Gastroesophageal reflux occurs when contents in the stomach flow back into the esophagus. This happens when the valve between the stomach and the esophagus, known as the lower esophageal sphincter, does not close properly.
Common (or typical) symptoms of gastroesophageal reflux disease are heartburn and/or acid regurgitation, but not everyone who has GERD may have heartburn. Heartburn is a burning sensation felt behind the breast bone that occurs when stomach contents irritate the normal lining of the esophagus. Regurgitation is the sensation of stomach fluid coming up through the chest which may also reach the back of the throat, the sinuses, and even the mouth. Less common (or atypical) symptoms that may also be associated with gastroesophageal reflux include unexplained chest pain, wheezing, sinusitis, hoarse voice, adult onset asthma, sore throat, and cough, among others.
Gastroesophageal reflux disease (GERD) occurs when there is an imbalance between the normal defense mechanisms of the esophagus and offensive factors such as acid, bile, and other digestive juices and enzymes in the stomach. Often, the barrier between the stomach and the esophagus is impaired by weakening of the muscle (lower esophageal sphincter) or the presence of a hiatal hernia, where part of the stomach is displaced into the chest. A major cause of reflux is obesity whereby increased pressure in the abdomen overcomes the barrier between the stomach and the esophagus. Obesity, pregnancy, smoking, excess alcohol use and consumption of a variety of foods such as coffee, citrus drinks, tomato based products, chocolate, peppermint and fatty foods may worsen reflux symptoms.
When a patient experiences common symptoms of gastroesophageal reflux disease, namely heartburn and/or acid regurgitation, additional tests prior to starting treatment are typically unnecessary and treatment can be initiated by your family doctor to help with your symptoms. However, it is highly recommended to have an upper endoscopy to rule out complications of GERD, such as esophagitis and Barrett’s esophagus. Upper endoscopy is a test in which a small tube with a light at the end is used to examine the esophagus, stomach and duodenum (the first portion of the small intestine). Before this test, you will receive medications to help you relax and lessen any discomfort you may feel. An upper endoscopy allows Dr. Simoni to see the lining of the esophagus and detect any evidence of damage due to GERD. A biopsy of tissue may be done using an instrument similar to tweezers. Obtaining a biopsy does not cause pain or discomfort. Another test, known as pH testing, measures acid in the esophagus and can be done by either attaching a small sensor into the esophagus (BRAVO pH) or by placing a thin, flexible probe (impedance pH) into the esophagus that will stay there for 24 hours while content of the esophagus as well as direction of contents is being measured. This information is transmitted to a small recorder that you wear on your belt. X-ray testing is an outdated test and has no role in the initial evaluation of individuals with symptoms of reflux disease. However, in order to ensure that you are a surgical candidate for treatment of GERD, an esophagram (X-ray of esophagus) may be ordered by Dr. Simoni.
1- Lifestyle modification (cheap but minimally effective): reflux symptoms sometimes disappear if dietary or lifestyle excesses that cause the symptoms are reduced or eliminated. Avoiding these items may reduce your discomfort:
2- Medications (more expensive, effective, but not great as a long term treatment): over-the-counter antacids may decrease discomfort of GERD. Antacids, however, only work for a short time and for this reason, they have a limited role in treating reflux disease.
Histamine H2 receptor antagonists (cimetidine, ranitidine, and famotidine) decrease acid production in the stomach. These medications work well for treating mild reflux symptoms and are quite safe, with few side effects. They are available over the counter at a reduced dose, or at a higher dose when given by prescription by a doctor.
Proton pump inhibitors (omeprazole, lansoprazole, pantoprazole, esomeprazole, and rabeprazole) are all highly effective in treating reflux symptoms. These medications act by blocking the final step of acid production in the stomach and are typically taken once or twice daily prior to meals. For reflux symptoms that occur frequently, proton pump inhibitors are the most effective medical treatment. However, these drugs were designed initially to treat ulcers and to be used for a short period of time.
Prokinetics, or medications that stimulate muscle activity in the stomach and esophagus, are sometimes provided for the treatment of reflux disease. The only available drug in the market is metoclopramide, which has little benefit in the treatment of reflux disease and has many side effects, some of which can be serious.
Lately, melatonin at a twice a day dose, has also shown decrease in symptoms of GERD especially when used with PPIs. However, since Gastroesophageal reflux disease (GERD) is a result of an abnormal valve, medications would not correct the mechanical problem and we may need to seek further treatment.
3- Surgery (may seem expensive in short term but will be less expensive than life-long use of drugs): should be considered in patients with well-documented reflux disease who cannot tolerate medications, do not like to be on life-long drug therapy, have other symptoms than typical heartburn, or continue to have cough and regurgitation despite maximal drug therapy. If symptoms persist despite medical treatment, a comprehensive evaluation should be completed prior to considering surgery. The surgery for treating reflux disease is known as fundoplication. In this procedure, a hiatal hernia, if present, is eliminated and part of the stomach is wrapped around the lower end of the esophagus to strengthen the barrier between the esophagus and the stomach. The operation is traditionally done via a laparoscope (Nissen fundoplications), an instrument that avoids a full incision of the stomach. However, due to invasive nature of these surgeries and some long term adverse symptoms in some patients (such as inability to belch or vomit, or excessive bloating and flatulence) many gastroenterologists shy away from them. Fortunately, since 2007, an FDA approved, minimally invasive procedure that does not require incisions and achieves an effective fundoplication called TIF (Transoral Incisionless Fundoplication) without long-term problems of Nissen fundoplication has been available in the United States. Dr. Simoni is one of the first gastroenterologists in the country who started to offer the TIF procedure to his patients in 2009. Since then, he has performed numerous successful TIFs with excellent outcomes and very high patient satisfaction. Due to the complexity of this surgery, it is important to seek a skilled expert, such as Dr. Simoni, who has experience in performing this procedure and can discuss the risks and benefits of the procedure.
You should see Dr. Simoni immediately if you have symptoms such as unexplained weight loss, trouble swallowing or internal bleeding in addition to heartburn and/or acid regurgitation. Symptoms that persist after you have made simple lifestyle changes also warrant a visit to Dr. Simoni. In addition, if you use over-the-counter medications regularly to reduce symptoms such as heartburn or acid regurgitation, you should consult Dr. Simoni to determine the best course of treatment for you.
The preceding information is intended only to provide general information and not as a definitive basis for diagnosis or treatment in any particular case. It is very important that you consult Dr. Simoni about your specific condition:
Advanced Gastroenterology, Inc.
Phone: (805) 719-0244
Fax: (805) 777-1730
555 Marin Street, Ste. 270
Thousand Oaks, CA 91360