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Dr Sewell Explains GERD:  

GERD Procedures:     

 What Our Patients Say:

Gastro Esophageal Reflux Disease (GERD) is a medical condition characterized by the persistent reflux of stomach contents up into the esophagus. Normally a circular valve called the  Lower Esophageal Sphincter (LES) keeps acidic stomach fluid from backing up into the esophagus. If the valve is weak, stomach acid can roll back up the esophagus, causing the burning sensation of heartburn. Anything that increases the pressure inside the abdomen, such as overeating, strenuous exercise, heavy lifting or straining or even tight clothing will tend to squeeze the stomach and push fluid past a weakened sphincter and up into the esophagus. Other conditions that often contribute to GERD include:

• Hiatal Hernia
  
• Obesity
• Aging
• Coughing or vomiting
• Fatty food diet
• Alcohol
• Nicotine (smoking or smokeless)
• Peppermint
• Caffeine
• Pregnancy
• Some prescription medication (bronchodilators, calcium channel blockers and diazepam)

Most patients are able to manage their heartburn symptoms with lifestyle changes and medications to neutralize or reduce stomach acid. However, these medication often lose their effectiveness over time, and some people are unable to take them due to side effects, including bloating, constitpation and cramping abdominal pain. Recently long term use of Proton Pump Inhibitors (PPIs) like Nexium, Prilosec, Prevacid, and others have been linked to problems with calcium and magnesium metabolism resulting in an increased risk of osteoporosis and pathologic bone fractures. (see FDA report). Whenever medications prove ineffective, or for patients who chose to avoid a lifetime of taking these drugs, surgical solutions are available that can stop the heartburn and other symptoms of GERD.  

Watch Video explanation of GERD

While Heartburn is the most common complaint, some patients with GERD complain of one or more of the following symptoms:

• Chronic Indigestion
• Chest pain
• Difficulty Swallowing
  
• Regurgitation of food or fluid into the throat or mouth
• Difficulty sleeping after eating
• Coughing or choking, especially when lying down
• Asthma and Asthma-like symptoms
• Chronic bronchitis, laryngitis or pneumonia
• Chronic sinus infections 

While many of these symptoms are due to the effects of stomach acid refluxing up into the esophagus, many continue even though medications have successfully stopped acid from being produced by the stomach. Any fluid or food material that reflux up from the stomach can potentially cause problems. 

LaryngoPharyngeal Reflux (LPR)

Some patients suffer from symptoms related to stomach contents refluxing all the way up into the back of the throat and even into the mouth. This is call LaryngoPharyngeal Reflux or LPR. Symptoms of LPR may include chronic laryngitis or bronchitis, chronic cough, painful or swollen tongue, frequent sinus infections or nasal congestion, dental problems and even bad breath. Not infrequently, one or more of these symptoms will be present even though the patient has no real heartburn. Likewise, these problems frequently fail to respond to antacid medications. Both the TIF procedure and Laparoscopic Nissen Fundoplication have been shown to provide relief from these symptoms in a significant percentage of patients with LPR.

Transnasal Esophagoscopy

It is now possible to use a very small flexible endoscope to evaluate the esophagus and stomach without the need for intravenous sedation or general anesthesia. The procedure, called Transnasal Esophagoscopy (TNE) is performed in the office using local anesthesia sprayed into the nose. The scope, which is about the size of a small soda straw, is passed through one nostril and down the back of the throat, through the esophagus and into the stomach. This allows for direct inspection of the lining of the structures and biopsies can be obtained to check for Barrett's esophagitis. CLICK HERE for detailed patient instructions for TNE.

In some patients, even the tiny scope may not be well tolerated, so for them a conventional endoscopy performed at the hospital under anesthesia may still be the best choice. 

