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REFLUX - GERD

Gastrointestinal surgery

Gastrointestinal colonoscopy surgery is a treatment for diseases of the parts of the body involved in indigestion. This includes the esophagus, stomach, small intestine, large intestine, and rectum. It also includes the liver, gallbladder, and pancreas.

 

Below are gastrointestinal conditions that may be treated with surgery:

 

Gastroesophageal reflux disease (GERD) and Hiatus Hernia

What is gastroesophageal reflux?

Gastroesophageal refers to the stomach and esophagus. Reflux means to flow back or return. Therefore, gastroesophageal reflux is the return of the stomach’s contents back up into the esophagus.

In normal digestion, the lower esophageal sphincter (LES) opens to allow food to pass into the stomach and closes to prevent food and acidic stomach juices from flowing back into the esophagus. Gastroesophageal reflux occurs when the LES is weak or relaxes inappropriately, allowing the stomach’s contents to flow up into the esophagus.

 

The severity of GERD depends on LES dysfunction as well as the type and amount of fluid brought up from the stomach and the neutralising effect of saliva.

Hiatal hernia may weaken the LES and increase the risk for gastroesophageal reflux. Hiatal hernia occurs when the upper part of the stomach moves up into the chest through a small opening in the diaphragm (diaphragmatic hiatus). The diaphragm is the muscle separating the abdomen from the chest. Recent studies show that the opening in the diaphragm helps support the lower end of the esophagus. Many people with a hiatal hernia will not have problems with heartburn or reflux. But having a hiatal hernia may allow stomach contents to reflux more easily into the esophagus.

 

Coughing, vomiting, straining, or sudden physical exertion can cause increased pressure in the abdomen resulting in hiatal hernia. Obesity and pregnancy also contribute to this condition. Many otherwise healthy people age 50 and over have a small hiatal hernia. Although considered a condition of middle age, hiatal hernias affect people of all ages.

 

Hiatal hernias usually do not require treatment. However, treatment may be necessary if the hernia is in danger of becoming strangulated (twisted in a way that cuts off blood supply) or is complicated by severe GERD or esophagitis (inflammation of the esophagus). The doctor may perform surgery to reduce the size of the hernia or to prevent strangulation.

The Role Of Hiatal Hernia In Gerd
What is the role of hiatal hernia in GERD?
What other factors contribute to GERD?

Dietary and lifestyle choices may contribute to GERD. Certain foods and beverages, including chocolate, peppermint, fried or fatty foods, coffee or alcoholic beverages, may trigger reflux and heartburn. Studies show that cigarette smoking relaxes the LES. Obesity and pregnancy can also play a role in GERD symptoms.

What are the symptoms of heartburn?

Heartburn, also called acid indigestion, is the most common symptom of GERD and usually feels like a burning chest pain beginning behind the breastbone and moving upward to the neck and throat. Many people say it feels like food is coming back into the mouth leaving an acid or bitter taste.

 

The burning, pressure, or pain of heartburn can last as long as 2 hours and is often worse after eating. Lying down or bending over can also result in heartburn. Many people obtain relief by standing upright or by taking an antacid that clears acid out of the esophagus.

 

Heartburn pain is sometimes mistaken for the pain associated with heart disease or a heart attack, but there are differences. Exercise may aggravate pain resulting from heart disease, and rest may relieve the pain. Heartburn pain is less likely to be associated with physical activity. But you can’t tell the difference, so seek immediate medical help if you have any chest pain.

How common is heartburn and GERD?

More than 60 million American adults experience heartburn at least once a month, and more than 15 million adults suffer daily from heartburn. Many pregnant women experience daily heartburn. Recent studies show that GERD in infants and children is more common than previously recognised and may produce recurrent vomiting, coughing and other respiratory problems.

What is the treatment for GERD?

We recommend lifestyle and dietary changes for most people needing treatment for GERD. Treatment aims at decreasing the amount of reflux or reducing damage to the lining of the esophagus from refluxed materials.

 

Avoiding foods and beverages that can relax the LES is often recommended. These foods include chocolate, peppermint, fatty foods, caffeine and alcoholic beverages. Foods and beverages that can irritate a damaged esophageal lining such as citrus fruits and juices, tomato products and pepper should also be avoided if they cause symptoms.

 

Decreasing the size of portions at mealtime may also help control symptoms. Eating meals at least 2 to 3 hours before bedtime may lessen reflux by allowing the acid in the stomach to decrease and the stomach to empty partially. In addition, being overweight often worsens symptoms. Many overweight people find relief when they lose weight.

 

Cigarette smoking weakens the LES. Stopping smoking is important to reduce GERD symptoms.

Elevating the head of the bed on 6-inch blocks or sleeping on a specially designed wedge reduces heartburn by allowing gravity to minimise reflux of stomach contents into the esophagus. Do not use pillows to prop yourself up; that only increases pressure on the stomach.

 

Along with lifestyle and diet changes, we may recommend certain medications.

