Heartburn
Heartburn is described as a harsh, burning sensation in the area in between your ribs or just below your neck that occurs 30 to 60 minutes after a meal. The feeling may radiate through the chest and into the throat and neck. Most often this is a symptom of improper digestion, but other conditions may produce this sensation. (It is important to note that any severe chest pain, lasting more than 15 minutes that does not respond to treatment requires immediate attention to rule out heart disease or a heart attack.)
Everyone is prone to heartburn, especially after overeating, but it is estimated that a high percentage of people suffer frequently enough to require evaluation. This chronic heartburn is most commonly a symptom of gastroesophageal reflux disease (GERD). It can be aggravated by exercise, bending over, and eating right before bed. Other symptoms may also include vomiting, difficulty swallowing and chronic coughing or wheezing.
GERD
In order to understand GERD, it is necessary to take a look at the esophagus. The esophagus is the muscular tube, about 25 centimeters long the moves the food from your mouth to your stomach. Near the end of the esophagus, where it enters the stomach there is a ring of muscles called the lower esophageal sphincter (LES). It relaxes when it needs to pass food into the stomach, and then it closes off to keep the food in the stomach while digestion begins. If the lower esophageal sphincter cannot maintain enough pressure to keep it closed, the stomach juices can come back up, or reflux into the esophagus. This causes irritation of the lining of the esophagus and can even cause permanent damage. This can be aggravated when eating just before bed. Laying down makes it easier for the acid to seep back into the esophagus.
Long-term exposure of the lining (or mucosa) of the esophagus to acidic gastric juices can result in changes in the normal esophageal tissue. These changes are known as Barrett’s esophagus. Barrett’s mucosa is pre-disposed to undergoing cancerous changes. Surgery for GERD can help, not only the discomfort associated with GERD, but also to halt the transformation of Barrett’s to cancer in many cases. Barrett’s esophagus requires frequent evaluation by a gastroenterologist.
The primary cause of GERD is the abnormal relaxing of the LES (lower esophageal sphincter). In most cases, it is not clear why the LES is weak. Some people are born with a weak LES.
Some of the things we ingest may either relax the LES or delay the emptying of the stomach. These include: fatty foods, peppermint, chocolate, alcohol and smoking. Strongly acidic foods like tomato products, citrus fruit, spicy foods and coffee can cause irritation of an already sensitized esophagus. The nonsteroidal anti-inflammatory drugs (NSAIDs), notably aspirin, also can irritate the esophagus directly.
Hiatal Hernia
Some people have a physical distortion of the lower esophageal sphincter that prevents it from building up enough pressure to keep it closed. A hiatal hernia is a condition where the stomach protrudes up through an abnormally large opening in the diaphragm. The condition has been estimated to exist in 40% of people in western countries, and is usually of no significance in people who don’t have heartburn. While it does not always cause GERD, a hiatal hernia may cause LES incompetence in some individuals, especially when the hernia is severe. Over 90% of patients who present with severe esophagitis will have a hiatal hernia.
It is important to look for other causes of GERD like poor esophageal clearance, medical conditions such as scleroderma, certain medications, and prior radiation treatments to this area of the body. Finally, delayed gastric emptying will also produce GERD. This may due to a weakening of the stomach action due to diabetes or an obstruction at the outlet of the stomach.
Patients with long-standing GERD, may develop scarring of the lower esophagus making their GERD even worse.
Treatment Options
There are several options in the treatment of GERD. These options range from lifestyle changes, to medications, to surgery for severe disease.
Smaller, more frequent meals helps as well as avoiding eating for 3 to 4 hours before bed. You can also use 15 cm blocks to elevate the head of your bed or a foam wedge to help prevent reflux. Also avoid those foods mentioned above and check your medication as a possible cause. Tight-fitting clothing or abdominal straining, lifting or bending can cause stress reflux.
Diagnosis of the disease
The diagnosis of GERD is considered a clinical diagnosis. This means that for most patients with the typical symptoms of heartburn and regurgitation and no complications (signs of bleeding) will be treated with medication and then evaluated.
In those patients with severe GERD, with complications, or who are unresponsive to therapy, the doctor may choose to have the patient undergo certain tests to see what is the cause of GERD and whether surgery might help.
Upper Endoscopy is a long flexible tube equipped with a video camera that is passed through your mouth and throat into the esophagus. Besides directly viewing the condition of the esophagus, the doctor can do a biopsy (take a small sample of tissue). Some patients with severe cases of GERD can develop a condition called Barrett’s esophagus. This is a change in the cells of the esophagus due to prolonged exposure to stomach acid. It is considered a pre-cancerous lesion which needs to be followed closely with endoscopy.
Barium Esophagography is a type of x-ray that is used to look at the outline of the barrel of the esophagus. This test looks at the anatomy and function of the esophagus.
Ambulatory pH Monitoring is the best way to document acid reflux. A probe is used to check the acidity of the lower esophagus at multiple times. This is useful when endoscopy appears normal, but patient does not respond to medication.
Esophageal Manometry is a way of measuring the pressure changes within the esophagus, and can be used to check the functioning of the esophagus.
GERD Surgery
If your symptoms are debilitating and your doctor has decided that medical therapy cannot ensure relief, you may have a surgical procedure to help strengthen the LES function thereby preventing reflux. The Nissen fundoplication is the most commonly performed procedure for GERD. It involves wrapping the top of the stomach (fundus) around the lower end of the esophagus, creating a cuff that acts as a valve. This procedure is also used to treat hiatal hernia, another cause of GERD.
A variation of the Nissen fundoplcation is the Toupet procedure. This involves a looser wrap around the esophagus. Today, most surgical treatment for GERD (Nissen or Toupet) is performed laparoscopically. The patient usually does not spend more than one or two days in the hospital after surgery.
Results are seen immediately, with many patients finding that they never need antacids again
Surgery for the Stomach
Stomach cancer is accounted around 2,6% of all cancer forms found in Cyprus each year. There are several different risk factors that may lead to stomach cancer such as certain infections, environmental exposures and genetic risks. The best chance for cure of cancer that is confined to the stomach is to treat it with surgical resection, followed by chemotherapy and radiation. Small cancers of the stomach can be removed laparoscopically while maintaining good outcomes for cure.
Peptic Ulcer Disease
A peptic ulcer is a deep erosion into the lining of the stomach or duodenum (first portion of the small intestine). Peptic ulcer disease (PUD) may result from the excess secretion of acid, poor protection against normal acid secretion, infections, or too much intake of non-steroidal anti-inflammatory drugs (NSAIDs).
Usually, PUD can be treated with medications such as antibiotics or antacid medications. Occasionally, peptic ulcers can result in serious complications such as perforation, bleeding, and obstruction of the outlet of the stomach.
Surgery is sometimes needed to treat the acute or chronic complications of PUD. Surgery may be performed to decrease acid secretion, stop bleeding, repair a perforation, or redirect the flow of gastric contents in the case of obstruction.
Paraesophageal Hernia and Gastric Volvulus
Gastric volvulus is a twist of the stomach that usually occurs in association with a large hiatal hernia. The stomach can twist up next to the esophagus through its opening in the diaphragm. This is known as a paresophageal hernia. A paraesophageal hernia may cause pain, difficulty eating or obstruction. This is an indication to surgically repair the problem to prevent a life-threatening problem.