Conventional Endoscopy

Before initiating any treatment of GERD, the inside of the esophagus and stomach should be examined directly with a procedure called an endoscopy, or EGD. The anatomy and relative health of the upper GI tract can be evaluated from the inside, and biopsies performed. Chronic GERD can sometimes cause ulcerations and even bleeding. It can also cause scarring, which may lead to a narrowing or stricture of the esophagus. In about 10% of patients with GERD, the lining of the lower esophagus undergoes a change that makes it look more like the lining of the stomach. This condition is called Barrett's Esophagus, and is associated with an increased risk of esophageal cancer.

pH Monitoring

When Acid Reflux is suspected but not confirmed, it may be necessary to actually measure the amount of acid in the esophagus over a 24-48 hour period to confirm the diagnosis of GERD. Traditionally, this was accomplished by placing a tube down through the nose into the esophagus, which was connected to a monitoring device. Today, this rather uncomfortable procedure has been replaced by a less cumbersome process where a tiny capsule, called a Bravo Probe, is attached during an endoscopy directly to the lining of the esophagus. The probe measures the amount of acid in the esophagus and transmits the information to a small electronic device about the size of a cell phone, which is worn on the patient's belt. After 2 days the data from the monitor is downloaded to a computer for analysis. For the test to be accurate the patient must remain off all acid supressing medication, like PPIs and H2-Blocker for 7 days prior to beginning the study. It is okay to use antacids like Rolaids, Tums, Maalox or Mylata to control acid symptoms during the pre-testing time, but even these medication need to be avoided during the 48 hours of the actual test.

The Bravo Probe is completely disposible and releases from the lining of the esophagus after about 7 to 10 days. It then passes through the intestinal tract and out of the body along with a bowel movement. While the probe is in place, some patients experience slight discomfort with swallowing, but this is temporary and generally does not require an alteration in diet. 

Esophageal Motilty

Additional testing is often required, not only to ensure the diagnosis is in fact gastroesophageal reflux, but also to assess the functional capability of the esophagus. One such test is called Esophageal Motility or Esophageal Manometry. To accurately measure the strength of esophageal contractions, a small catheter is placed through the nose down into the stomach. There are multiple pressure monitors along the length of the catheter which provide a clear picture of exactly what is happening during the process of swallowing. The test typically take about 30 minutes to perform, and the information obtained can be very helpful in determining the safest and most effective treatment. We use the latest "state-of-the-art" High Definition system, which provides the most accurate information and is well totlerated by most patients.

X-ray Studies

Over the counter antacids temporarily improve heartburn by simply neutralizing stomach acid. Other medications like Tagamet, Zantac, and Pepcid work by partially blocking the stomach's ability to make acid, and are available without a prescription. Their effect may last anywhere from a few hours to a day or more. Prescription drugs known as Proton Pump Inhibitors (PPIs), include:

• Prilosec
• Prevacid
• AcipHex
• Protonix
• Nexium
• Zegrid
• Dexilant

These medicines work by stopping the production of acid by the stomach. They are often extremely effective at reducing or even eliminating heartburn symptoms, but to do so they must be taken on a regular basis. The overall effectiveness of PPIs often decreases over time, requiring the dosage or the frequency of the medication to be increased. Likewise, some patients switch from one drug to another in order to get the heartburn relief they are seeking. Other patients may have trouble taking these medications due to side effects, which can include bloating, abdominal cramps, constipation or diarrhea, as well as others. Recently these powerful drugs have been identified as being associated with an increased risk of osteoporosis and pathologic fractures due to interference with Calcium and Magnesium absorption by the GI tract..                  

Read the FDA Advisory About PPIs and Osteoporosis and Osteopenia Related Fractures

FDA Issues Warning About PPI use and C' difficile Infections

In general, PPIs are considered to be quite safe and for most people who suffer from occasional heartburn symtoms these drugs are the only treatment necessary. However, for those who have had to significantly altered their lifestyle or eating habits just to control their GERD symptoms, it may be advisable to consider one of the surgical treatment options. Surgery may be particularly appropriate for patients who are having trouble controlling their heartburn symptoms even with medication. Other patients with GERD-related symptoms such as chronic cough, asthma, trouble sleeping, regurgitation, laryngitis and even sinus infection may also benefit from anti-reflux surgery. This type of reflux is categorized as LaryngoPharyngeal Reflux (LPR) and is often not well managed with acid supressing medication alone.