 

Antacids can help neutralise acid in the esophagus and stomach and stop heartburn. Many people find that antacids provide temporary or partial relief. An antacid combined with a foaming agent helps some people. These compounds are believed to form a foam barrier on top of the stomach that prevents acid reflux from occurring.

 

Long-term use of antacids, however, can result in side effects, including diarrhea, altered calcium metabolism (a change in the way the body breaks down and uses calcium) and buildup of magnesium in the body. Too much magnesium can be serious for patients with kidney disease.

For chronic reflux and heartburn, the doctor may recommend medications to reduce acid in the stomach. These medicines include H2 blockers, which inhibit acid secretion in the stomach. H2 blockers include: famotidine, nizatidine and ranitidine.

 

Another type of drug, the proton pump inhibitor (or acid pump), inhibits an enzyme (a protein in the acid-producing cells of the stomach) necessary for acid secretion. Some proton pump inhibitors include dexlansoprazole, esomeprazole, lansoprazole, omeprazole, pantoprazole and rabeprazole.

What if heartburn or GERD symptoms persist?


People with severe, chronic esophageal reflux or with symptoms not relieved by the treatments described above may need more complete diagnostic evaluation. Doctors use a variety of tests and procedures to examine a patient with chronic heartburn. Endoscopy is an important procedure for individuals with chronic GERD. By placing a small lighted tube with a tiny video camera on the end (endoscope) into the esophagus, the doctor may see inflammation or irritation of the tissue lining the esophagus (esophagitis). If the findings of the endoscopy are abnormal or questionable, biopsy (removing a small sample of tissue) from the lining of the esophagus may be helpful. An upper GI series may be performed during the early phase of testing. This test is a special X-ray that shows the esophagus, stomach, and duodenum (the upper part of the small intestine). While an upper GI series provides limited information about possible reflux, it is used to help rule out other diagnoses, such as peptic ulcers. Esophageal manometric and impedance studies or pressure measurements of the esophagus may occasionally help identify low pressure in the LES or abnormalities in esophageal muscle contraction. For patients in whom diagnosis is difficult, doctors may measure the acid levels inside the esophagus through pH testing. Testing pH monitors the acidity level of the esophagus and symptoms during meals, activity and sleep. Newer techniques of long-term pH monitoring such as Bravo Capsule are improving diagnostic capability in this area.




Does GERD require surgery?


A small number of people with GERD may need surgery because of severe reflux and poor response to medical treatment. However, surgery should not be considered until all other measures have been tried. The standard surgical treatment of GERD is a laparoscopic repair of the Hiatus Hernia and fundoplication. This means that the loose Hiatal muscle is approximated with sutures and the stomach is fixed within the abdominal cavity to prevent it from migrating into the chest. Occasionally, if the Hiatus hernia is large, a mesh may be placed to reinforce the defect. The doctor can perform it through a laparoscope (small holes through the belly). The Stretta procedure is minimally invasive. The doctors goes down the esophagus with a small tube and uses radiofrequency to tighten the barrier between the esophagus and stomach. LINX surgery is a newer procedure where the doctor wraps a band of titanium beads around the lower part of the esophagus to prevent stomach acids from splashing back up into the esophagus. This procedure is done using a laparoscope.




What are the complications of long-term GERD?


Sometimes GERD results in serious complications. Esophagitis can occur as a result of too much stomach acid in the esophagus. Esophagitis may cause esophageal bleeding or ulcers. In addition, a narrowing or stricture of the esophagus may occur from chronic scarring. Some people develop a condition known as Barrett’s esophagus. This condition can increase the risk of esophageal cancer. Barrett’s esophagus is a potentially serious complication of GERD, which stands for gastroesophageal reflux disease. In Barrett’s esophagus, normal tissue lining the esophagus — the tube that carries food from the mouth to the stomach — changes to tissue that resembles the lining of the intestine. About 10% of people with chronic symptoms of GERD develop Barrett’s esophagus. Barrett’s esophagus does not have any specific symptoms, although patients with Barrett’s esophagus may have symptoms related to GERD. It does, though, increase the risk of developing esophageal adenocarcinoma, which is a serious, potentially fatal cancer of the esophagus. Although the risk of this cancer is higher in people with Barrett’s esophagus, the disease is still rare. Less than 1% of people with Barrett’s esophagus develop this particular cancer. Nevertheless, if you’ve been diagnosed with Barrett’s esophagus, it’s important to have routine examinations of your esophagus. With routine examination, your doctor can discover precancerous and cancer cells early, before they spread and when the disease is easier to treat.




What is GERD and how does it relate to Barrett's Esophagus?


