Robotic
Esophageal Surgery
Samer A.Kanaan, MD, FACS

Gastroesophageal Reflux Disease

What is Gastroesophageal Reflux Disease?

Gastroesophageal reflux disease (GERD) is a condition where the stomach contents (food or liquid) rise up from the stomach into the esophagus, a tube that carries food from the mouth to the stomach.

Why does it occur?

Normally the stomach contents do not enter the esophagus due to a constricted lower esophageal sphincter (LES). But in patients with GERD stomach content travels back into the esophagus because of a weak or relaxed LES. The lower esophageal sphincter is a ring of muscle fibers that surrounds the lower-most end of the esophagus where it joins the stomach. The LES acts like a valve between the esophagus and stomach preventing food from moving backward into the esophagus.

The exact cause of what weakens or relaxes the LES in GERD is not known, however certain factors including obesity, smoking, pregnancy, and possibly alcohol may contribute to GERD. Common foods that can worsen reflux symptoms include spicy foods, onions, chocolate, caffeine containing drinks, mint flavorings, tomato based foods and citrus fruits. Certain medications can also worsen the reflux.

What are the symptoms of GERD?

Heartburn is usually the main symptom; a burning-type pain in the lower part of the mid-chest, behind the breast bone. Other symptoms such as a bitter or sour taste in the mouth, trouble swallowing, nausea, dry cough or wheezing, regurgitation of food (bringing food back up into the mouth), hoarseness or change in voice, and chest pain may be experienced.

How does your doctor diagnose GERD?

There are several tests that can be performed to diagnose GERD and they include:

  • Endoscopy: This test allows the doctor to examine the inside of the patient's esophagus, stomach, and portions of the intestine, with an instrument called an endoscope, a thin flexible lighted tube.
  • Barium X-rays: These are diagnostic x-rays in which barium is used to diagnose abnormalities of the digestive tract. You are asked to drink a liquid that contains barium. The barium coats the walls of the esophagus and stomach and makes the abnormalities more clearly visible. Then X-rays are taken to see if there are strictures, ulcers, hiatal hernias, erosions or other abnormalities.
  • Twenty four-hour pH monitoring - In this procedure, a tube will be inserted through the nose into the esophagus and positioned above the LES. The tip of the tube contains a sensor which can measure the pH of the acid content refluxed into esophagus. A recorder, strap-like device that can be worn on the wrist, will be connected to record the pH of the acid content. The tube will be left in place for 24 hours.  Patients can also go back home and perform their regular activities and can record the pH of the acid content when they experience symptoms. On the next day the recorder will be connected to a computer and the data will be analyzed.
  • pH Capsule:  This is a new method of measuring acid exposure in the esophagus. A small wireless capsule is introduced into the esophagus by a tube through the nose or mouth. The tube is removed after the capsule is attached to the lining of the esophagus. The pH sensor transmits signals to a computer which collects the data about the acid exposure over the usual 24 hours. The capsule falls off the esophagus with time and is passed in the stool.
  • Impedance study: This test is similar to the pH test but requires two probes; one is placed in the stomach and the other just above the stomach. The dual sensor helps to detect both acidic and alkaline reflux.

What are the treatments for GERD?

Antacids are over-the-counter medicines that provide temporary relief for heartburn or indigestion by neutralizing acid in the stomach. Other medications such as proton pump inhibitors and H2 antagonists may be prescribed to reduce the production of acid in the stomach.

Surgery may be an option for patients whose symptoms do not go away with medications. Nissen’s fundoplication is a surgical procedure in which the upper part of the stomach is wrapped around the lower end of your esophagus and esophageal sphincter, where it is sutured into place. This surgery strengthens the sphincter and helps prevent stomach acid and food from flowing back into esophagus.

Endoluminal gastroplication or endoscopic fundoplication technique requires the use of an endoscope with a sewing device attached to the end, known as an EndoCinch device. This instrument place stitches in the stomach below the LES to create a plate which helps reduce the pressure against the LES and strengthen the muscle.

What if GERD is ignored?

Chronic GERD left untreated can cause serious complications such as inflammation of the esophagus, esophageal ulcer, narrowing of the esophagus, chronic cough, and reflux of liquid into the lungs (pulmonary aspiration). Some people develop Barrett’s esophagus, in which there are changes in the esophageal lining that can lead to esophageal cancer.

What measures can I take control reflux?

General measures the patient can take to reduce reflux are:

  • Avoid eating before going to bed as this may increase acid production
  • Eat smaller, more frequent meals
  • Lose weight if you are over weight
  • Elevate the head of the bed
  • Eliminate foods that increase symptoms
  • Avoid smoking and use of alcohol
  • Check with your physician regarding side effects of prescription medications