Dr Michail S Kourkoulos MSc FRCs, Laparoscopic GastroIntestinal and Bariatric Surgeon
Director of Upper GastroIntestinal and Antireflux Surgery, Mediterraneo Hospital
Gastro-Esophageal Reflux Disease (GERD) or Acid Reflux, is a chronic condition affecting 10-20% of the general population. It’s usually treated with diet and lifestyle modification, although frequently requiring further treatment with medication, and occasionally either endoscopic or surgical treatment methods. Below are the usual questions asked by GERD sufferers.
Which symptoms are suggestive of Gastro-esophageal reflux disease?
GERD presents with a variety of symptoms, caused by the pathological entry of gastric contents into the chest, to the point of mimicking coronary disease. It can present as regurgitation of food up to the mouth, or frequent vomiting. There can be respiratory problems or worsening asthma due to reflux of acid into the lungs. It can also cause halitosis and tooth decay due to chronic contact with acidic gastric contents. Most of these symptoms are worse at night due to sleeping horizontally, and after large meals.
What is the cause of GERD?
The most common cause is the presence of a hiatal hernia, which means that part of the stomach, along with the lower esophageal valve mechanism which under normal circumstances prevents reflux, is lying in the wrong anatomical part of the body, within the chest instead of the abdomen. Other causes include obesity, pregnancy which causes hormonal relaxation of the valve mechanism, medication such as cortisone and substances that lead to relaxation of the lower esophageal sphincter, as well as rare syndromes which cause either hyperacidity of the stomach, or esophageal dysfunction. GERD is usually worsened by increased body weight, eating habits and lifestyle. Symptoms can therefore be improved by weight reduction and lifestyle modification according to specialist guidance.
Is Gastro-Esophageal Reflux Disease dangerous?
Long term exposure of the esophagus to gastric acid can cause a wide range of problems. Initially there is chronic inflammation of the surface of the esophagus called esophagitis. If this is not dealt with, chronic intense inflammation can lead to stricture of the esophagus due to scarring, presenting as difficulty in swallowing solid foods. The most worrying complication of GERD is the development of Barrett’s Esophagus, a metaplastic transformation of the cells of the lining of the lower esophagus to another type which is also benign, but has a chance of malignant transformation and development of Lower Esophageal Adenocarcinoma if the symptoms are ignored.
What are the necessary dietary and lifestyle changes which help improve symptoms and reduce the possibility of further problems?
Weight loss is the most important change which leads to improvement of GERD symptoms. Avoidance of triggering foods is also very important. Coffee and chocolate contain substances which lead to relaxation of the lower esophageal sphincter, and avoiding them improves symptoms. The same applies for smoking. Fizzy drinks and beer expand the stomach due to release of CO2 gas, and increase the intragastric pressure causing the gastro-esophageal valve mechanism to open leading to worsening symptoms and therefore have to be avoided. Red wine also leads to reflux due to the flavonoids contained. It is also advised to avoid large meals, which once again lead to reflux via gastric distention. Spicy meals and certain foods such as tomato cheese and occasionally even apples worsen symptoms. It is advised to leave at least 3 hours between dinner and sleep, as a full stomach in a horizontal position will certainly cause reflux. Many patients use 2-3 pillows as a dependent position utilizes gravity to reduce reflux, although these tend to slip away during the night. My personal preference is elevating the top of the bed with either supports under the mattress or under the legs of the bed. Alternatively, there are purpose made wedge pillows that can be used.
Is there some form of treatment for improving symptoms until lifestyle changes take effect?
First line treatment for GERD symptoms consists of medications which reduce acidity of gastric contents, neutralize gastric acid, or protect the surface of the esophagus. The type, dosage and duration of treatment as well as any further investigation prior to its commencement, depend on the type, severity and duration of symptoms. Mild typical symptoms which improve with lifestyle changes alone do not require any further investigation, although this decision is best made by a specialist. The most common first line treatment is a 4–6-week trial of Proton Pump Inhibitors such as Omeprazole, Lansoprazole, Esomeprazole etc., alone or in combination with Gaviscon. In case of side effects, alternative medication can be used according to doctor’s guidance. Medical management reduces the acidity of refluxate and acid exposure of the esophagus, but does not treat the cause of reflux, which is dysfunction of the valve mechanism of the lower esophagus.
What happens if symptoms recur as soon as treatment stops?
Indeed, in many cases GERD symptoms reappear as soon as the above treatment is stopped. Should this happen, medication needs to be continued for life, at the lowest possible dose. There are no serious long-term effects from this type of medication, although there may be contraindications in certain conditions such as osteoporosis, as they may effect calcium absorption. There may also be side effects such as headache, bone and joint pains.
Is there another treatment option if medical management is ineffective, causes side effects, or the patient doesn’t wish to take lifelong medication?
In those cases, one can consider the possibility of Antireflux interventions or Surgery. It is necessary to perform meticulous investigation of reflux with a Barium Swallow, pH study and manometry. There is a choice of endoscopic techniques (Stretta, Esophyx etc), or Laparoscopic Antireflux Surgery (Laparoscopic Fundoplication, Linx procedure)
Who is the ideal specialist for advice regarding antireflux interventions?
The decision on the ideal interventional treatment should ideally be made by a Laparoscopic Surgeon with specialization in Gastrointestinal Surgery and a specialist interest in esophagogastric surgery, and experience in all antireflux endoscopic and surgical procedures