Gastroesophageal Reflux Disease (GERD)

Gastroesophageal reflux disease (GERD) is a common digestive disorder that is caused by gastric acid flowing from the stomach into the esophagus. Also known as reflux, or heartburn, nearly 44 percent of Americans experience recurrent GERD and 18 percent of these individuals use some type of nonprescription medication for their problem.

In normal digestion, food travels from the mouth, through the esophagus and into the stomach. In the stomach, the gastric secretions, which include acid, fluids, and enzymes, break down the food as it moves into the intestines. Normally, following a swallow, the lower esophageal sphincter (LES) relaxes and allows food to pass into the stomach. It then closes to prevent this food from backing up into the stomach. However, for some people, the LES stays relaxed. This allows the acidic contents of the stomach to reflux back into the esophagus and damage the lining.

Gastroesophageal reflux disease can be successfully treated most of the time. However, chronic GERD can lead to other problems in the esophagus including inflammation, ulceration, scarring, stricture (narrowing) and precancerous changes (Barrett’s esophagus). In a very small percentage of patients, the changes in the esophagus can lead to esophageal cancer.

The Division of Thoracic Surgery at Brigham and Women’s Hospital (BWH) provides specialized services for GERD, such as extensive diagnostic testing. Our board-certified surgeons are experts in the latest minimally invasive thoracic surgical techniques, including Nissen fundoplication, Toupet fundoplications, the Linx procedure and transoral incisionless fundoplication.

GERD/Reflux Topics

Risk Factors for GERD/Reflux

Many people experience occasional heartburn. However, there are known factors that can increase your risk of developing long term GERD/reflux.

Lifestyle:

  • Eating certain foods such as citrus, chocolate, peppermint, spicy and fatty foods
  • Drinking caffeinated beverages
  • Certain medications, such as aspirin and ibuprofen
  • Being overweight
  • Overeating
  • Cigarette smoking
  • Drinking alcohol

Other conditions associated with heartburn include:

  • Pregnancy
  • A weak lower esophageal sphincter
  • Hiatal hernia which occurs when the stomach moves up into the chest
  • Gastritis (inflammation of the stomach lining)
  • Ulcer disease
  • Asthma
  • Diabetes
  • Connective tissue disorders, such as scleroderma
Symptoms of GERD/Reflux
Some people with GERD/reflux do not experience any symptoms. For the vast majority, however, the most common symptoms are:
  • A burning pain behind the breastbone, radiating up into your throat
  • Repeated episodes of heartburn with reflux
  • Regurgitation of sour tasting food or liquid into your throat
  • Difficulty swallowing
  • Sensation of a lump in the throat
  • Chronic cough
  • Breathing problems or Asthma-like symptoms
  • Changes in your voice

Heartburn typically occurs after a large meal or when you bend over or lie down. Certain foods tend to make GERD worse. These foods include:

  • Fatty foods
  • Fried foods
  • Spicy foods
  • Onions
  • Peppermint
  • Caffeine (coffee, tea, chocolate, sodas, energy drinks)
  • Alcohol
  • Citrus fruits and juices
  • Tomatoes and tomato products
  • Peppers

Most children younger than 12 years of age, and some adults, will not experience typical symptoms of heartburn. Their symptoms may include:

  • Dry cough
  • Asthma symptoms
  • Trouble swallowing

Heartburn is usually not associated with physical activity.

The symptoms of GERD/reflux may resemble other medical conditions or problems. If your thoracic surgeon discovers another cause for your symptoms, he will refer you to an appropriate Brigham and Women’s Hospital physician 

