrophic gastritis (chronic inflammation of the stomach). This condition is a risk factor for stomach cancer. To compound concerns, long-term use of PPIs may mask symptoms of stomach cancer and thus delay diagnosis. To date, however, there have been no reports of an increased risk of stomach cancer with the long-term use of these drugs.
Agents that Protect the Mucous Lining (Sucralfate)
Sucralfate (Carafate) protects the mucous lining in the gastrointestinal tract. It seems to work by sticking to an ulcer crater and protecting it from damage from stomach acid and pepsin. It may be helpful for maintenance therapy in people with mild-to-moderate GERD. Other than constipation, which occurs in 2.2% of patients, the drug has few side effects. Sucralfate interacts with a wide variety of drugs, however, including warfarin, phenytoin, and tetracycline.
Anti-Spasm Drugs to Prevent Acid and Non-Acid Reflux
Most drugs used for GERD have no effect on non-acid reflux, such as back-up of bile. Baclofen, known as a gamma-amino butyric acid agonist, is commonly used to reduce muscle spasms. Investigators are now showing that it can reduce both acid and non-acid reflux episodes (as much as 70% in one study) and increase LES pressure, an important factor for preventing back-up.
Surgery
The standard surgical treatment for GERD is fundoplication. The goal of this procedure is twofold:
- To increase LES pressure and, therefore, prevent acid back-up (reflux)
- To repair any present hiatal hernia
There are two primary approaches:
- Open Nissen fundoplication (the more invasive technique)
- Laparoscopic fundoplication
In general, the overall long-term benefits of these procedures are similar. Some studies report that more than 90% of patients are free of heartburn after the operation and satisfied with their choice, even after 5 years. Fundoplication relieves GERD-induced coughs and some other respiratory symptoms in up to 85% of patients. (Its effect on asthma associated with GERD, however, is unclear.) It may enhance stomach emptying and improve peristalsis in about half of patients. (It may actually cause abnormal peristalsis in some patients, although in such cases the problem does not appear to be very significant.)
Still, it has other significant limitations and postoperative problems. For example, many patients still requir anti-GERD medications or experience new symptoms (such as gas, bloating, and trouble swallowing). Most of these new symptoms occur more than a year after surgery. Fundoplication does not cure GERD, and evidence suggests that the procedure does not reduce the risk for esophageal cancer in high-risk patients, such as those with Barrett's esophagus.
Candidates. Fundoplication is recommended for patients whose condition includes one or more of the following:
- Esophagitis (inflamed esophagus)
- Symptoms that persist or are recurrent in spite of anti-reflux drug treatment
- Strictures
- Failure to gain or maintain weight (in children)
Fundoplication has little benefit for patients with impaired stomach motility (an inability of the muscles to move spontaneously).
The Open Nissen Fundoplication Procedure. Until recently, most fundoplication procedures for GERD have been the 360° Nissen fundoplication. This is called an open procedure because it requires wide surgical incisions.
- With this procedure, the physician wraps the upper part of the stomach (fundus) completely around the esophagus to form a collar-like structure.
- The collar places pressure on the LES and prevents stomach fluids from backing up into the esophagus.
- Open fundoplication requires a hospital stay of 6 - 10 days.
Click the icon to see an illustrated series detailing gastroesophageal reflux surgery.
Laparoscopic Fundoplication. The standard invasive fundoplication procedure has been replaced in many cases by a less invasive fundoplication procedure that uses laparoscopy. In the operation:
- Tiny incisions are made in the abdomen.
- Small instruments and a tiny camera are inserted into tubes, through which the surgeon can view the region.
- The surgeon creates a collar using the fundus, although the area is smaller to work with.
When performed by experienced surgeons, the procedure shows results that are equal to those of standard open fundoplication, but with faster recovery time.
Overall, laparoscopic fundoplication appears to be safe and effective in people of all ages, even babies. Laparoscopy is more difficult to perform in certain patients, including those who are obese, who have a short esophagus, or who have a history of previous surgery in the upper abdominal area. It may also be less successful in relieving atypical symptoms of GERD, including cough, abnormal chest pain, and choking. In about 8% of laparoscopies, it is necessary to convert to open surgery during the procedure because of unforeseen complications.
