Esophageal Reflux

What is Esophageal Reflux?

Esophageal reflux is usually a multifactorial condition. Physiologic, anatomic and environmental factors account for most cases of GERD.

Normally the esophagus (food pipe) attaches to the stomach and there is a valve (Lower Esophageal Sphincter) between them that prevents the acid from the stomach to reflux back up into the esophagus. If dysfunction of the valve develops esophageal reflux can happen. Below we will outline some of the most common causes of esophageal reflux.

• Medications
• Obesity
• Diet: Spicy foods, chocolate, coffee, pizza
• Hiatal or paraesophageal hernias
• Smoking
• Alcohol
• Pregnancy

Obesity, poor diet and eating late at night are some of the most common culprits of reflux. Pregnancy is also a common factor but most of the time it tends to be temporary and complete resolution happens after delivery. Medications that relax smooth muscles can have acid reflux as a side effect. For example, certain blood pressure medications and erectile dysfunction medications are notorious to cause esophageal reflux. Smoking and alcohol are also known to relax the esophageal sphincter causing reflux.

Anatomic conditions like hiatal hernias or larger paraesophageal hernias are a well-known risk factor for GERD.  This is a short list but it covers many common causes of reflux.

The most common symptom associated with esophageal reflux is heartburn. This is a burning sensation behind the breastbone that can extend all the way up to the throat sometimes leaving a bitter taste in the mouth. Patients can also experience teeth discoloration, hoarseness, chronic cough, asthma, regurgitation, spasms, and pain.

Many patients will present to the emergency room with substernal chest pain thinking that they are having a heart attack. After an extensive negative workup many times they will be diagnosed with GERD.

Some patients won’t experience the heartburn but they will complain of chronic cough at night or frequent asthma. Another presentation can be anemia from chronic inflammation, esophageal ulcers, and slow bleeding.

Most patients will require multiple studies in order to diagnosed acid reflux and what is causing it. After a thorough history and physical examination, most physicians will obtain an upper endoscopy and/or an upper GI series.

The Upper Endoscopy (EGD) is usually performed by a gastroenterologist or a surgeon. This study is an excellent tool to evaluate the esophagus for acute and chronic complications from reflux. Esophageal inflammation, Barrett’s esophagus, esophageal ulcers, and/or esophageal strictures are some of the common things identified.

An Upper GI Series is a series of X-rays that are taken while the patient is drinking barium or another type of contrast. The test can diagnose reflux by actively seen contrast refluxing back into the esophagus. Anatomic causes of reflux can also be seen, examples are hiatal hernias, paraesopheal hernias or diverticulums.

The gold standard test for diagnosing acid reflux is a pH Study. This study will diagnose reflux but it won’t diagnose the cause of reflux. That is the reason why other studies are necessary. If reflux is diagnosed with above mentioned upper GI series or EGD then a pH study is not routinely necessary. Dr. Caban will discuss this study in detail in another section.

Esophageal Manometry is another specialized test that is only selectively used by Dr. Caban. The manometry is an unpleasant study that evaluates the function of the esophagus and measures the pressure of the lower esophageal sphincter. This information can be useful in finding causes for the reflux and also in determining the type of treatment that will benefit the patient.

A Gastric Emptying Study can also be useful in the workup of patients with esophageal reflux.  The test measures the function of the stomach. If a patient is found to have a weak stomach the surgical treatment of choice for esophageal reflux might need to be reconsidered. More details below.

The first line of treatment for esophageal reflux is lifestyle modifications. First, you need to recognize if possible what is precipitating your symptoms. For example, if you get symptoms every time you eat pizza late at night then you need to prevent eating pizza late at night. Changing your eating habits can be the only treatment necessary in mild cases. Eliminating chocolate, coffee, alcohol, smoking, spicy foods and/or acidic foods are usually recommended by most physicians.

Eating several hours before going to bed can be beneficial. Changing the inclination of the bed is another common lifestyle modification. Eliminating or changing certain medications might be needed.

For patients that are overweight, losing weight is a must do. Increase intra-abdominal pressure due to obesity is one of the most common causes of reflux in North America.

After trying lifestyle modifications the next step in the treatment of acid reflux is over the counter medications. Most patient will start with the milder medications first that include Tums, Pepto-Bismol or Mylanta. The next step up is Pepcid or Zantac, followed by a proton pump inhibitor (PPI). Several examples of PPI are Nexium (the purple pill), Omeprazole, and Protonix.

The introduction of PPI many years ago changed the way acid reflux and stomach ulcer diseases were treated. They are highly effective medications but in recent years many concerns have been reported.  Studies have shown significant side effects from long term use of PPI. They were associated with chronic kidney disease and dementia.

If all the above treatments fail or if discontinuation of chronic PPI use is desire then the next line of treatment is surgery.

• Patients with Esophageal and/or extraesophageal reflux symptoms that have an incomplete response to medications
• Patients with Non-Acid or biliary reflux
• Patients with long term complications from esophageal reflux
• Patients that have documented reflux and desire to stop chronic use of reflux medications
• Patients with lung transplants or in the lung transplant list that have documented reflux

What Is A Nissen Fundoplication?

In long term studies, the resolution of symptoms after a Nissen Fundoplication approached 90 percent at five years after surgery. Patient satisfaction was also between 90-95 percent in similar studies.

Several variations of a Nissen Fundoplication have also been described in the surgical literature. The most common variations are a 270-degree partial posterior wrap also known as a Toupet Fundoplication. The second variation is a 180-degree partial anterior wrap also known as a Dor Fundoplication.

Partial fundoplications are only used in special circumstances. The most common indication is in patients with difficulty swallowing due to esophageal dysmotility. This is done to prevent difficulty swallowing after surgery. The biggest disadvantage is a lower percentage of symptoms resolution but good results can be obtained. Good patient satisfaction has also been described in long term studies.

What Is A Linx Procedure?

Once the food bolus passes into the stomach the device closes and maintains a resting pressure that prevents acid reflux. The recently published 5 years follow up long term study comparing the Linx Device to a Nissen Fundoplication showed very similar results. Patient satisfaction, resolution of esophageal reflux symptoms and discontinuation of medications were comparable to each other. 

Esophageal reflux surgery in the hands of Dr. Caban is done laparoscopic or minimally invasive 99 percent of the time. This approach provides the patient with less pain, faster recovery and faster return to regular activities. 

After surgery, you will be in the recovery room for 2-3 hours. After a Linx procedure, you will be discharged home the same day of surgery with several days supply of pain medication. You will stop the antireflux medications immediately after surgery. Patients are encouraged to eat normal food right away to prevent stiffness of the device. Some discomfort is expected after swallowing, this will resolve spontaneously with time. 

After a Nissen Fundoplication, most patients will be admitted to the hospital for 24-48 hours. They will be started on a clear liquid diet on day one and a full liquid diet on day two. Patients are required to stay on a full liquid diet for 2 weeks. The diet is advanced to a soft diet for two more weeks after that.

You will follow up with Dr. Caban in 2-3 weeks and at 3 months after surgery.

Most patients that have office type job can expect to return to work after 1-2 weeks. For those of you that have a heavy labor job were heavy lifting more than 15-20 pounds is necessary, you should account for 4-6 weeks out of work.