People with GERD may experience symptoms such as heartburn, a sour, burning sensation in the back of the throat, chronic cough, laryngitis and nausea. When you swallow food or liquid, it automatically passes through the esophagus, which is a hollow, muscular tube that runs from your throat to your stomach. The lower esophageal sphincter, a ring of muscle at the end of the esophagus where it joins the stomach, keeps stomach contents from rising up into the esophagus. The stomach produces acid in order to digest food, but it is also protected from the acid it produces. With GERD, stomach contents flow backward into the esophagus. This is known as reflux. Most people with acid reflux don’t develop Barrett’s esophagus. But in patients with frequent acid reflux, the normal cells in the esophagus may eventually be replaced by cells that are similar to cells in the intestine to become Barrett’s esophagus.




Does GERD always cause Barrett's Esophagus?


No. Not everyone with GERD develops Barrett’s esophagus and not everyone with Barrett’s esophagus has GERD. But long-term GERD is the primary risk factor. Anyone can develop Barrett’s esophagus, but white males who have had long-term GERD are more likely than others to develop it. Other risk factors include the onset of GERD at a younger age and a history of current or past smoking.




How Is Barrett's Esophagus diagnosed?


Because there are often no specific symptoms associated with Barrett’s esophagus, it can only be diagnosed with an upper endoscopy and biopsy. Guidelines from the American Gastroenterological Association recommend screening in people who have multiple risk factors for Barrett’s esophagus. Risk factors include age over 50, male sex, white race, hiatal hernia, long standing GERD and overweight, especially if weight is carried around the middle. To perform an endoscopy, a doctor called a gastroenterologist inserts a long flexible tube with a camera attached down the throat into the esophagus after giving the patient a sedative. The process may feel a little uncomfortable, but it isn’t painful. Most people have little or no problem with it. Once the tube is inserted, the doctor can visually inspect the lining of the esophagus. Barrett’s esophagus, if it’s there, is visible on camera, but the diagnosis requires a biopsy. The doctor will remove a small sample of tissue to be examined under a microscope in the laboratory to confirm a diagnosis. The sample will also be examined for the presence of precancerous cells or cancer. If the biopsy confirms the presence of Barrett’s esophagus, your doctor will probably recommend a follow-up endoscopy and biopsy to examine more tissue for early signs of developing cancer. If you have Barrett’s esophagus but no cancer or precancerous cells are found, the doctor will still most likely recommend that you have periodic endoscopies. This is a precaution, because cancer can develop in Barrett tissue years after diagnosing Barrett’s esophagus. If precancerous cells are present in the biopsy, your doctor will discuss treatment and surveillance options with you.




Can Barrett's Esophagus be treated?


One of the primary goals of treatment is to prevent or slow the development of Barrett’s esophagus by treating and controlling acid reflux. This is done with lifestyle changes and medication. Lifestyle changes include taking steps such as:

  • Make changes in your diet. Fatty foods, chocolate, caffeine, spicy foods, and peppermint can aggravate reflux.
  • Avoid alcohol, caffeinated drinks and tobacco.
  • Lose weight. Being overweight increases your risk for reflux.
  • Sleep with the head of the bed elevated. Sleeping with your head raised may help prevent the acid in your stomach from flowing up into the esophagus.
  • Don’t lie down for 3 hours after eating.
  • Take all medicines with plenty of water.
The doctor may also prescribe medications to help. Those medications may include:
  • Proton pump inhibitors that reduce the production of stomach acid
  • Antacids to neutralise stomach acid
  • H2 blockers that lessen the release of stomach acid
Promotility agents — drugs that speed up the movement of food from the stomach to the intestines




Are there treatments that specifically target Barrett's Esophagus?


There are several treatments, including surgery, that are designed specifically to focus on the abnormal tissue. They include:

  • Radiofrequency ablation (RFA) uses radio waves delivered through an endoscope inserted into the esophagus to destroy abnormal cells while protecting the healthy cells underneath.
  • Photodynamic therapy (PDT) uses a laser through an endoscope to kill abnormal cells in the lining without damaging normal tissue. Before the procedure, the patient takes a drug known as Photofrin, which causes cells to become light-sensitive.
  • Endoscopic spray cryotherapy is a newer technique that applies cold nitrogen or carbon dioxide gas, through the endoscope to freeze the abnormal cells.
  • Endoscopic mucosal resection (EMR) lifts the abnormal lining and cuts it off the wall of the esophagus before it’s removed through the endoscope. The goal is to remove any precancerous or cancer cells contained in the lining. If cancer cells are present, an ultrasound is done first to be sure the cancer hasn’t moved deeper into the esophagus walls.
  • Surgery to remove most of the esophagus is an option in cases where severe precancer (dysplasia) or cancer has been diagnosed. The earlier the surgery is done following the diagnosis, the better the chance for the cure.
It’s important to keep several facts in mind:
  • GERD is common among American adults.
  • Only a small percentage of people with GERD (less than one out of every 10) develop Barrett’s esophagus.
  • Less than 1% of those with Barrett’s esophagus each year go on to develop esophageal cancer.
A diagnosis of Barrett’s esophagus is not a cause for major alarm. Barrett’s esophagus, however, can lead to precancerous changes in a small number of people and has an increased risk for cancer. So, a diagnosis is a reason to work with your doctor to be watchful of your health