GENERAL SURGERY
Abdominal Surgery
Gastroesophageal Reflux Disease: GERD
Gastroesophageal reflux disease (GERD) is a common condition related to bouts of heartburn. Heartburn occurs when acid in the stomach refluxes back up into the esophagus (the tube that takes food from your mouth to your stomach) and damages the soft tissue there, causing the burning sensation we call heartburn. At the base of the esophagus is a ring of muscle called the lower esophageal sphincter (LES), that acts like a valve between the esophagus and the stomach. Normally, this valve closes to prevent stomach contents from traveling back into the esophagus, but when it malfunctions, stomach contents can leak back into the esophagus and damage the tissue there. Hiatal hernia and conditions that cause increased pressure within the abdomen, such as pregnancy and obesity, may lead to GERD.
A hiatal hernia occurs when the top portion of the stomach bulges into the chest cavity through the hiatus, which is the opening where the esophagus goes through the diaphragm. The diaphragm is the muscle that separates the chest from the abdomen, and normally it helps the LES keep acid from refluxing up into the esophagus, but sometimes it needs strengthening or repair. A hiatal hernia does not always cause GERD.
Other causes of GERD include:
- Certain medications, including aspirin and sedatives.
- Smoking, caffeine, and alcohol intake, which increase stomach acid production.
- Pregnancy or excess weight that increases the pressure in the abdomen.
- Foods that increase stomach acid, including citrus fruits, chocolate, fatty and fried foods, garlic, onions, peppermint, spicy foods, and tomato-based foods.
Complications of GERD
The esophagus is lined with sensitive tissue that can be damaged by stomach acid. Over time, damage can lead to the following problems:
- Inflammation, leading to pain, pressure, and burning in the chest and throat.
- An ulcer in the lining of the esophagus can produce pain and bleeding, making it difficult to swallow.
- Scarring in the esophagus narrows the opening, making it harder to swallow food, and eventually difficult to swallow even liquids. This narrowing is called a stricture.
- Increased risk of esophageal cancer. The growth of a tumor in the esophagus can also cause a stricture.
Evaluating GERD
Heartburn occurring over a long period of time may be a symptom of more than one medical problem. To confirm the diagnosis of GERD your doctor will ask you a lot of questions related to your symptoms, perform a physical exam, and request diagnostic tests. These tests are explained below.
- An Upper GI or Barium Swallow Study is a series of x-rays that show your digestive tract in action. Barium is a harmless dye that can be seen on x-ray and will show if reflux or a hiatal hernia is present. This study is done while you are awake and it is important that you not eat or drink anything for 6 to 8 hours before this brief, painless test.
- Esophageal Endoscopy allows the doctor to directly visualize the inner lining of your throat, esophagus, and stomach through a small camera the doctor inserts through your mouth. Before the test, you will be sedated so that you do not remember the procedure. Patients with GERD will usually have areas of irritation or ulceration of the esophagus and stomach that can be seen by the camera. It is important that you do not eat or drink anything for 6 to 8 hours before the test.
- A pH monitoring test can measure the acid present in the esophagus. A thin measuring probe is placed in the esophagus for 24 hours to record how much acid refluxes from the stomach back into the esophagus.
Treatment Options
Lifestyle Changes
In some individuals, GERD symptoms can be controlled with lifestyle changes including the following:
- Avoid foods that increase stomach acid or relax the LES.
- Eat six smaller meals per day.
- Maintain a healthy weight.
- Take short walks after eating to help digestion.
- Avoid bending or lying for 2 to 4 hours after eating.
- Do not drink alcohol or smoke.
- Raise the head of your bed 6 to 8 inches.
- Avoid wearing tight-waisted clothing.
Medications to Reduce Stomach Acid
Antacids: Over-the-counter antacids such as Alka-Seltzer, Maalox, Mylanta, Pepto-Bismol, Rolaids, and Tums contain various combinations of magnesium, calcium, and aluminum that neutralize stomach acids. Possible side effects include diarrhea and constipation.
H-2 blockers: A stronger class of medications, called H-2 blockers, are also available over the counter. These include Pepcid, Tagament, Zantac, and Axid.
PPIs: For severe GERD symptoms, your doctor may prescribe a proton pump inhibitor or PPI. These medications include Prilosec, Prevacid, Nexium, Protonix, and Aciphex. They work by stopping the production of acid in the stomach, so they are only recommended for short-term use. Side effects include nausea, diarrhea, headache, and pain.
Surgical Treatment
Dilation: If there is a narrowing of the esophagus, a dilation can be performed to stretch and widen the esophagus. After being sedated, a flexible tube with a small camera on the end, call an “endoscope” is put down the mouth and into the esophagus. Lubricated instruments are then used to stretch the esophagus. This may need to be repeated over several days until the esophagus is wide enough to allow food to pass.
Esophageal Nissen: During this surgery, the top part of the stomach is wrapped around the lower part of the esophagus to strengthen the lower esophageal sphincter. If a hiatal hernia is contributing to the GERD symptoms it will also be repaired during the surgery.
Laparoscopic Esophageal Fundoplicaiton: This procedure is the same as the Esophageal Nissen, but it is done with a laparoscope, so the abdominal cavity does not need to be opened. The surgeon makes several small incisions in the belly and uses a harmless gas to inflate the abdominal cavity. A camera is inserted to allow the surgeon to see inside and perform the operation, during which special small laparoscopic instruments are used to wrap the stomach around the esophagus. The gas is removed at the end of the procedure. This approach is typically less painful and recovery time is shorter. A discussion with your doctor can determine whether you are a candidate for a laparoscopic procedure.