The TIF Procedure is generally not recommended for patients who are either overweight or have a significant hiatal hernia. But, in selected cases it may be possible to perform a TIF procedure in combination with a laparoscopic repair of a small to moderate sized hiatal hernia or removal of the "fat pad" that is frequently found around the lower end of the esophagus. Such procedures are referred to as either a "Hybrid Procedure" or a "Hybrid TIF". Obviously they require both a laparoscopic and an endoscopic approach to be performed under the same anesthetic.

To date, there is insufficient data to show any clear benefits of the Hybrid TIF over a standard Laparoscopic Fundoplication. However, early reports suggest that patients may have fewer problems with difficulty swallowing and "gas bloat" following the Hybrid TIF compared with more traditional fundoplications. 

What is a Hiatal Hernia?

The diaphragm is a broad, flat muscle that separates the chest cavity from the abdominal cavity. It moves up and down when you breathe, creating negative pressure in the chest cavity. The esophagus passes through a small opening in the diaphragm called the hiatus. If this opening becomes stretched, some or all of the stomach is pulled up into the chest cavity. This condition is called a hiatal hernia. While the majority of hiatal hernias are relatively small, with only the upper part of the stomach sliding up through the diaphragm, they often become larger over time. If the hernia becomes large enough, the entire stomach and even other abdominal organs can become permanently displaced above the diaphragm.

Symptoms of Hiatal Hernia

The most common symptoms of hiatal hernia include:

• heartburn
• regurgitation
• frequent belching 
• chest pain

Most patients who have been diagnosed with a hiatal hernias experience one or more symptoms on a regular basis. They may also be under the impression that they have no choice but to live with their symptoms. However, defects in the diaphragm can and often should be surgically repaired as a means of controlling the symptoms. Huge defects in the diaphragm can result in a twisting or obstruction of the stomach with symptoms ranging from nausea and persistent vomiting of undigested food, to weight loss and even malnutrition. Ulcerations can also occur within the herniated portion of the stomach and are a common source of upper GI bleeding and chronic anemia.

(Watch Dr. Sewell provide a video explanation)

Testing for Hiatal Hernia

Large hernias can sometimes be seen on a standard chest x-ray, but most hiatal hernias are only identified by either an Upper GI x-ray or at the time of endoscopy. One or both of these diagnostic procedures should be performed when hiatal hernia is suspected. If the diagnosis is confirmed, initial treatment may include acid suppressing medicines to control heartburn, along with lifestyle changes to reduce symptoms of GERD. However, once a hiatal hernia occurs it will never resolve on its own. Since the pressure in the abdominal cavity is greater than the pressure in the chest cavity, the hernia will only get larger over time as more and more of the stomach is pushed up through the defect.

Minimally Invasive Treatment Options

Laparoscopic surgery can offer patients with a hiatal hernia a minimally invasive repair that typically only requires an overnight stay in the hospital. Even very large hernias can usually be repaired in this way by an experienced laparoscopic surgeon. (Watch video of Laparoscopic Hiatal Hernia Repair)  In rare cases the stomach may not be able to be completely mobilized out of the chest cavity due to a shortened esophagus. In these rare situations an esophageal lengthening procedure, called a Collis Gastrostomy may need to be performed before the hernia can be repaired.

