Health Chats
GERD/Heartburn: Advances in the Treatment of Severe GERD
Wednesday Apr 07, 2010, 05:00PM - 06:00PM (EST)
Elliot R Goodman, MDBlank
Chief of Bariatric Surgery Service
Beth Israel Medical Center
Surgery, New York, NY
GastroEsophageal Reflux Disease (GERD), also referred to as heartburn, is reflux and regurgitation of the contents of the stomach into the esophagus that is frequent and severe enough to impact daily life and may even damage the esophagus. Normally, after swallowing, a valve between the esophagus and stomach opens to allow food to pass into the stomach, then closes to prevent reflux of the food back into the esophagus. In GERD, this valve is weakened or absent, causing the acidic digestive juices from the stomach to flow back (or reflux) into the esophagus. <br><br> The esophagus is not designed to handle the acidic environment of the stomach. This reflux is not only painful and uncomfortable, but can burn the esophagus, cause chronic inflammation, and can lead to major damage and cancer of the esophagus. GERD is one of the most common diseases, with over 60 million Americans experiencing symptoms at least once a month. For many lifestyle modifications can significantly decrease the occurrence and severity of GERD and are usually the appropriate first step in the treatment process. <br><br> Drug therapies such as proton pump inhibitors (PPI) and H2 (H2RA) blockers reduce ‘typical' GERD symptoms caused by acid exposure, but they are not effective in treating non-acidic or alkaline reflux and ‘atypical symptoms' like asthma, or chronic cough. Even if drug therapy is effective, it may be needed for life, since symptoms and disease return as soon as medication is stopped. Surgery is sometimes indicated for patients with severe GERD who have failed less invasive treatments. Laparoscopic repair has been shown to be effective in 75-90% of patients in alleviating heartburn and 50-75% in alleviating cough, asthma, and laryngitis. Unfortunately, even laparoscopic surgical repair can be invasive and typically has a high incidence of side effects like gas bloat and difficulty swallowing. For this reason, less than 1% of GERD patients currently choose invasive surgical therapy to treat their condition. <br><br> Transoral Incision Free Fundoplication (TIF) is the third wave in the evolution of surgical procedures for the treatment of GERD and builds upon the principles of proven open and laparoscopic procedures used to effectively treat the disease. The key differences are that EsophyX TIF is performed through the mouth, does not require any incisions, and does not dissect any part of the natural internal anatomy. Benefits include reduced recovery time and discomfort and most patients are able to return to work and normal activities within a couple of days after the procedure. <br><br>
Dr. Elliot Goodman:
Make sure you have modified your behavior & diet appropriately - e.g., no smoking, no coffee, no alchohol etc.
Dr. Elliot Goodman:
If you still have an ulcer in spite of the protonix, you may have to have blood tests to rule out certain other conditions causing resistant ulcers.
Dr. Elliot Goodman:
If your ulcer can be healed, then surgery may be appropriate for your GERD.  
Dr. Elliot Goodman:
This could be laparoscope or endoscopic.
maree1:
my daughter is 17 yrs and has chronic eonsiphlic esophagutis, a nut cracker esophagus, and a cork screw esophagus, she has had a fundopocation at age 5 none of the medications the specialist have given her have worked.  They are talking about small amounts of chemotherpy, have you any ideas on what else could be done?
Dr. Elliot Goodman:
It sounds like your daughter may have a problem with esophageal contractions
Dr. Elliot Goodman:
They may respond to various medications and sometimes endoscopic stretching.
Dr. Elliot Goodman:
Occasionally surgery might help to reduce the spasms of the esophagus.
Dr. Elliot Goodman:
I don't know exactly which chemotherapy might help your daughter, but I am sure she has been seen by a GI specialist and surgery might be performed by a thoracic surgeon.
Zoelula:
I have had GERD for about 12 years (I'm 61). I take Nexium 40mg and Sucralfate after meals. Recently my symptoms have gotten worse.  It has never been typical, no feeling of acid coming up. Just pain or tightness and it makes my arrhythmia worse (palpitations). GI recommended endoscopy and other tests. What do you think can be going on and is their a danger from just "living with it"?
Dr. Elliot Goodman:
People with GERD for many years may develop Barrett's Esophagus.
Dr. Elliot Goodman:
This is a precursor to esophageal cancer.
Dr. Elliot Goodman:
I would recommend therefore, at least an endoscopy and then other appropriate tests based on the results of the endoscopy.
Dr. Elliot Goodman:
This should be taken very seriously - don't put off the endoscopy recommended by your GI doctor!
jasonv11:
Dr Goodman  about the  Esophyx Tif   how safe is it? is this a life time fix? I read that you can only have a H.H. of less then <2mm can it be used on bigger HH? If the Esophyx is not a life time fix how long does it last? can a person have a normal life after the Esophyx or will they have to watch what they lift and eat?
Dr. Elliot Goodman:
Esophyx is very safe.
Dr. Elliot Goodman:
It carries the same risk associated with any endoscopic procedure performed under general anesthesia.
Dr. Elliot Goodman:
It is relatively new, so we do not know it's results beyond 2-3 years after surgery.
Dr. Elliot Goodman:
However, Esophyx is as effective as regular anti-reflux surgery.
Dr. Elliot Goodman:
80-90% of patients have their GERD cured and are off PPI's at 2 years after Esophyx.
Dr. Elliot Goodman:
It can fix a hiatal hernia of less than 20mm (not 2 mm).
Dr. Elliot Goodman:
Patients after Esophyx are on a regular diet within 6 weeks after the procedure and have no lifting restrictions after 6 weeks.
patunia467:
My son has been vomiting everyday all day long for over a year now.  They have done many tests for reflux and say that is not it.  But they also don't know what it is.  They did a barium swallow, they put him to sleep and went down his throat and they did an emptying study.  What do you think it could be?  He is not in pain he just feels sick in the belly a few seconds before he actually vomits.
Dr. Elliot Goodman:
The actual diagnosis will depend on your son's age.
Dr. Elliot Goodman:
Further useful tests might be Ph and manometry.
varbetz:
I don't have taking  heartburn ,but I have excessive burping with reflux,I am taking Omerprazole DR 20 mg is this the correct medication for this problem.
Dr. Elliot Goodman:
Based on what you have stated, you might consider increasing the dose to 40 mg and the frequency to twice per day.
Dr. Elliot Goodman:
Again, remember that these medications do not fix the underlying problem, which might be a faulty valve - in which case only surgery would repair that.
blujayne:
Had reguar heartburn for years and self medicated. Just had endoscopy and found evidence of Barrett's Esophagus, Have recently had NO heartburn, but vomiting, weight loss, early satiety, epigastric pain and bloating. Have not recieved biopsy results yet. I was wondering if it is possible to experience these symptoms just as a result of the BE itself or if BE is normally asymptomatic?
Dr. Elliot Goodman:
BE is often asymptomatic.
Dr. Elliot Goodman:
As I said before, it is a risk factor for esophageal cancer and must be taken seriously.
Dr. Elliot Goodman:
There is a new procedure called the HALO - which can remove the abnormal lining seen in Barrettps Esophagus, which will reduce that risk of esophageal cancer.