What Is GERD ?

The oesophagus is a muscular tube that carries food into the stomach. The secretions of the oesophgus are alkaline and the secretions of the stomach are acidic.

---

There is a sphincter at the lower end of the oesophagus ( LES) that maintains unidirectional flow of contents from the oesophagus to the stomach and not vice versa. This sphincter is basically a ring of muscles at the lower end of the oesophagus merging with the muscular fibres at the upper end of the stomach. This means that when the LES relaxes (opens), it allows food to flow from oesophagus to stomach, following which it closes. This LES when closed does not allow the return or reflux of food or acid from the stomach to enter into the oesophagus. The LES is not under voluntary control.

---

---

Gastroesophageal reflux disease (GERD) is a disease wherein the stomach acid frequently flows back into the oesophagus. This return or reflux of acidic contents into the alkaline environment of the oesophagus tends to irritate the mucosal lining of the oesophagus causing discomfort, the severity of which could vary. This plethora of discomfort is called as GERD.

Symptoms:Heartburn and acid regurgitation are the two most common symptoms of those suffering with GERD. Heartburn is usually after eating, which might be worse at night

Other symptoms include chest pain, nausea, pain while swallowing, sudden excess of saliva, Chronic sore throat, Inflammation of the gums, bad breath, disturbed sleep.

Uncommon symptoms are laryngitis or hoarseness of voice and chronic cough. Many a time people are treated for chronic cough and hoarseness of voice and and not getting any relief with the treatment taken. A simple test like an upper GI endoscopy can diagnose GERD and remedy can be sought.

Worsening of existing asthma: acid reflux can make asthma symptoms worse by irritating the airways and lungs. This, in turn, can lead to progressively more serious asthma.

---

Medications management includes:

Diet and Lifestyle Changes :

Avoid chocolate, peppermint, fatty foods, caffeine, and alcoholic beverages that can relax the LES and thus aggravate GERD symptoms. Avoiding citrus fruits and juices also helps.

Avoid eating full stomach: Splitting the meals into smaller portions, chewing properly and eating slowly helps. This can be compensated if hungry by an additional small meal.

Eat slowly: Take your time at every meal.

Quitting smoking: If one is a smoker, symptoms are reduced to a great extent if one quits smoking as cigarette smoking seems to weaken the LES.

Raising the head end of the bed while sleeping: This is not a treatment method, but help in decreasing the reflux in severe cases until surgical line of treatment is sought for.

Weight reduction: If the person is obese , then substantial amount of weight loss will help reduction in the intra-abdominal pressure and thus decrease the symptoms of GERD along with medication.

Medications :

Neutralise the acid: Antacids: These tend to give initial relief by neutralizing the acid in the stomach to relieve heartburn, but this is temporary relief .

Reduce acid production: H-2-receptor blockers. These reduce the acid production by blocking the H2 receptors and give longer relief.

Block acid production: Proton pump inhibitors have brought a mega change in the treatment of Gerd as they block the acid production, thus giving time for the healing of the inflamed mucosa in the oesophagus.

Increase gastric emptying: Prokinetics. These drugs enhance gastric emptying and thus do not allow much acid and food to remain in the stomach, thus decreasing the chances of reflux. Associated bloating is also taken care of by these drugs.

Strengthen the lower esophageal sphincter. Baclofen may ease GERD by decreasing the frequency of relaxations of the lower esophageal sphincter.

Surgical management of GERD

Laparoscopic Fundoplication: This is the treatment of choice and can be called the gold standard as it has stood the test of time in giving good results in GERD patients not responding to medical line of treatment. The lower oesophagus is dissected all around. The fundus of the stomach is freed from the omentum (short gastric vessels) and is wrapped around the lower end of the oesophagus in an attempt to mimic the function of the LES. This prevents reflux and symptomatic relief. The wrapping of the fundus around the lower end of the oesophagus could be partial or complete. When the wrap is 180degree, it is called a Dor fundoplication, 270 degree when it is called a Toupet fundoplication and 360 degree when it is called a Nissens Fundoplication. The crura of the diaphragm are approximated, depending on the laxity of the hiatus.

Nissen’s Fundoplication

Toupet Fundoplication

Dorr Fundoplication

Nissen’s Fundoplication with crural closure:

Bariatric surgery. If Obesity is associated with GERD, then just doing a fundiplication will not work as weight loss is an important part in the management of GERD. In fact doing a gastric bypass surgery alone will serve the purpose in mild cases of GERD without a hiatus hernia. In such cases weight loss surgery i.e the gastric bypass will do a dual job--- weight loss and correction of GERD. No need for a fundoplication.

But, if a moderate or large hiatus hernia is associated with GERD , then along with the gastric bypass hiatal repair is a must.

LINX device. A ring of tiny magnetic beads is wrapped around the junction of the stomach and esophagus. The magnetic attraction between the beads is strong enough to keep the junction closed to refluxing acid, but weak enough to allow food to pass through. The LINX device can be implanted using minimally invasive surgery.

Transoral incisionless fundoplication (TIF). This new procedure involves tightening the lower esophageal sphincter by creating a partial wrap around the lower esophagus using polypropylene fasteners. TIF is performed through the mouth with a device called an endoscope and requires no surgical incision. Its advantages include quick recovery time and high tolerance.

GERD or Gastroesophageal reflux disease is an ailment wherein the acidic fluid in the stomach flows back into the esophagus. When it refluxes, acidic content reacts with the alkaline environment of the esophagus and irritates the mucosal lining. It causes discomfort, which is known as GERD.

Common symptoms are heartburn and acid regulation. Initially, these symptoms are there only occasionally during the day related to the meals, but as time goes by and severity increases, the person may have these nagging and troubling symptoms all through the day. It begins after eating, which worsens at night. This really plays a major role in disrupting one’s daily routine putting all jobs on a hold and seeking a permanent solution. Other symptoms are chest pain, pain while swallowing, nausea, excess of saliva, inflammation of gums, chronic sore throat, bad breath, etc. Disturbed sleep is also complained about by some people.

Lax LES ( lower esophageal sphincter), Hiatus Hernia, increased intraabdominal pressure due to various reasons are the common causes of GERD. Obesity itself increases the intraabdominal pressure and makes people more prone to GERD. Loss of weight helps in a major way in relieving symptoms.

The first line of treatment is medication and strict lifestyle and dietary modifications. If there is no relief with medication, then surgical management is necessary.

Dietary modification in trms of quantity, quality ( type of food) and timely intake of food are the foremost in the management of GERD along with medications like antacids PPI’s ( Proton pump inhibitors) etc.

When GERD is really severe and not relenting to medication and dietary andlifestyle modification, Laparoscopic fundoplication plays a major role and give excellent results. Fundoplication could be Nissens, Toupet fundoplication, depending on your symptoms, diagnostic test results and intraoperative findings.

Dr Tulip’s Obesity and Diabetes Surgery Hospital Bangalore is the best place where you get systematic diagnosis and treatment for GERD.

Doctors analyze the risk factors and offer remedies according to individual requirement. The problem of GERD should not be overlooked as refluxing acids can cause metaplastic changes in the esophageal mucosal cell lining in the lower portion of the esophagus if neglected over years.

---