By Avik Karmaker, MD, Surgery, CareMount Medical
October 6, 2021
If you’re one of the estimated 17 – 27%* of adults who experience heartburn at least once a month, you know the signs: a harsh, burning feeling in your chest usually after eating a large meal, spicy food, or when you’re lying down. Frequent, persistent heartburn is the most common symptom of GERD (gastroesophageal reflux disease). GERD not only interferes with quality of life, it can lead to serious illness. If you have chronic GERD that is not relieved by lifestyle changes or medicines, surgery may be an option.
But first, what causes GERD?
When you eat, food travels from your mouth, down the esophagus and into to your stomach. At the lower end of the esophagus is a small ring of muscle, the lower esophageal sphincter (LES) that acts like a one-way trap door that allows food to pass into your stomach. Normally, the LES closes immediately after swallowing to prevent back-up of stomach fluids.
When the LES isn’t functioning properly, highly acidic fluids flow back up into the esophagus, irritating and inflaming it, causing heartburn and other symptoms such as vomiting or regurgitation, difficulty swallowing and chronic coughing or wheezing. Left untreated, chronic reflux can lead to severe esophageal damage including Barrett’s esophagus, a pre-cancerous condition that increases the risk of esophageal cancer.
Some people are born with a naturally weak LES. Other things that can cause the LES to relax and result in reflux are diet, medications, smoking, drinking alcohol, or changes in body position (bending over or lying down). A hiatal hernia, in which the top part of the stomach bulges above the diaphragm and into the chest cavity, may also contribute to GERD.
How is GERD diagnosed?
If your primary care physician suspects reflux they may refer you to a gastroenterologist (or GI) for diagnosis. As part of the work-up, the GI may perform an upper gastrointestinal endoscopy and an esophageal pH monitoring test.
An endoscopy is generally an outpatient procedure, usually with light sedation. During the procedure a very thin lighted tube, an endoscope, is inserted into the esophagus enabling the doctor to closely examine it. Esophageal pH monitoring is done to detect stomach acid in the esophagus and the severity of reflux disease. It involves either placement of a small catheter through the nose into the esophagus or use of a small capsule directly attached to the esophagus during endoscopy known as the Bravo™ pH Monitoring System.
What are the treatment options for heartburn?
GERD is generally treated in three progressive steps. Simply making lifestyle and diet changes such as losing weight, quitting smoking, reduced alcohol consumption, and altering eating and sleeping patterns may help. If symptoms persist, you can ask your doctor about over-the-counter medications including antacids to neutralize stomach and/or other non-prescription medicines to reduce the amount of acid your stomach produces. If these do not provide effective relief, prescription drugs may be needed to alleviate symptoms and to aid in healing esophageal irritation. Always consult with your doctor before taking any medication.
If none of these steps works, or if you prefer not to rely on medications indefinitely, anti-reflux surgery may be an option for you. Commonly, GERD surgery includes hiatal hernia repair and fundoplication. Fundoplication is a procedure to tighten the LES by wrapping the upper portion of the stomach around the lowest portion of the esophagus – much the way a bun wraps around a hot dog. In many cases this can be performed during a minimally invasive laparoscopic procedure under general anesthesia requiring a short hospital stay. During the procedure, surgeons make small incisions (1/4 to 1/2 inch) to enter the abdomen through narrow, tube-like instruments. Carbon dioxide gas is used to temporarily expand the abdomen, giving the surgeon room to see and work. Laparoscopic fundoplication leaves several small scars, and results in less blood loss, a shorter hospital stay, fewer complications and quicker recovery. Studies show the vast majority of patients who undergo GERD surgery are either symptom free or have significant symptom improvement. Your surgeon can best explain the benefits and potential short- and long-term side effects of anti-reflux surgery.
If you have persistent heartburn, speak with your doctor who can assess which treatment is right for you.
* National Institutes of Health