Heartburn Question & Answer with Rex Physicians
Why doesn't my lower esophageal sphincter close?
The mechanism that keeps stomach acid from refluxing back into the esophagus is actually the result of a complex interaction which involves 1) the tone of the muscle in the lower esophagus as it enters the stomach, 2) the angle at which the esophagus enters the stomach, 3) the length of esophagus which is in the upper abdomen, 4) the contractility of the stomach, or how forcefully it churns-up and empties the food. It is usually a combination of problems among these factors that lead to GERD, rather than a single cause.
Normally, the lower esophagus acts a little like a one way valve. It's muscle has a slightly higher resting tone, squeezing the end of the esophagus shut. When we swallow, this relaxes and allows food to pass into the stomach. There are many reasons that this muscle loses its tone and ability to close. Nicotine from cigarette smoke, caffeine, certain medications, viruses etc. can all lead to a loss of sphincter function. Reflux itself can lead to damage, further interfering with the muscles ability to contract and close off the lower esophagus.
Many people with significant reflux have a hiatal hernia. This is where the esophagus passes through the muscle of the diaphragm , which separates the chest and abdominal cavities. If there is a weakness where the esophagus enters, a hole can form and part of the stomach can rise up into the chest cavity. This is a hiatal hernia. The significance of this is quite important for reflux to occur. First, the angle at which the esophagus enters the stomach is straightened out; instead of there being a sharp "kink" which impedes backward flow of the stomach juices, the esophagus and stomach junction can be lined up more directly, allowing easier flow of acid into the esophagus. Second, the part of the esophagus that is normally in the abdomen below the diaphragm can ride-up into the chest cavity. The abdomen's pressure is positive, helping to squeeze the esophagus closed. The chest has a negative pressure, and this can aid in pulling the lower esophagus open, allowing reflux to occur. Hiatal hernias can exist in up to 30% of people, but they often do not cause any problems. In those people who have reflux, the hernia is often a major contributing factor. Obesity, which raises the pressure in the abdomen and pushes up the abdominal contents against the diaphragm, is one of the primary causes for developing a hiatal hernia.
Finally, the stomach itself needs to be working correctly. If there is scar at the outlet of the stomach from previous ulcer disease, there can be resistance to the stomach emptying, leading to over-distention of the stomach and reflux. Diseases such as diabetes can lead to poor muscle function of the stomach, poor emptying, and subsequent reflux. And of course, our tendency to overeat at times and stretch-out the stomach places us in a vulnerable situation for reflux to occur.
Despite the complexity of the interactions which keep acid from refluxing into the esophagus, when it occurs it is often easily treated by simply reducing the amount of acid contained in the stomach juices. When this fails, the surgery to correct the problem is aimed at restoring all the factors that make-up the lower esophageal sphincter mechanism: fixing the hiatal hernia, restoring part of the esophagus to an intra-abdominal position, re-creating the acute angle the esophagus enters the stomach, and creating a "wrap" of stomach around the lower esophagus which acts as the muscular one way valve.
What if the medication and the surgery fail to treat my reflux?
Because GERD is a disease which involves complex physiology and anatomy, there are times that despite adequate treatment or technically successful surgery, the symptoms still persist. However, the importance of the extensive evaluation to determine the nature of a patients symptoms before definitive treatment is started is aimed at avoiding treatment failures: if you are treating the right problem, you will likely fix it with appropriate care. The majority of patients respond to acid suppression therapy. People who have damage to the esophagus will almost certainly heal, and since most GERD patients desire relief from their symptoms, reducing their experience of heartburn to a minimum is often all that is needed. One of the major reasons people fail in their treatment is a lack of compliance to the treatment. Losing weight, avoiding nicotine and caffeine, avoiding over-eating, taking the medication each day, are critical to the success of GERD therapy. Often the failure is not in the prescribed treatment, but in the compliance with the treatment.
Approximately 10-15% of GERD patients are good candidates for anti-reflux surgery (Nissen). These are patients who have failed medical treatment, have severe regurgitation symptoms, or complicating factors of their reflux. The critical element to surgery is patient selection. If the symptoms are not due to reflux, then anti-reflux surgery won't fix them!! In experienced hands, 90% of patients benefit from surgery long-term. Some may still need to occasionally take medication, but their quality of life is significantly improved. Failures of surgical treatment can be due to technical failure, worsening of an underlying disease process like diabetes or severe lung disease, or surgical treatment of atypical reflux symptoms that ultimately have a separate underlying cause. Overall, GERD is a highly treatable disease, with very high "cure" rates. Most of the treatment failures are due to factors that are actually uncommon, and that unfortunately may not be very amenable to standard therapies.
Dr. R. Schwarz
Will I have to take medicine for the rest of my life?
