What is Esophageal Reflux?
Acid Reflux is when the stomach content or stomach acid backs up into the esophagus causing burning, pain, inflammation or other chronic esophageal. It is also commonly known as GERD or Gastro-esophageal reflux disease.
In the United States, approximately 40% of the population will experience these symptoms at least once a month and 7-10% once a day. The incidence of esophageal reflux is increasing in the western hemisphere due to obesity, poor diet, and several other factors.
What Causes Acid 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.
- Diet: Spicy foods, chocolate, coffee, pizza
- Hiatal or paraesophageal hernias
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.
Symptoms of Gastro-Esophageal 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.
How Is Acid Reflux Diagnosed?
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.
Long Term Complications
Long Term Effects of Esophageal Reflux
Most patient will never develop serious long term complications from acid reflux. This is particularly true in patients with mild symptoms or patients that are adequately treated. However, some patient can progress to more severe cases of GERD.
Esophagitis or inflammation of the esophagus is the first stage. This usually happens due to chronic exposure of the esophageal lining to stomach acid.
Esophageal Ulcers can form in more advanced cases of chronic acid exposure and esophagitis. Esophageal ulcers can cause pain or bleeding. Many times the bleeding is slow and is only detected after a workup for chronic anemia.
Esophageal Strictures can develop due to scar tissue formation secondary to healing ulcers and chronic inflammation. Patients can present with difficulty swallowing or choking sensation after eating secondary to narrowing of the esophageal lumen.
Barretts Esophagus is a condition that happens when the natural lining of the esophagus is replaced by stomach type lining. This is the bodies natural response in an attempt to protect itself from stomach acid. This process increases the chances of developing esophageal cancer. For that reason, patients diagnosed with Barretts Esophagus are advised to have frequent surveillance endoscopies.
Esophageal cancer is the ultimate long term complication of esophageal reflux disease. Esophageal adenocarcinoma is increasing in the United States but only a small number of patients with chronic reflux will progress to cancer. We will discuss this topic in a separate section.
How Is Esophageal Reflux Treated?
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.
Indications For Esophageal Reflux 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
Esophageal Reflux Surgery
What Is A Nissen Fundoplication?
A Laparoscopic Nissen Fundoplication is the gold standard procedure for esophageal reflux. This type of surgery has been done around the world for many years and it has great results when done by a qualified surgeon. A fundoplication is when the fundus of the stomach is wrapped around the lower part of the esophagus in order to increase the pressure of the lower esophageal sphincter (LES). A 360-degree fundoplication is called a Nissen Fundoplication. By increasing the pressure in the LES area the chances of getting acid reflux is minimized.
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.
Esophageal Reflux Surgery
What Is A Linx Procedure?
The Linx sphincter augmentation procedure is the most recent antireflux procedure created. The magnetic device was approved by the FDA in 2012. Since then, several thousands of Linx devices have been implanted in the US. Only well qualified and trained surgeons are credential to place the device. Dr. Angel Caban is one of the few surgeons in north-central Florida that is able to perform the Linx procedure.
The Linx is a magnetic ring that is designed to mimic the normal function of the lower esophageal sphincter. Every titanium bead is magnetized and attached to each other by individual wires allowing it to expand freely when the patient swallows.
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.
Acid Reflux Surgery Recovery
What Happens After Reflux Surgery?
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.
What People are Saying
“Dr. Angel Caban performed my surgery almost 5 years ago on 6/2/2014. He is a kind doctor and always treated me fairly. I always felt welcome in his office. I recommended him to many over the past 5 years”.
“Me encanta no lo cambio. Exelente el doctor caban y su personal. Muy buen grupo”.
“Another successful experience”
“Dr. Caban did my colon resection and did an outstanding job all the way across the board. I highly recommend him as well”.
“Very fortunate to have him”
“I have the privilege of working with Angel M Caban in the hospital environment. I also have had him be the surgeon to one of my family members. I would like everyone to know that he is a great surgeon. We are fortunate to have him here in Ocala. He is personable, easy to talk too and has excellent bedside manners”.
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