Medical, surgical treatment for gastroesophageal reflux disease (GERD)

Gastrointestinal reflux disease (GERD) is defined as the reflux of stomach contents into the esophagus, causing symptoms or complications that adversely affect an individual’s well-being. Reflux is among the most common conditions affecting adults in the United States. More than 60% of Americans have reflux symptoms at some point and nearly 10% have daily symptoms.

There are several functional and anatomic mechanisms that normally work to prevent reflux. The esophagus is a muscular tube that propels contents downward into the stomach. The lower portion of the esophagus thickens just above its junction with the stomach. This is known as the lower esophageal sphincter (LES). The function of the esophagus, the length and muscle tone of the LES, and the normal attachments of the esophagus to the diaphragm are all important in preventing reflux. If a hiatal hernia is present, the opening in the diaphragm through which the esophagus passes is enlarged, thus disrupting the normal anatomy and function of the LES and allowing the stomach to slip upward into the chest. When these mechanisms fail, the acid in the stomach travels upward into the esophagus, leading to the symptoms and complications associated with GERD.

Typical symptoms of GERD are heartburn (a burning sensation in the chest), regurgitation (the sudden return of stomach contents into the throat and mouth), water brash (sour or salty fluid in the mouth) and dysphagia (difficulty swallowing). Symptoms may be worsened by large meals, lying down after eating, smoking and certain foods such as citrus, chocolate or alcohol. Reflux can also have atypical symptoms, including asthma, chronic cough, bronchitis and hoarseness. Chronic acid exposure can lead to damage to the lining of the esophagus, or a condition called Barrett’s esophagus that results in an increased risk of esophageal cancer.

Specific testing for GERD is not always necessary initially, and medical treatment can begin based simply on your symptoms. However, if you have had reflux symptoms for more than 10 years, it is important to have an endoscopy to look for Barrett’s esophagus. In this test, a lighted instrument is passed through your mouth to inspect the lining of the stomach and esophagus. This is also a good test to identify a hiatal hernia. Additional testing may be necessary if you have any signs of complicated reflux disease or are considering surgery. An esophagram is an X-ray procedure that evaluates the function of your esophagus and can identify a hiatal hernia or other anatomic abnormalities. A pH probe can directly measure the levels of acid within the esophagus to confirm that this is truly the cause of your symptoms. Manometry testing evaluates the muscle function of your esophagus to assist in diagnosis and surgical planning.

Over-the-counter antacid medications can help to neutralize the acid in your stomach and provide some relief of heartburn symptoms when they occur. In general, these measures work well for patients with only occasional reflux symptoms. For more frequent symptoms, medications such as histamine receptor blockers (H2RBs) and proton pump inhibitors (PPIs), which actually decrease the amount of acid your stomach secretes, are far more effective. Most patients (>90%) will have excellent long-term symptomatic response with PPI therapy.

If you experience significant side effects from your medications, have worsening symptoms despite appropriate therapy, or simply do not want to continue long-term medications, anti-reflux surgery may be appropriate. Additionally, if you have a hiatal hernia or complications of reflux such as esophagitis or Barrett’s esophagus, you may benefit from surgical treatment. Anti-reflux surgery essentially recreates the reflux barrier by wrapping the upper portion of the stomach (the fundus) around the lower part of the esophagus to recreate the LES in a procedure known as a fundoplasty or fundoplication. This is done either laparoscopically or robotically through five small (about ½-inch each) incisions in your abdomen. Surgical risks are very low with this procedure, and it typically requires only a one-night hospital stay. Long-term outcomes of anti-reflux surgery are similar to medical therapy, with around 90% of patients experiencing significant improvement in their reflux symptoms. If you are considering surgery for your reflux, the tests mentioned above are typically required.

At the Prisma Health Hernia Center, our surgeons are trained specifically in laparoscopic and robotic surgery for reflux and hiatal hernia repair, and have over 25 years of combined experience. We work closely with our Gastroenterology colleagues to ensure that you receive a thorough evaluation of your reflux and the best medical and surgical treatments possible. For additional information or consultation, please call the Prisma Health Hernia Center at (864) 676-1072.

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