Gastro-esophageal reflux disease is a backflow of acid from the stomach into the food pipe(esophagus).Although” heart burn” is often used to describe a variety of digestive problems, it is most often secondary to gastroesophageal reflux disease.
When you eat, food travels from your mouth to your stomach through a tube called esophagus. At the lower end of the esophagus is a small ring of muscle called the lower esophageal sphincter(LES).The LES acts like a one way valve, allowing food to pass into the stomach. Normally the LES closes immediately after swallowing to prevent back-up of stomach juices, which have high acid content, into the esophagus. GERD occurs when LES does not function properly allowing acid to flow back and burn the lower esophagus. This irritates and inflames the esophagus, causing heartburn and eventually may damage the esophagus.
GERD can afflict any person regardless of age, gender, socioeconomic status. People above 40 years, however, are greater risk of acquiring the disease.
Some people are born with a naturally weak LES. Others, however, fatty and spicy foods, smoking, drinking alcohol, vigorous exercises or change in the body position (bending over or lying down) may cause the LES to relax, causing reflux.
- Heart burn (uncomfortable, rising, burning sensation behind the breast bone).
- Regurgitation of gastric acid or sour contents into the mouth
- Chest pain- This can mimic heart attack.
- Difficult or painful swallowing.
- Bloating sensation in the abdomen.
When GERD is not treated, serious complications can occur such as
Esophageal stricture-Narrowing or obstruction of the esophagus.
Barrett’s esophagus- This is premalignant change in the esophagus caused due to chronic recurrent reflux. This can lead to cancer of the esophagus in future.
Symptoms suggesting that serious damage may have already occurred include
Dysphagia: Difficulty in swallowing or a feeling that food is trapped behind the breast bone.
Choking: Sensation of acid refluxed into the windpipe causing shortness of breath, coughing or hoarseness of voice.
Bleeding: Vomiting blood or passing black tarry stools Weight loss
We take a detailed history of the patient’s symptoms and over the counter medications he has taken .If the history and our findings indicate GERD we perform the following tests to confirm GERD
Upper GI Endoscopy: This helps us to know the degree of damage caused by acid reflux to the lower esophagus, laxity of the LES, associated any changes in the esophageal mucosa(Barrett’s esophagus) , presence of any stricture in the lower esophagus or associated hiatus hernia.
Esophageal manometry: This helps to rule out any associated Esophageal motility disorders.
24 hour PH monitoring: This helps to confirm the diagnosis of GERD in certain patients.
This is the herniation of Gastroesophageal junction or upper part of the stomach into the thorax
GERD is generally treated in 3 progressive steps-
1. Drug therapy.
2. Life style changes.
Proton pump inhibitors (PPI’S) neutralize the stomach acids and reduce the amount of stomach acid produced. Antacids also may be used for symptomatic relief. In patients with persistent symptoms , particularly aggravated at night , H2 Blockers such as Ranitidine may need to be added.
How frequently should I take these medicines?
Once the diagnosis of GERD is established we prescribe PPI’S to be taken twice daily and then taper it once a day , depending on severity of symptoms and endoscopic findings of severity of damage to the lower esophagus.
How long should I take these medicines?
Normally we give a course of proton pump inhibitors to be taken for 6 -12 weeks. Most patients get relieved of their symptoms with these medications and life style modifications.
2. Life style changes:
These are modifications made in food and behaviours that trigger heart burn.
This is treating GERD through self care.
Following these simple guidelines may take care of the problem
• Watch what you eat:
Triggers include fatty or fried foods, citrus fruits or juices, tomato sauces, spicy foods, chocolate, coffee, peppermint , carbonated beverages and alcohol
Big meals overfills the stomach and an overstretched stomach can increase pressure on the muscle that’s meant to keep stomach acid out of esophagus.
Try 4 or 5 small snack-like meals instead of 3 large ones
Extra pounds increase pressure on the stomach and forces the acid up into the esophagus.
Start weight loss by increasing (low acid/non citrus) fruit, vegetables and high fiber foods in your diet. Add regular exercise.
Tobacco inhibits saliva,the body major buffer against damage to the esophagus.Tobacco also stimulate acid production and relaxes the muscle between theesophagus and stomach,permitting acid reflux.
•Don’t snack at bed time:
Allow enough time for your stomach to empty before you lie down.It’s better to eat atleast 2-3 hours before bedtime
•Raise the head of your bed:
Gravity helps to keep acid in the stomach.Lying flat in bed makes it easier for the gastric acid to back up into the esophagus. Raising head end of your head six to eight inches can help to reduce the acid reflux.
•Watch your posture:
Avoid bending from waist or stooping just after meals.Eat your meals while sitting on an upright chair rather than slumped in front of the television.
This is the most promising method of permanently treating GERD.
The diagnosis of GERD and its cause must be clearly established before considering surgical approach. Unfortunately the recommended lifestyle modifications are usually ignored and although most patients with GERD can be managed adequately with proton pump inhibitors, many eventually require escalating doses over time, relapse quickly when medicines are stopped or desire to be free of medications and their significant expense. There is also a small group of patients who experience intolerable side effects of proton pump inhibitors, such as headache or diarrhoea.It is this group of patients who benefit greatly from Anti reflux Surgery.In addition to Objective evidence of GERD the following are the indications for Surgery.
- Complications of GERD not responding to medical therapy( eg: esophagitis , stricture, Barrett esophagus, recurrent aspiration or pneumonia)
GERD symptoms interfering with lifestyle despite medical therapy
- GERD associated with paraesophageal hernia
- Need for continous drug treatment in a patient desiring discontinuation of medical therapy ( eg : financial burden ,non compliance ,intolerance to medication , life style choice, young patient)
Antireflux surgery (commonly reffered to as Nissen’s Fundoplication) involves reinforcing the “valve” between the esophagus and the stomach by wrapping the upper portion of the stomach around the lowest portion of the esophagus-Much the way a bun wraps around a hot dog. About 4 cms of the intrathoracic esophagus is mobilized intraabdominally and a tension free wrap of 1.5-2 cms of the fundus of the stomach is created at the lower end of the esophagus. We routinely perform this surgery by laparoscopic approach in which 5 tiny cuts are made over the abdominal wall to accomplish this procedure.
Since this procedure is performed laparoscopically, there is less post operative pain, shorter hospital stay and faster return to work. Most of the patients get admitted the evening before or the morning of surgery and are discharged within a day or two following surgery.
As with any surgical procedure, there are risks associated with this surgery.
Surgery is safe in expert hands and in hospitals with a good infrastructure and equipment.
Some patients develop temporary difficulty swallowing immediately after the operation. This usually resolves 2-4 weeks after the surgery. Some patients report stomach bloating. Though rare in experienced hands, some patients may require a procedure to stretch the esophagus (endoscopic dilatation) or a re-operation for a failed wrap .
We will work with you to create a personalized treatment plan which will be given to you during your discharge from the hospital.
Usually you should be on a liquid diet for a week following surgery in order to give time for the swelling or edema near the wrap site to resolve.
Avoid carbonated beverages and smoking
Chew your food slowly and thoroughly
Have small portions of meals
Do not sleep 2-3 hours after meals
You will be advised to consult in the clinic 7 days following surgery. You are advised to report immediately in case of persistant fever, abdominal pain, vomiting or you are unable to eat or drink liquids.