If you have chronic heartburn, you may actually be suffering from GERD or Gastroesophageal Reflux Disease. This condition develops when stomach acids ‘back up’ or refluxes into the esophagus. The burning sensation may radiate into the chest, throat and neck, and in between the shoulder blades. Other symptoms of GERD include are vomiting, difficulty in swallowing/ dysphagia, chronic wheezing or coughing and dental caries. In certain cases, GERD can actually lead to asthma due to recurrent micro-aspirations of gastric content into lungs causing bronchospasm, and asthma can be cured if GERD is appropriately treated.
There is a small muscle ring at the place where the esophagus meets the stomach at the lower end. It is the lower esophageal sphincter (LES); it acts like a one-way valve that allows food and drink to pass into the stomach. Normally, the muscle valve closes immediately after you swallow to prevent the reflux of stomach acids into the esophagus. If the LES does not function, as it should, the ‘back up’ of the stomach acids inflames and irritates the food pipe, which patients experience as heartburn.
Some patients may develop Barrett’s esophagus with chronic acid exposure. This is a condition, in which the cells of the lining of the lower esophagus start mutating and the mucosal lining changes from the normal squamous to columnar epithelium. This is important since Barrett’s esophagus increases the chances of developing esophageal cancer over time.
Some are born with a weak sphincter (LES), but in others, the development of GERD is related to lifestyle patterns. LES dysfunction can be associated with conditions like hiatus/ paraesophageal hernia, and with certain lifestyle conditions like obesity, heavy alcohol intake, smoking and certain diets. Sudden changes in body positions over prolonged periods of time may also cause the LES to relax prematurely and cause reflux.
Many people who suffer from GERD have hiatal hernia. A hiatal hernia is caused when the top portion of the stomach rises above the diaphragm and protrudes into the chest cavity. This condition is also thought to be responsible for the acid reflux. This condition is automatically treated with GERD surgery if other causes for acid reflux are also present.
Clinical History:
A good clinical history will be able to diagnose GERD, and differentiate from other conditions mimicking GERD like gallstones or cardiac issues like angina. It is also important to rule out esophageal / stomach cancer as this can mimic GERD, or , GERD can lead to cancer with time. If any history of difficulty swallowing is noted, then contact the doctor immediately.
Endoscopy:
The doctor will recommend endoscopy to evaluate the mucosa/ inner lining of the esophagus and stomach to document any damage caused to the lining due to acid reflux. Due to the acid damage, the mucosa lining can show inflammation streaks/ esophagitis, and with time, can cause Barrett’s esophagus. In this condition, the normal columnar lining is replaced by squamous lining, and if left unchecked, can lead to development of esophageal cancer. The endoscopy will also enable to visualize if any hiatus hernia exists, and also look at the LES (lower esophageal sphincter).
An endoscope is a tiny video camera fitted to a slender, flexible tube. The endoscope is inserted into the esophagus via the throat, and the doctor carefully examines the mucosal lining of the esophagus, stomach and the duodenum. The procedure is very safe, and is usually less than 10 minutes. Mostly it is carried out with a throat spray, and the patient can return to normal activities within few hours. If any abnormalities or changes are noted on the examination, the doctor will proceed to take a sample/ biopsy from the concerned area.
24 hour pH and Manometry test:
In certain cases, this test is also recommended to evaluate the acid exposure in the lower esophagus. A small pipe is inserted via the nose into the esophagus, and the tip is positioned a few centimeters above the LES. The tube is attached to a recorder and left for 24 hours. This test documents the amount of time the acid is refluxed into the esophagus, and also provides details about the motility of the esophagus. The doctor will use this report in conjunction with endoscopy report to advice treatment.
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The doctor will evaluate the lifestyle choices of the patient, and will recommend changes to diet and eating habits to address GERD. Specific advice on smoking and alcohol drinking will also be given to minimize symptoms. If patient is overweight/ obese, losing the excess weight will also help with reducing the reflux symptoms. Pharmacotherapy in the form of stomach-acid reducing drugs ( H2 blockers, Proton pump inhibitors – PPI) and prokinetics ( metoclopramide) can be prescribed for short duration in conjunction with lifestyle advice to ease symptoms.
GERD affects quality of life, and is the main determinant for interventions. If the symptoms are bad enough that even conservative measures like pharmacotherapy are not working, and increased dependence on medications may lead to the surgeon recommending surgical intervention for curing symptoms. Long-term use of PPI has been shown to cause adverse side effects on health, and is one of the indications to proceed with surgery.
Endoscopic approaches to GERD are relatively new in the last decade. Many forms of endoscopic treatment are described : Radiofrequency Ablation ( RFA), Transoral Incisionless fundoplication ( TIF), STRETTA, AntiReflux Mucosectomy (ARMS) and Antireflux Mucosal Ablation (ARMA). The main aims of endoscopic treatment are to augment the LES sphincter via mucosal or submucosal treatment, and provide an additional barrier to reflux. Patient selection is the key while planning the intervention, and is usually not advised for patients with hiatus hernia. ARMA is the new treatment on horizon and has shown promising results in the initial trials. ARMA is further discussed under endoscopic surgery.
Surgery has remained the gold standard of treatment for GERD refractory to medical treatment. Generally, treatment for GERD begins with changes in lifestyle. If the ‘heartburn’ still persists, medications like antacids, cane neutralise the effects of the acid reflux. In ore severe cases, where both these option are ineffective, the ultimate treatment option is surgery. In more severe cases, surgery may be the preferred option.
In a laparoscopic Nissen fundoplication, surgeons make small incisions (quarter to half inch). The laparoscope is a tiny video camera, which is inserted into the abdomen, which gives the surgeon a magnified view of the internal conditions on a television screen. Carbon dioxide is also infused to expand the abdomen and give the surgeon better visibility. A fundoplication fixes the hiatal hernia, if present, by bringing down the stomach and wrapping it around the lower end of the esophagus. This procedure helps strengthen the LES, enabling it to function normally.
The actual operation is performed by tiny surgical instruments, which are inserted through the other small incisions. The surgeon conducts the entire procedure by guiding these instruments with the help of the images on the television screen. There are various types of fundoplication: NISSEN, ANTERIOR WATSON, POSTERIOR TOUPET and the surgeon will tailor according to the patient’s symptoms and surgical experience. Most of the patients go within 1-2 days of the operation, and are on a liquid diet for 4-6 weeks until the swelling around the ‘new wrap’ settles. Patients resume normal diet after that. Surgery has stood the test of time, and 10-year outcomes are now reported.
