GERD (Gastroesophageal Reflux Disease) / Acid Reflux Disease Denver
What is GERD?
Gastroesophageal reflux disease (GERD), also known as acid reflux disease, occurs when excess stomach juice comes up into the esophagus. The most noxious component of stomach juice is acid. Medications can reduce the acid content in stomach juice, but for many patients, non-acid reflux will occur even with medication because the medication stops acid production – not reflux. Exposing the esophagus to stomach juice can cause heartburn, chest pains, indigestion, excess throat clearing, hoarseness, chronic cough, asthma, and other problems with the throat and lungs.
Many people have heartburn, acid reflux, and indigestion on an occasional basis. When GERD symptoms occur regularly, medical advice should be sought. Gastroesophageal reflux disease can cause permanent injury to the esophagus, and sometimes result in precancerous changes to the esophagus. GERD – once you have it – generally doesn’t go away.
GERD, or acid reflux disease, is due to a weakness in the valve mechanism that normally prevents stomach contents from going back up into the esophagus. It is not due to excess acid production by the stomach. This valve mechanism is called the Lower Esophageal Sphincter (LES). Some patients with GERD may also have a hiatal hernia. Hiatal hernias further weaken the valve mechanism and can contribute to the severity of acid reflux. Procedures to treat acid reflux disease repair this defective valve mechanism and, if needed, the hiatal hernia – something that medication cannot do.
GERD/Acid Reflux Disease Treatment Goals
The primary goals of acid reflux disease treatment are to reduce GERD symptoms to the point where they don’t interfere with a patient’s quality of life, and to minimize acid reflux-related injury to the esophagus. Complete elimination of every symptom is not necessary, nor realistic, for therapy to be successful – the endpoint realistically is elimination of daily troublesome symptoms.
Gastroesophageal reflux disease is a chronic condition – 90% of patients who have GERD for 6 months will continue to have GERD symptoms 10 years later – and beyond.
As we understand more about GERD as a chronic condition, we recognize the need for multimodality therapy to treat acid reflux disease. Similar to treatment of heart disease, having an intervention to open clogged arteries doesn’t mean that patients may not continue to benefit from some cardiac medications.
Medical Treatment of GERD/Acid Reflux Disease
Limitations of Medical Therapy for Acid Reflux Disease
Medicines that treat GERD most effectively do so by reducing the amount of acid the stomach secretes, but they do not correct the defective valve. Acid reflux causes much of the burning and injury to the esophageal lining. Medications have been the mainstay of GERD treatment because they are very effective at alleviating symptoms, healing erosions in the lining of the esophagus, and they have been thought to be very safe. However, both the effectiveness and the long-term safety of medication have been questioned. Medical therapy for acid reflux works well at controlling GERD symptoms and healing esophageal injury. Most patients tolerate the medications very well, with few side effects, but, medication has drawbacks including failure to control non-acid reflux, requirement for increased dosing, increased risk of side effects including osteoporosis, and cost.
Surgical techniques to correct acid reflux have been demonstrated to be as effective, if not more effective, than medical therapy at alleviating GERD symptoms. More importantly, these techniques work very well for patients whose GERD symptoms are not adequately controlled by medication. However, many patients are not even aware that alternatives to medical therapy exist.
Increasingly, physicians are recognizing that acid reflux persists despite taking anti-acid medication. Non-acid reflux can also result in many problems.
Although refluxed acid is the most injurious compound in stomach contents, non-acid reflux can cause persistent heartburn and reflux sensation. Non-acid reflux has been tied to chronic cough, hoarseness, worsening of asthma, persistent vocal cord irritation. Since it has only been in the past 20 years that stomach acid could be almost completely eliminated by medication, we are just now beginning to understand the degree to which non-acid reflux occurs and what problems it incurs.
Many patients require ever-increasing doses of medication or switching medications in order to keep symptoms under control. We commonly see patients who have tried many different PPIs with multiple dose ranges but still have persistent, uncontrolled symptoms of GERD. Many of these patients are never informed that procedures to repair the anti-reflux valve and eliminate reflux exist.
Proton Pump Inhibitors (PPIs) have been the most commonly used medication to treat acid reflux disease in the past 20 years. Nexium, Prilosec (omeprazole), Prevacid, Protonix, Aciphex, and Zegerid are trade names of the most common PPIs. Although PPIs have an excellent safety record overall, a 2006 study published in the Journal of the American Medical Association showed a significant increase in the risk of osteoporosis in patients over 50 years of age who were taking PPIs for more than a year. Patient who took PPIs twice a day for more than a year were at nearly a threefold risk of developing a hip fracture.
The American Academy of Family Physicians has a bulletin on the use of PPIs. In the publication, they outline potential side effects of PPIs, including when other medication dosing should be altered with the addition of PPIs. Although the list is fairly short compared to many other medications, there are still potential interactions of which many patients are unaware.
Additionally, cost is becoming an issue for more and more patients. Nexium, which is probably the most potent acid-suppressive medication available, is a purified form of Prilosec, which is now available over the counter. Some insurance prescription programs have stopped covering Nexium for this reason – and patients are left to pay for Prilosec over-the-counter at great cost to them.
In general, if one pill a day controls heartburn and acid reflux symptoms, the patient has no upper-airway symptoms that are due to GERD, the patient takes supplemental calcium and has bone density monitored, and the medication is affordable, it seems reasonable to say that PPI therapy is the safest way to manage that patient’s acid reflux disease.
- increasing doses are needed,
- patients are having to switch medications because one is not working,
- heartburn, acid reflux, or other GERD symptoms persist despite taking medication,
- upper airway or laryngeal symptoms are due to non-acid reflux, or
- the patient is already at high risk for osteoporosis
then strong consideration should be given to procedures to repair the antireflux valve.
Evaluation for GERD Surgery
The evaluation for surgery is very important. Recent studies have shown that up to 30% of people that take antacids on a regular basis do not have acid reflux. For this reason, we need to be sure that there is a disease process present that surgery will indeed be helpful for before we discuss surgery as an option. Currently, there is not one single test that can be done to document the presence of pathologic reflux and determine the best surgical option for each individual. As a specialty center, we require a full workup of anatomy, reflux testing, and documentation of symptom severity in all patients. This workup includes a high resolution impedance manometry, pH testing impedance or pH testing bravo, EGD or TNE, cine esophagram. For some patients, other testing might be indicated, such as solid gastric emptying study, abdominal ultrasound, CCK HIDA test for the gallbladder, CAT scan.
Acid Reflux Disease/GERD Surgery Options
- Laparoscopic Nissen Fundoplication
- Laparoscopic Partial Fundoplication
- LINX Reflux Management System
After Acid Reflux Disease/GERD Surgery
After acid reflux disease surgery, you will be on a liquid diet (yogurt consistency) for a few weeks, followed by soft foods for a few weeks (except for the LINX procedure – see below). We restrict your physical activity for about a month after, so that the area has time to heal. You may drive when you’re not on pain pills, and may return to non strenuous work when you feel up to it – usually after 2-3 weeks.
For the LINX Reflux Management System procedure, we encourage you to return to a normal diet as quickly as you are able to. Some patients feel pain or difficulty swallowing right after surgery and may need to slowly increase the consistency of the food. We restrict your physical activity for about a month after, so that the area has time to heal. You may drive when you’re not taking pain pills, and may return to non strenuous work when you feel up to it – usually after 2-3 weeks.