Heartburn and GERD

Gastroesophageal reflux disease (GERD), commonly called heartburn or acid indigestion, is a common digestive disorder in which stomach contents regurgitate (reflux) into the esophagus. It is associated with a burning sensation in the chest. GERD often causes inflammation and damage to the esophagus and occasionally to the lungs and vocal cords. Afflicting an estimated 25 million Americans, GERD has a variety of causes. Most patients respond well to non-surgical measures including dietary modification, weight loss and antacid therapy; however, lasting control of symptoms is sometimes difficult to attain.

Causes of GERD

Gastroesophageal reflux disease (GERD) is caused by the movement of acidic stomach contents into the esophagus. Patients with this disorder suffer from a wide spectrum of symptoms including heartburn, regurgitation and dysphagia (difficulty swallowing).

A defective LES (lower esophageal sphincter — a muscle at the junction of the esophagus and stomach) contributes to the failure of the body's natural anti-reflux mechanism.

Weak LES valve allows food to wash back into esophagusNormal LES valve keeps food in stomach.

Diagnosis of GERD

It is important that the diagnosis and particular cause of the GERD is confirmed. The patient's history of signs and symptoms is reviewed, and tests are performed. Tests include:

An upper endoscopy may also be necessary to look for possible areas of stricture. Biopsies (small tissue samples) can also be obtained from an endoscopy to confirm the diagnosis of esophageal inflammation and to exclude Barrett's esophagus, the transformation of esophageal cells into stomach lining cells after years of reflux.

Other tests include an upper GI series or a barium swallow x-ray, which can show the acid reflux and inflammation of the esophagus as well as the presence of hiatal hernia (also called diaphragm hernia), which occurs when the upper part of the stomach moves up into the chest through a small opening in the diaphragm, often causing LES dysfunction.

Treatment for GERD

Medical therapy, consisting of anti-acid medications and lifestyle modifications, results in symptomatic relief for most patients. Surgical therapy is indicated for patients in whom medicine has proven ineffective, is poorly tolerated, or is too expensive to continue. It is also indicated for complications of reflux disease such as an esophageal stricture (narrowing) and the development of pre-cancerous changes in the esophagus.

For those patients in whom a medical regimen has not been successful in treating GERD, anti-reflux surgery can offer gratifying, durable results. While GERD can have several causes, surgery is most effective for those patients whose GERD is caused by a defective lower esophageal sphincter (LES), the muscle connecting the esophagus with the stomach. More than 90% of patients who undergo surgery have no reflux afterward. Surgery may be done as either an open or a laparoscopic procedure, and treats the reflux by making a new valve mechanism at the lower esophagus as a barrier to reflux. Minimally invasive procedures enable the patient to return home the same day and return normal activity.

Called fundoplication, the surgery involves constructing a new "valve" between the esophagus and the stomach by wrapping the upper portion of the stomach (the fundus) around the lowest part of the esophagus. As the stomach becomes distended during a meal, the wrap compresses the lower esophagus, preventing reflux. Fundoplication may involve repair of a hiatal (diaphragm) hernia, if present. For patients who have other problems contributing to or accompanying their GERD, such as a swallowing disorder, a shortened esophagus, or gastric outlet obstruction, there are variations to this surgery.