Other Variations. There are now a number of variants of fundoplication procedures. Examples include:
- Toupet fundoplication employs only a partial wrap, as does Thal fundoplication. Partial fundoplication procedures may be more effective in patients with poor or no esophageal muscle motility. Those with normal motility may do better with the full-circle wrap.
- Others use a very short and "floppy" Nissen full wrap.
Many surgeons report that such limited fundoplications result in earlier feeding and discharge from the hospital and a lower incidence of complications (trouble swallowing, gas bloating, and gagging) than the full Nissan fundoplication. A British study, however, reported no significant differences in swallowing problems.
Postoperative Problems and Complications after Fundoplication. Problems after surgery can include a delay in intestinal functioning, causing bloating, gagging, and vomiting. These side effects usually go away in a few weeks. A 2003 study suggested, however, that 38% of patients develop these symptoms, and most occur more than a year after their procedures. If symptoms last or start weeks or months after surgery, particularly if vomiting is present, surgical complications are likely. Complications include:
- An excessively wrapped fundus. This is fairly common and can cause difficulty swallowing (dysphagia), as well as gagging, gas, bloating, or an inability to burp. (A follow-up procedure that dilates the esophagus using an inflated balloon may help correct dysphagia, although it cannot treat other symptoms.)
- Bowel obstruction
- Wound infection
- Injury to nearby organs
- Respiratory complications, such as a collapsed lung. These are uncommon, particularly with laparoscopic fundoplication.
- Muscle spasms after swallowing food. This can cause intense pain, and patients may require a liquid diet, sometimes for weeks. This is a rare complication in most patients, but it can be very high in children with neurologic abnormalities. Such children are already at very high risk for GERD.
Reasons for Treatment Failure. Long-term failure rates after fundoplication are 30% after 5 years and 63% after 10 years. Hiatal herniation is the most common reason for surgical failure and the need for a repeat fundoplication. Other common reasons for reoperation include breakdown, slippage, and excessive tightness of the wrap. Surgeon experience can lessen complication risks. Some studies have reported that repeat operations after open procedures occur in 9 - 30% of cases and 13% after laparoscopy. (Repeat surgery usually has good results.)
Surgical Treatments Using Endoscopy
A number of treatments that make use of endoscopy are being used or investigated for increasing LES pressure and preventing reflux, as well as for treating severe GERD and its complications. In general, most of these techniques have not been well studied in comparative trials, nor have had ample long-term follow-up to evaluate their effectiveness and possible complications.
Transoral Flexible Endoscopic Suturing. Transoral flexible endoscopic suturing (sometimes referred to as Bard's procedure) uses a tiny device at the end of the endoscope that acts like a miniature sewing machine. It places stitches in two locations near the LES, which are then tied to tighten the valve and increase pressure. There is no incision and no need for general anesthesia.
Radiofrequency. Radiofrequency energy generated from the tip of a needle (sometimes called the Stretta procedure) heats and destroys tissue in problem spots in the LES. Either the resulting scar tissue strengthens the muscle, or the heat kills the nerves that caused the malfunction. Patients may experience some chest or stomach pain afterwards. Few serious side effects have been reported, although there have been reports of perforation, hemorrhage, and even death. A recent study reported that 81% of patients remained symptom-free for up to 3 years following the Stretta procedure.
Dilation Procedures. Strictures (abnormally narrowed regions) may need to be dilated (opened) with endoscopy. Dilation may be performed by inflating a balloon in the passageway. About 30% of patients who need this procedure require a series of dilation treatments over a long duration in order to fully open the passageway. Long-term use of proton-pump inhibitors may reduce the duration of treatments.
Resources
- http://digestive.niddk.nih.gov -- National Digestive Diseases Information Clearinghouse
- www.gastro.org -- American Gastroenterological Association
- www.acg.gi.org -- American College of Gastroenterology
- www.asge.org -- American Society for Gastrointestinal Endoscopy
- www.ssat.com -- Society for Surgery of the Alimentary Tract
- www.naspgn.org -- North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition
- www.reflux.org -- Pediatric/Adolescent Gastroesophageal Reflux Association
- www.iffgd.org -- International Foundation for Functional Gastrointestinal Disorders
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Reviewed By: Reviewed by: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
