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This is a term to describe contents from the stomach splashing up into the esophagus. It is normal for humans to experience some reflux of gastric contents, but the frequency that exceeds a normal exposure diagnoses gastroesophageal reflux disease. Notice that the word "disease"  is in the phrase and is the "D" in the acronym GERD. There is a pathological level of gastroesophageal reflux earning a patient the diagnosis of the disease.

Causes

Gastroesophageal reflux disease comes from the failure of the natural reflux barrier. The failure can occur in several ways. Some of these common causes include a hiatal hernia, a weak or short lower esophageal sphincter, pregnancy, delayed gastric emptying, and certain diets.

Diagnosis

Just like other diseases, GERD progresses over time. Often times patients start early in their life with symptoms that cause their physician to diagnose them with GERD. The patients are then started on an acid-suppressing medication like a Proton Pump Inhibitor, or PPI. Usually, patients have already exhausted over the counter medications to help with the symptoms of GERD. Using the PPI will alleviate the heartburning symptom which will essentially make the diagnosis of gastroesophageal reflux disease. However, the true test for an absolute diagnosis is a pH study, such as a 24 hour pH catheter or a BRAVO probe. These tests will demonstrate elevated levels of acid in the esophagus which definitively makes the diagnosis of GERD. These tests have become less common to diagnose GERD because the disease is extremely common and is easier done by a trial with a PPI.


BRAVO probe placement in the esophagus
 

In either situation, the diagnosis of gastroesophageal reflux disease is reliably made and can be treated. The progression of the disease will often exceed the ability of the PPI to control the symptoms of GERD. Patients will often return several times to their prescribing physicians for the persistent symptoms and complaints. Physicians will titrate to a higher dose and frequency of the medications and emphasize a strict regimen. But with continued use of PPIs, the symptoms will often return as the disease progresses. At this point, PPIs will no longer control the symptoms and surgery is indicated to stop the gastroesophageal reflux.

Treatment

Surgery is indicated for patients that have failed management with medications (such as PPIs), have a desire to no longer take medications, or have a hiatal hernia. The knowledge of the physiological changes with regard to GERD have been studied extensively and surgical treatments have improved. The steps to repair gastroesophageal reflux disease with surgery are at the discretion of the surgeon. Examples include:

Hiatal Hernia – see the section on Hiatal hernias

Fundoplication – this is a procedure that has evolved over the last 40 years. The ability of the surgeon to tailor the fundoplication to the patient's needs have improved greatly. There is a preoperative workup that needs to be undertaken for the surgeon to determine the best fundoplication for the patient.

    • Th ere is a variety of fundoplications available, but most commonly discussed are partial fundoplications and complete fundoplications (often called a Nissen fundoplication). Partial fundoplications are created to help accommodate patients with poor esophageal function. Nissen fundoplications are used more readily.
    • Th e fundoplication does not create a new lower esophageal sphincter or provide a new valve. It simply prevents the effacement of the walls of the esophagus with increased pressure and reestablishes the natural reflux barrier by restoring some of the features of the angle at which the esophagus enters the stomach.


Complete fundoplication (Nissen)


 

Magnetic Lower Esophageal Sphincter Augmentation or LINX procedure – This procedure has been performed in Europe before 2012, but in March of that year, the FDA approved the LINX device in the United States. This is an implant that is surgically implanted around the bottom of the esophagus and prevents the effacement of the walls of the esophagus. Once implanted, the walls of the esophagus don't open to allow stomach contents into the esophagus, thus preventing the GERD symptoms. This procedure typically does not have some of the side effects that are present with the fundoplications. Only certain patients are candidates for this procedure. Click here to learn more about the LINX device.

LINX position below the diaphragm

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Size of the LINX device

Other endoscopic techniques are available such as Stretta and the TIF procedure. Please contact our office to discuss these surgical options.