As a final part of virtually any hiatal hernia repair, the top part of the stomach is wrapped around the lower esophagus creating what is called a fundoplication. This helps prevent problems with gastric reflux after surgery and further reduces the chances of the hernia coming back. Your diet will be restricted for a few weeks following surgery to allow time for the swelling to resolve. Click HERE to review the post-operative diet instructions. (Hear what our patients have to say)

Recurrent Hiatal Hernia Repair

Occasionally, despite what was an initially an effective repair, the hiatal hernia can come back. This may be due to excessive retching or vomiting, heavy lifting or straining, or in some cases for no apparent reason. The symptoms of a recurrent hiatal hernia include chest pain, typically through into the back, indigestion or heartburn, and occasionally even trouble swallowing. Having a recurrence of the hernia is obviously disappointing, but the good news is it can generally be repaired again using the same minimally invasive procedure. A recurrence is more likely if the initial hernia was very large and this is also the case with subsequent repairs. The routine use of some type of mesh material to strengthen the diaphragm closure is generally recommended to reduce the chances of the hernia coming back. The most commonly used type of mesh is made of biological materials rather than any type of plastic. This reduces the risk of mesh problems down the road. But, if the defect in the diaphragm is extremely large, it may require placement of mesh made of artificial materials.

We will be happy to discuss the cost and payment options with you. Just call our office at 817-748-0200 and ask for Suzanne.

What is Barrett's Esophagus?

Barrett's Esophagus, also known as Barrett's Disease, is a condition where some of the lining of the esophagus changes from the normal smooth appearing mucosa (squamous cell epithelium) into tissue that resembles the lining of the stomach (columnar epithelium). This change is due to the effects chronic exposure to stomach acid, which injures the lining of the esophagus. Not everyone with chronic reflux develops Barrett's esophagus, (only about 10%) but those who do, have an increased risk of subsequently developing cancer of the esophagus. Other than the non-specific symptoms associated with reflux, there are no specific symptoms of Barrett's esophagus. The only way to identify Barrett's changes is by having an upper GI endoscopy, which would include biopsies of any suspicious appearing areas. 

Increased Risk of Esophageal Cancer

Most of the time when Barrett's Esophagus is detected its in what is called an intestinal metaplasia. Typically, these changes are not very likely to become malignant, but over time they may undergo further progression into what is called dysplasia, which carries a risk of becoming invasive cancer of approximately 1-2% per year. Read Dr. Sewell's editorial on esophageal cancer.

All patients who are diagnosed with Barrett's Esophagus should undergo an endoscopic examination and biopsy of the esophagus at least every two years, and more frequently if dysplasia is found. In the event "high-grade dysplasia" is identified it may be necessary to pursue a more agressive surgical treatment, either to burn away the lining of the esophagus (The Halo Procedure) or remove the esophagus (total esophagectomy). Obviously, these are major procedures, which are best avoided by preventing Barrett's changes in the first place. This is perhaps the most compelling argument for adequately controlling acid reflux either with daily acid supressing medications or a surgical fundoplication.

Screening for Barrett's Esophagus

Patients who are risk for developing Barrett's esophagus include virtually anyone who suffers from chronic gastroesophageal reflux. The group that is at the greatest risk incluses caucasian men over the age of 50 who have a history of heartburn or regurgitation. Even patients who's reflux is reasonable well controlled on medication whould probably be checked for Barrett's changes at some point.

Traditionally the only option for diagnosing Barrett's esophagus has been through conventional transoral flexible endoscopy. For most people this procedure is too uncomfortable to be done with significant sedation and therefore is almost exclusively performed in an outpatient endoscopy or surgery center. Recently a new technique has been developed which allows for an endoscopic inspection of the esophagus to be performed without the need for sedation and can therefore be performed in the physician's office. It is called Transnasal Esophagoscopy (TNE) and as the name implies, it is perfomed by passing a very small high resolution scope down through the nose to inspect and even biopsy the lining of the esophagus. Since there is no need for sedation, patients are able to have this type of examination and return immediately back to work. There is also no need to have someone drive you to and from you appointment. More Info

Treating Barrett's Esophagus

There remains considerable controversy in the medical community about how best to control reflux in patients who already have Barrett's Esophagus, since there is no scientific evidence to suggest that either optimal medical therapy or effective antireflux surgery will reverse these changes. However, there is clear evidence that persistent, poorly controlled acid reflux increases the risk of progression to esophageal cancer.