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Digestive Diseases

Gastroesophageal Reflux Disease (GERD)

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GERD occurs when gastric acid from the stomach backs up into the esophagus (known as acid reflux), usually because of a weakness in the esophageal sphincter that keeps it from closing the esophagus off from the stomach. The acid can cause heartburn, chest pain, and even respiratory symptoms. Adverse effects of reflux range from inflammation (esophagitis) to more serious conditions including bleeding, ulcers, and even esophageal cancer. GERD is often treated very successfully with medication, but some people with persistent symptoms choose surgery to alleviate their discomfort. In particular, patients with large hiatal hernias are frequently referred for surgical treatment.

Symptoms

Symptoms include heartburn, which is a sense of burning in the chest behind the breastbone or in the abdomen especially when bending or lying down. GERD also may cause regurgitation of food, trouble swallowing, hoarseness, coughing, wheezing, sore throat, and asthma.

Risk Factors

Risk factors for GERD include obesity, hiatal hernia, smoking, pregnancy, and diabetes. Eating large meals, lying down right after eating, spicy foods, alcohol, chocolate, caffeine, tomato sauce, onions, and carbonated beverages may worsen GERD.

Diagnosis

GERD is initially diagnosed by symptoms and a patient's response to a class of drugs called proton pump inhibitors, which reduce the stomach's production of acid.

Complicated cases of GERD may require endoscopy, in which a thin, flexible tube equipped with a light and camera is inserted through the mouth and into the throat to view the esophagus and stomach and determine if there is inflammation or an ulcer. A tissue sample can be taken to test for Barrett's esophagus, a precancerous condition in which cells in the esophagus become abnormal.

Treatment

Physicians will usually begin to treat GERD by prescribing long-acting, prescription-strength proton pump inhibitors to suppress the production of stomach acid. Other medications used include H2-receptor blockers, which also reduce acid production, and prokinetic drugs, which help the stomach empty faster and may tighten the lower esophageal sphincter – the muscular valve between the esophagus and stomach.

People who do not respond to medication may require a surgical procedure. The standard surgical treatment for GERD is a procedure known as Nissen Fundoplication. However, surgeons at NewYork-Presbyterian are also testing two alternate procedures: Endoscopic Fundoplication and a second procedure where surgeons install a "bracelet" of magnetic beads near the gastroesophageal junction.

Nissen Fundoplication

Nissen Fundoplication is a surgical procedure used to treat gastroesophogeal reflux disease (GERD). It is also used to treat hiatal hernia, which occurs in more than half of GERD cases. Hiatal hernia is when part of the stomach bulges into the chest cavity through an opening in the diaphragm.

In a Nissen Fundoplication, named for the Swiss doctor Rudolph Nissen, who perfected the procedure, the upper part of the stomach is "wrapped" 360 degrees around the lower portion of the esophagus, and sutured to create a new valve between the two areas. This allows the lower esophageal sphincter to close, eliminating the acid backflow from the stomach.

Though the surgery itself is considered very safe, rarely side effects can occur, including temporary difficulty in swallowing, difficulty vomiting, or accumulation of gas in the stomach (bloating). A patient's diet may need modification before the surgery, but the objective is for the diet to return to normal following the operation. Most people can discontinue their reflux medications after the procedure.

Over time, variations of Nissen Fundoplication have been introduced, including a variety of partial wraps. In the 1990s, less invasive laparoscopic fundoplication surgery became the gold standard for surgical treatment of GERD and is practiced by most experienced surgeons.

Endoscopic Fundoplication

Endoscopic Fundoplication offers an even less invasive alternative to Nissen Fundoplication that can be completed in an hour or less without any incisions. Tools are inserted through a tube placed in the esophagus and used to perform a partial wrap of the stomach around the esophagus, aided by a small camera. The procedure has been evolving for several years, and though it is too soon to know its long term effectiveness, early results indicate that it completely relieves symptoms in approximately half of patients and allows most of them to discontinue taking daily medications.

Endoscopic Fundoplication cannot address large hiatal hernias, which need to be corrected with a different procedure, but have proven effective at treating GERD in patients with small ones.

Magnetic Beads

Another new procedure currently being examined involves using magnetic beads to place pressure on the gastroesophageal junction. The beads resemble an expandable bracelet that is placed on the lower esophageal sphincter using a laparoscopic incision. When a person eats or drinks, the esophageal pressure pushes apart the magnets, allowing swallowing. Then the bracelet resumes its shape, once again tightening the seal between the esophagus and the stomach.

Both Endoscopic Fundoplication and the magnetic bead treatment are considered safe, although long term results are not yet known. Some side effects associated with open or laparoscopic surgery, including temporary difficulty swallowing or gas bloat syndrome, are less common when these newer techniques are used.

Contact

Digestive and Liver Diseases, NewYork-Presbyterian/Columbia
Directions
(212) 305-1909
Gastroenterology and Hepatology, NewYork-Presbyterian/Weill Cornell
Directions
(646) 962-4463
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