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Acid Reflux

 Acid Reflux

 Acid Reflux Fact:  Acid reflux is a condition in which the liquid contents of the stomach regurgitate (back up) into the esophagus sometimes causing irritation and pain. 

CONCEPTS

Gastroesophageal reflux is a normal phenomenon. It typically occurs transiently after eating. Gastro esophageal reflux disease(GERD) is the condition where degree of exposure of esophageal mucosa to gastric contents is greater than normal. The most common symptom is heartburn but patients may have other symptoms. The modern concept of reflux esophagitis appears to emerge in a publication by Winkelstein in 1935 when he said: One can't escape the suspicion that the disease in these cases is possibly a peptic esophagitis i.e. an esophagitis occurring as a result of acid and pepsin�. You may ask: So what is the big deal. Well folks, It really is a big deal. Did U know that according 1988 survey, more than 61 million or 44% of adult Americans suffer at least once monthly. Did you know that as many as 13% of adult Americans reported taking antacids two or more times per week. As many as 7% of adult Americans have daily occurrence of heart burn. As such, you would agree with me that this disorder has potential for considerable morbidity and socio-economic consequences.

ACID AND ALKALI

Traditionally, acid has been thought to be the noxious substance in producing reflux symptoms. And the therapy has been directed at that and quite successfully so. A definite role for duodenogastric reflux and alkaline reflux into the esophagus may be important in some patients but not clearly established.

PROTECTION AGAINST REFLUX

There are normal mechanisms protecting against GERD.The pump includes the squeezing (peristaltic) function of the esophageal body,effect of gravity in upright position and the neutralizing effect of saliva.All these tend to limit the exposure of the esophagus to the refluxed acid. The VALVE function is the Lower esophageal sphincter. The RESERVOIR function of the stomach predisposes to GERD when there is delayed gastric emptying,hypersecretion of acid or gastric outlet obstruction. Most reflux occurs during transient periods after meals in an upright position and this is rapidly cleared from the stomach. The mechanisms leading to the acid induced injury of esophagus have not been well studied. Conceptually injury occurs when esophageal defense mechanisms are overwhelmed by the prolonged exposure to noxious gastric refluxate.

PRESENTATION

We of course all know how the GERD presents i.e. heartburn and pain etc. Or its complications. However, that is oversimplification and there are lots of other ways GERD can present e.g. Hoarseness, chronic cough, asthma, laryngitis, recurrent pneumonia and ENT infections, nocturnal choking, sleep apnea, loss of dental enamel, bad breath and globus sensation. Acid reflux has been implicated in sudden infant death syndrome. Many pulmonologists routinely try acid suppression in cases of atypical asthma. The mechanisms of these extra esophageal manifestations are not clearly established and include aspirations or neurogenic reflexes.

MANAGEMENT

More often than not, empirical treatment is initiated and if no satisfactory response to medical treatment, investigations are carried out. A structural lesion of the upper gastrointestinal tract should be excluded by contrast studies or preferably endoscopy. Of note, many patients with GERD may not show endoscopic evidence of reflux esophagitis. As such, if the above studies fail to show any significant abnormality, a possible diagnosis of GERD should still be pursued with ambulatory 24 hour pH monitoring etc. Use of provocative tests and esophageal manometry for diagnosis of routine GERD is controversial.

DIET

Okay now that we have covered the essential work up, let us go on to the therapeutic options. At this time I would like to reiterate that patients. who have relatively severe Gastro-Esophageal Reflux Disease are a small fraction and most just take Over-the-counter medications and never see the doctor. It is well documented that certain foods promote or worsen symptoms of acid reflux. Citrus, tomato and coffee directly irritate the mucosa while onions, chocolate, peppermint and high fat lower the pressure. Other foods to avoid include garlic, onions, fatty foods and alcohol. Overeating as well as going to bed within 2-3 hours of supper should be avoided since gastric distention promotes reflux. Weight gain, smoking and alcohol have also been implicated in the pathogenesis of Gastro-Esophageal Reflux Disease and thus should be avoided.

HEAD ELEVATION

Reflux symptoms may be reduced simply by elevating the head end of the bed or by using a wedge under upper body. The esophageal acid exposure time is reduced by gravity.

SMOKING

Many of these patients are smokers. So they should be counseled about cessation of smoking.

