Gastroesophageal reflux disease is the abnormal backflow, or reflux of stomach acid and juices into the esophagus, the tube that leads from the throat to the stomach. This backflow occurs when the valve between the lower end of the esophagus and the stomach (the lower esophageal sphincter, or LES) does not close tightly enough.
The main symptom of GERD is frequently called heartburn. Heartburn is a feeling of burning, warmth, heat, or pain that often starts in the upper abdomen just beneath the lower breastbone (sternum) and ribs. This discomfort may spread in waves upward into the throat. A sour taste in the mouth may occur with this burning sensation. Heartburn may be called indigestion, acid regurgitation, or sour stomach.
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Heartburn may cause burping, nausea, or bloating. It often is worse after eating. Difficulty swallowing may also be related to heartburn. The discomfort and pain of heartburn can last up to 2 hours and sometimes longer. It usually is made worse by lying down or bending over and often is made better by sitting or standing up. In some people, heartburn symptoms may cause sleep problems, a chronic cough, asthma, wheezing, or choking episodes.
Treatment for people who have symptoms of GERD begins with making lifestyle changes and if necessary, taking nonprescription antacids of acid reducers. Lifestyle changes include the following. If you smoke or chew tobacco stop. The nicotine from tobacco relaxes the valve between the esophagus and stomach (LES). This can allow the stomach acid and juices to back up into the esophagus, which causes the heartburn. Change your eating habits. Some foods may relax the valve between the esophagus and stomach, so it does not close as tightly. This again causes reflux. These foods include chocolate, onions, peppermint, coffee, high-sugar foods, and possibly high-fat foods. Other foods do not relax the valve but may cause heartburn if the esophagus is already irritated. These include spicy foods, citrus products, and tomato products. Lose weight if you are overweight. Being overweight puts additional pressure on your stomach and increases the likelihood of heartburn occurring. Raise the head of your bed 6 –8 in. by putting blocks underneath your bed frame or by placing a foam wedge under the head of your mattress. This will help keep stomach acid from flowing into your esophagus when you are sleeping. Using extra pillows does not work. Severe GERD symptoms usually require stronger prescription medications as well as lifestyle changes for successful treatment.
Nissen fundoplication is the most common surgery used today to treat GERD. In the past the surgery was done by an open operation but we now can usually perform the surgery by a laparoscopic technique. Surgery may be an option for treatment of GERD under the following conditions. First the medical treatment does not completely relieve a person’s symptoms, and the remaining symptoms are caused by reflux of stomach juices. Also, a person does not want to or because of side effects is unable to take medications over and extended period to control his or her GERD symptoms and is willing to accept the risks of surgery. A third reason would be a person has symptoms such as asthma, hoarseness, or cough along with reflux that does not improve when treated with medications.
All patients who are candidates for a laparoscopic fundoplication surgery need to undergo preoperative evaluation that may include an upper GI series, endoscopy, esophageal manometry, and ambulatory pH monitoring. Endoscopy is absolutely necessary to evaluate the degree of reflux present and to rule out the possibility of cancer as the cause for symptoms. Esophageal manometry provides useful information about the motor function of the esophagus by determining the length and resting pressure of the lower esophageal sphincter (LES) and assessing the quality of the esophageal peristalsis. Ambulatory pH monitoring is the most reliable test for the diagnosis of GERD. This test is used if there is any question about the diagnosis.
The surgery for GERD is usually a laparoscopic Nissen fundoplication. The patient comes to the hospital on the day of surgery and the operation is performed under general anesthetic. To perform the operation five small 10mm trocar are made on the abdomen and through these ports instruments are inserted to perform the operation. The esophagus and upper portion of the stomach are cleared of their attachments and then the top part of the stomach is wrapped around the esophagus to form a new muscle (LES) between the stomach and esophagus and thus prevent the reflux of stomach juices. Usually after the operation the patient is admitted to the hospital for 1-2 days. When the patient goes home he or she will be drinking liquids and over the next 1-2 week will increase the diet to solid foods. In the future there are no food restrictions.
The complications at the time of surgery could be injury of the stomach, esophagus, spleen , or vagus nerve. Following the surgery the patient may feel a sticking feeling in the esophagus with eating but this should resolve as the swelling from surgery resolves. Bloating sensation can occur the first few months but this should also resolve with time. Occasionally diarrhea can occur. The only restriction following surgery is no lifting greater then 20 lbs. for 6 weeks. Most people are off work for 2—4 weeks but not fully recovered from surgery for 6-8weeks from the time of surgery.
The success rate for relieving the symptoms of GERD is good but not perfect. About 80% of people will have their symptoms relieved. Another 10-15% of patients will have their symptoms improved but may still have to take some medication for complete relief of their symptoms. The remaining 5% of patients may not be improved with surgery. The other unknown is that over time the repair may weaken and the symptoms could return.
