Acid Reflux Syndrome
Here you will find information on the treatment of acid reflux disorders and whether an operation is the right thing for you. If you don't want to read it all, select a link below to jump to a specific section.
Overview of acid reflux syndrome
Acid reflux syndrome, properly referred to as "gastroesophageal reflux disease" (GERD), is a chronic condition in which stomach acids escape, or reflux, into the lower esophagus. The acids inflame the lining and wall of the esophagus, causing heartburn and other symptoms. Acid reflux syndrome generally does not go away on its own and at times requires surgical intervention to treat properly. The surgery (Nissen fundoplication) has a very high success rate, with about 90% of patients experiencing complete relief or a significant reduction in the amount of reflux.
Evaluation of acid reflux symptoms
Patients with reflux of acid up into the esophagus may experience a variety of symptoms: heartburn, chest pain or achiness, hoarseness, sore throat, wheezing, asthma, sinus problems, vocal cord polyps, and others. Usually heart disease must be ruled out as a possible source of chest symptoms.
Our purpose is to determine:
- How much acid is actually refluxing?
- How effective are the esophageal contractions and the lower esophageal sphincter (valve muscle)? These are necessary to push food into the stomach.
- What is the state of the lower esophageal inner membrane or lining? Are there pre-cancerous cells? (Barrett's esophagitis)
- Are there any other abnormalities, such as stomach ulcers or gallbladder problems influencing the situation?
To answer these questions, Dr. Beutel will run run a series of tests. This will determine whether the symptoms are caused primarily by acid reflux, or caused by some other problem.
Determining your condition
Any or all of the following tests may be ordered to help determine your condition:
Twenty-four-hour pH study
This study answers question 1 under Symptoms, and gives a running count of the acid splashes into the lower esophagus. A tiny plastic coated probe, which is placed through the nostril into the lower esophagus, measures acid during a 24-hour period of normal activity at home or work.
Manometry
For this test, which answers question 2 under Symptoms, another small probe is used over a thirty to forty minute period to determine the strength of the esophageal muscle. The patient swallows cool water while the probe measures the pressures of the esophageal muscle during the swallows.
Upper endoscopy
Using a rubber-coated scope, or light, the doctor looks into the stomach to help answer questions 3 and 4 under Symptoms. Biopsies or tiny "nibbles" of the membrane are taken to allow the pathologist tissue to examine under the microscope.
Upper GI series
Barium X-rays may help to give a "road map" of your esophagus and to confirm other reports.
If the diagnosis is acid reflux syndrome, laparoscopic surgery may in some cases be the best treatment.
Surgical procedures
For many years, Nissen fundoplication has been a valuable treatment of acid reflux and GERD. Dr. Rudolf Nissen pioneered the operation, which continues to be successful in reducing or eliminating the abnormal or excessive acid in the esophagus.
Fundoplication refers to wrapping the "fundus," or top part of the stomach, around the lower esophagus. This procedure creates a functional valve around the lower esophagus, which then prevents most of the reflux of acid or stomach juices from coming up, or refluxing, into the espohagus. At the same time, it allows nearly normal swallowing activity, and most patients are capable of "burping" which allows release of trapped stomach gas.
The procedure usually takes two to three hours. Nissen fundoplication is considered a safe procedure; however, the success of the operation rests on the skill and extensive experience of the surgeon. Approximately 5% of cases will need to resort to an open incision as opposed to using a minimally-invasive laparoscopic technique.
At least 90% of patients have good, very good, or excellent results. In most patients no further stomach medications are needed beyond the first few weeks. In a few cases medication may still be needed, but in those, a low dose of a less expensive medicine is often adequate.
Most patients will be home within 24 hours after surgery. Pain medication may be needed during the first 3 to 7 days after the operation. However, the pain is usually not severe and is well managed with oral prescription pain medications. Patient adjustment to the "wrap" or "tuck" in the stomach can take from four weeks to a year.
Diagram of a Nissen fundoplication
1. Normal stomach. Stomach acid comes up the esophagus (refluxes), causing heartburn and other related symptoms.
2. Successful Nissen fundoplication. The fundus is folded or wrapped all the way around the lower esophagus and then surgically attached to itself. This creates a sort of "valve" that still allows food into the stomach, but prevents the stomach acid from escaping up into the esophagus.
Post-operative instructions
Following surgery, Nissen fundoplication patients will need to observe the following regimen until fully recovered.
Diet
- Pureed diet for three days. Soft diet for three weeks.
- Eat slowly and chew well. Take small bites. No eating on the run.
- Avoid steak and bread for 3-4 weeks.
- Avoid carbonated "fizzy" drinks and greasy foods.
- Breads may cause a slow or troublesome passage to the stomach, so be careful.
Medications
- At first, use Reglan 10 mg. one half-hour before meals to help prevent excessive bloating.
- Gradually wean off the Reglan over a 3-4 week period, if possible, but keep some with you to use if bloating symptoms occur.
- Otherwise, use your usual medicines.
- Antacids or laxatives are okay.
- You will probably not need Prilosec, Prevacid, or Aciphex.
- Pepcid over the counter can be taken if needed.
Activity
- Walking is good. Stairs are okay.
- No weight lifting or strenuous activity for six months.
- Driving is okay after seven days.
- Shower or bathe as usual.
Frequently asked questions
Dr. Beutel answers some of the most common questions concerning acid reflux syndrome and its surgical treatment.
As a patient, how will I know whether I should consider surgery?
"This is a good question, because some patients have minimal reflux and can do well with antacids, so they do not need surgery.
"Other patients have moderate reflux which can be managed with antacids, the Zantac class of drugs, and/or the more expensive Prilosec class of drugs, which is available now in a less expensive generic form. However, some physicians feel that it may not be the best long-term solution to the problem for several important reasons. Surgery provides an excellent alternative.
"Still other patients have nearly continuous reflux during the day or the night, or both, and for these patients surgery is the best option. Any patient with 'pre-cancerous cells', which is called Barrett's esophagitis, should strongly consider surgery, since it may be more successful in preventing progression of this condition to cancer (studies on this issue are still in progress).
"Some symptoms in the chest and sternal area may be due not to reflux but to other medical conditions. This is why you need a qualified physician to help you understand your situation."
What about my hiatal hernia?
"A hiatal hernia certainly has a bearing on the situation, and can be in some patients the primary cause of their reflux, though repairing the hiatal hernia, alone, would not be sufficient to stop the reflux. The hiatal hernia repair is usually done laparoscopically, at the time of surgery for acid reflux syndrome."
How much does surgery really help?
"Many patients do experience dramatic results. In some cases, however, the side effect of slower swallowing can be temporarily bothersome. In the great majority, the benefits far outweigh the minimal side effects."
What is the most frequent problem after the surgery for heartburn?
"Mild gas bloating may occur after Nissen fundoplication. This is a feeling of fullness particularly after meals, which will be less of a problem as the patient learns to eat more slowly and smaller meals. Avoiding carbonated beverages and greasy or heavy foods, and taking a Reglan tablet a little while before meals will also help. Usually this symptom tapers off after several days or a few weeks. Certain aspects of my operative technique have helped to minimize this problem for my patients."
What are the risks of the operation?
"Risks include bleeding, which could lead to splenectomy (unusual), perforation of esophagus or other organ, which could lead to other operations and serious infections in the abdomen or chest (<0.5%), and difficult adjustment to operation, which could require revisional surgery (<0.5%).
"Approximately 5% of cases will need to resort to an open incision as opposed to using a minimally-invasive laparoscopic technique."
Related documents: 
Acid reflux information, Acid reflux diet & lifestyle