DRUGS

Pharmacological treatment involves the use of H2 antagonists (Tagamet, Zantac, Pepcid, Axid) and proton pump inhibitors (PPI) like Prilosec, Prevacid, Aciphex or Protonix for treatment of acute disease. The doses required may be higher than those in peptic ulcer disease. Literature suggests that PPI produce greater relief of esophagitis than H2 blockers.

PROKINETIC AGENTS

What about prokinetic agents(drugs promoting gastrointestinal motility). Treatment with reglan has been disappointing in general. Cisapride is a new prokinetic agent an addition to our armamentarium. It has shown some efficacy in GERD treatment remission and is a useful adjunct stage. However, the concerns for toxicity related to heart complications and deaths while taking this drug have essentially forced it out of market.

COMPLICATIONS

Treatment of GERD not only improves symptoms like heartburn, but early recognition and treatment of clinically significant GERD may prevent the development of some of the complications. Bleeding obstruction and even malignancy can complicate the matters in the long run.

TREATMENT OF STRICTURE

Most peptic strictures can be effectively dilated by gastroenterologists without resorting to surgery. Perforation is a known complication of the procedure.

MAINTENANCE THERAPY

Patients with significant GERD may need acid-suppression as maintenance therapy for the long haul.

FAILURE OF MEDICAL THERAPY

Let us now go on to the problems with medical therapy. During medical therapy, loss of esophageal function can occur which can impair the ability to perform surgery. Drugs also do not improve pre-malignant Barrett's esophagus. Also long term safety of newer potent medications has not been established. Patients are referred often at late stage when surgery has poor results.

SURGERY IS ALWAYS THE SECOND BEST

So what can we do surgically for these pts with GERD especially the ones we cannot treat with drugs and endoscopic interventions. Actually, in contrast to peptic ulcer disease, surgery has a lot to offer to patients with GERD.

INDICATIONS FOR SURGERY

Every one has a different threshold for referring for surgery.

I believe that an anti-reflux operation performed by a skillful and experienced surgeon on an appropriately selected patient can be satisfying and cost effective treatment for reflux esophagitis and its complications.

A young patient with severe Gastro-Esophageal Reflux Disease may require years and years perhaps life long medical treatment. This entails lot of cost and while these drugs appear to be safe, long term effects are not known. So in YOUNGER patients with SEVERE esophagitis and normal PERISTALTIC function, surgical option should be considered even when medical treatment may be effective.

Stricture not responding to dilatation requires esophagus replacement. Perforation is a known complication of dilatation. Strictures that can be dilated are usually treated by fundoplication.

Patients with low grade dysplasia may be followed closely with aggressive acid suppression. High grade dysplasia need surgery because many of these pts have undetected malignancy.

SUCCESS OF SURGERY

On the basis of recent literature, approximately 70-90% of patients undergoing an operation by a highly experienced surgeon have good results that are maintained for 10 years after surgery. After about 20 years after surgery, approximately 1/3 have failed, although long term outcome has not been well studied. BEST chance of repair is the first one. Repeat anti-reflux procedures are much more technically difficult than the initial repair. Therefore success of first repair is important. Initial reports of Laprascopic Nissen's fundoplication.

MEDICAL VERSUS SURGICAL TREATMENT

Randomized controlled trials comparing medical therapy and surgical anti-reflux procedure demonstrate that the surgical group overall fares better. However, the caveat is that these studies were done prior to advent of the very potent anti-secretory agents used today. So the jury is still out. In addition, the problem with surgical literature is that the published experience reflects the best experience and especially in the realm of anti-reflux surgery; the local experience and the published experience can be widely discrepant.

NON-SURGICAL ENDOSCOPIC TECHNIQUE

Please read article on "Advances in Digestive Diseases "

CONCLUSION

Gastro- Esophageal Reflux Disease (GERD) is extremely common disorder and is primarily treated with changes in lifestyle as well as acid suppression. Changes in life style like diet modification, elevation of head end of bed and cessation of smoking are important. Acid suppressive agents are the most frequently used drugs. GERD is a chronic problem and may need life long treatment to prevent relapses. Controlled studies have shown surgery to be superior although these studies were undertaken prior to the very effective and potent acid suppressive drugs available now. Surgical option should be considered in appropriately selected patients especially the ones difficult to manage or those with complications. Type of surgery should be tailored according to the presence of complications as well as the manometric characteristics.

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