Not necessarily. For many people, however, reflux is a chronic condition like hypertension. Stopping medications will likely lead to a recurrence of symptoms. For those with complicated disease - erosive esophagitis, strictures, or Barrett's esophagus - it is important to stay on medication. Those with symptoms only can try stopping their treatment periodically and resume treatment as needed. Some people may be able to make lifestyle changes that will allow them to come off medication. This includes above all stopping smoking. Weight loss, low fat diet, avoiding eating before laying down, moderating caffeine and alcohol use may also allow coming off medicines.
What happens if I just stop taking my medicine?
Probably whatever problems you had before treatment will recur. For those with non-erosive disease this means just a return of symptoms such as heartburn. People with complicated disease and a history of bleeding, erosions, stricture or Barrett's esophagus should not stop their medicine.
What has smoking got to do with GERD?
Smoking lowers the pressure of the lower esophageal sphincter, predisposing to reflux. It increases the stomach's production of acid, further contributing to reflux. And it reduces saliva formation, which impairs clearance of acid from the esophagus.
Do any medications make GERD worse?
Virtually not. Caffeine, peppermint and chocolate are
offenders, but medications rarely provoke reflux. One class of
anti-hypertensives, the calcium channel blockers, especially Nifedipine (Procardia) does lower the esophageal sphincter pressure and can promote reflux in some patients.
If I have GERD, does that mean I will get cancer?
Very unlikely. The only people at increased risk for esophageal cancer are those whose reflux is complicated by a change in the esophageal lining called Barrett's esophagus. This is easily detected by an endoscopic evaluation of the upper GI tract (gastroscopy). That is why endoscopy is recommended for those with frequent reflux (more than 3-5 times weekly) especially males over the age of 40. Even Barrett's patients have only a relatively increased risk, probably less than a 1 in 200 chance of cancer per year. For those patients, endoscopy surveillance is recommended every 3 years or so.
What is the surgery I can have for GERD?
The main goal of surgical therapy for GERD involves re-establishing the "valve mechanism" at the junction of the stomach and the esophagus thus minimizing "backwash" or reflux of stomach contents into the esophagus. This goal is accomplished by using part of the upper stomach (the fundus) to create a "wrap" or "turtleneck" at the stomach-esophagus junction.
This operation, termed a fundoplication, can be a complete 360 degree wrap or, in some cases, a partial wrap. The large majority of these cases are now performed laparoscopically with minimally -invasive surgical techniques. This "small incision" surgery accomplishes the same operation previously requiring a large upper midline abdominal incision and greatly decreases post operative pain, length of hospitalization (usually only 1 day), and time away from work. For the best surgical results, both short and long term, it is essential the patient is evaluated
And treated by a surgeon well-qualified in advanced laparoscopic techniques and in dealing with this specific disease process of GERD
What kind of complications can happen with surgery for GERD?
The primary potential complications of surgery for GERD include injury to those organs involved in the procedure- i.e., the esophagus and stomach. Risk of damage to or bleeding from the spleen is also present and also a very low incidence. Risks common to all operations, including anesthesia and infection, are present and very low. Decision by the surgeon to convert from a laparoscopic to an open, large incision operation is a small risk, but should be considered a judgment call rather than a complication. Similarly, side effects (rather than complications) of the procedure can include temporary difficulty swallowing, belching or vomiting and abdominal bloating. These issues are almost always self-resolving in 2 weeks to 3 months.
Will having a fundoplication help me lose weight?
Post prandial early satiety ("feeling full" quicker) is not uncommon, but usually resolves in 1-3 months. Stomach capacity is minimally decreased by this operation which is thus not a weight reduction procedure.
Can anyone have that surgery at anytime?
For optimal care, it is important that patients receive proper screening and evaluation of GERD from both medical and surgical standpoints, ideally suited to a Heartburn Center. If medical assessment indicates need for surgery, the patient should be seen by an experienced laparoscopic anti -reflux surgeon who will discuss with the patient "pros and cons" of surgery. There are both general and specific conditions that would weigh against surgery; these are best reviewed on an individual basis.
Dr. D. Vig
Can GERD be cured?
Yes, GERD can be cured. The symptoms of GERD can be treated with medication and with surgery. Most symptoms can be controlled completely or at least enough to improve quality of life.
When is surgery needed for heartburn?
A majority of people who suffer from GERD symptoms can get relief from medication. Most of the time, heartburn is one of the symptoms. There are some other more unusual symptoms that some people with GERD suffer from as well. Many of these can be relieved by medication also. People whose symptoms are not relieved by medications are often candidates for surgery. Some people would rather not take medication to relieve symptoms. They may want to consider surgery as well.
Rex Heartburn Center
Phone: (919) 784-BURN (2876)
FAX: (919) 784-7532