Diagnosis of GERD/Reflux
In addition to a complete medical history and physical examination, diagnostic procedures for GERD may include the following:
  • Chest X-ray, electromagnetic energy produces images of internal tissues, bones and organs.
  • Upper endoscopy visually examines the esophagus, the stomach and part of the duodenum.
  • Barium Swallow/Upper GI study involves X-ray pictures of your esophagus and stomach after you have swallowed a small amount of contrast material. If a patient complains of trouble swallowing, a barium swallow may be helpful in identifying areas of narrowing called strictures.
  • Bernstein test helps to confirm that the symptoms are a result of acid in the esophagus. Mild acid is dripped through a tube placed in your esophagus.
  • Manometry, a thin, flexible tube containing sensors is passed through the nose, down the esophagus, and into the stomach to measure the pressure in the esophagus.
  • Esophageal pH study measures the amount of acid in your esophagus.
  • Bravo study, a capsule is placed in the esophagus to measure acidity in the esophagus
Treatment for GERD/Reflux
There are many ways your thoracic surgeons can help you to manage and treat your GERD/reflux. Typical treatment ranges from lifestyle changes to medications. In more serious cases of GERD, surgery is considered. The goal of treatment is to pinpoint the cause of your GERD, so you can make changes to prevent it from recurring.
Diet and lifestyle changes can have a huge impact on your GERD symptoms. Actions you can take to relieve your symptoms are:
  • Avoid foods that aggravate your symptoms (as listed above)
  • Add foods to your diet that tend to improve GERD:
    • Non-acidic fruits (bananas, apples, pears)
    • Foods lower in fat and calories
    • High fiber foods (whole wheat, oatmeal, brown rice, beans)
  • Avoid overeating
  • Lose weight
  • Stop smoking
  • Reduce consumption of alcohol and caffeine
  • Avoid medications that can irritate the lining of your stomach or esophagus (aspirin, ibuprofen)
  • Wait a few hours after eating to lie down or go to bed
  • Elevate your head when sleeping – raise the head of your bed by 6-8 inches
Medications may be needed if changes in your lifestyle do not offer enough relief for your symptoms. There are many options for medications and they can be extremely helpful. In some cases, patients may need lifelong medication:
  • Over-the-counter oral antacids, such as Tums™, Maalox™, Mylanta™
  • Over-the-counter H2 blockers, such as Tagamet™, Pepcid™, Zantac™
  • Stronger, prescription-strength antacids
  • Proton pump inhibitors, such as Prilosec™ and Previcid™
  • Medications that make your stomach empty faster, such as Reglan™ 
Surgery
For some patients who do not get relief from GERD/medications and lifestyle changes, surgery is often advised. The goal of surgery is to fix the anatomy rather than just treating the symptoms of GERD/reflux. Thoracic surgeons at BWH have excellent long-term success in these procedures, resulting in a cure rate of 90 percent. Surgery should be considered for patients who:
  • Have not had success with medications
  • Do not want to take chronic medication
  • Have complications of GERD (stricture, Barrett's esophagus; grade III or IV esophagitis)
  • Have medical complications attributable to a large hiatal hernia(bleeding, dysphagia)
  • Have atypical symptoms (asthma, hoarseness, cough, chest pain, aspiration) and documented reflux
Minimally Invasive Surgery:
  • Nissen fundoplication tightens the lower esophageal sphincter and helps to decrease acid from coming up from the stomach into the esophagus. Fundoplication is usually performed as a laparoscopic procedure.
  • Linx Procedure is a minimally invasive operation that is indicated for a small percentage of patients with GERD and no hernia where a chain is placed around the esophagus to prevent reflux.
  • Transoral Incisionless Fundoplication (TIF), a transoral (through the mouth) procedure in which the EsophyX device is used to wrap around the esophagus and create a fold. This is then repeated several times to create a tight valve to prevent stomach contents from flowing back up into the esophagus.
What You Should Expect

You will receive a thorough diagnostic evaluation and receive treatment by a board-certified thoracic surgeon who specializes in GERD/reflux. Careful monitoring and the involvement of an experienced thoracic surgeon are important to the successful outcome for patients with GERD/reflux.

If you need surgery, you will be taken care of in the operating room by surgeons, anesthesiologists and nurses who specialize in surgery for patients with thoracic problems. After surgery you will go to the recovery room (Post Anesthesia Care Unit) and then you will be transferred to the Thoracic Intermediate Care Unit (TICU) where you will receive specialized comprehensive care by an experienced medical and nursing staff to get you better rapidly.

Multidisciplinary Care

Brigham and Women’s Hospital provides a multidisciplinary approach to patient care, collaborating with colleagues in other medical specialties. If your thoracic surgeon discovers an underlying illness or concern, you will be referred to an appropriate BWH physician for an expert evaluation.

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