Gastroesophageal reflux disease

Reflux – causes

In the stomach, food is broken down by acidic gastric juice. Between the esophagus and stomach, there is a sphincter muscle that normally prevents the reflux of food and stomach acid into the esophagus. The function of this sphincter muscle can be weakened by the following causes:

• Hiatal hernia: In a hiatal hernia, the stomach slips upwards into the chest. Since the function of the sphincter muscle is no longer supported by the diaphragm, reflux disease occurs in 10% of cases. For large hiatal hernias, the stomach shifts from the abdominal cavity into the chest. This condition is called upside-down stomach.
• Overweight
• Pregnancy
• Poor diet
• Smoking

Gastroesophageal reflux disease – symptoms

Esophagitis (also known as reflux disease, gastroesophageal reflux or short GERD) refers to inflammation of the esophagus caused by the reflux of stomach contents into the esophagus. The most common reflux symptoms are:

• Heartburn: Manifests as burning pain behind the breastbone or in the upper abdomen.
• Acid regurgitation or regurgitation of food residues.
• Bloating
• Swallowing difficulties, hoarseness, or irritative cough.
• Nausea
• Salty taste in the mouth
• Bad breath and dental damage
• Sleep disturbances and cardiac arrhythmias

How is a Reflux Diagnosis Made?

Although reflux disease symptoms already indicate esophagitis, a gastroscopy (endoscopy) is required before initiating treatment to exclude other causes such as ulcers or cancer. This examination is performed painlessly as an outpatient procedure with appropriate medication. Additional examinations, such as X-ray images with contrast filling of the esophagus (videokinematography), computed tomography, long-term pH-metry, and esophageal manometry may be necessary.

Reflux treatment and GERD therapy

General measures can alleviate mild reflux symptoms. These measures include:

• Weight reduction
• Dietary adjustment and nutrition
• Loose clothing
• Sleeping with the head end raised

Reflux medication

If reflux disease symptoms persist under this therapy or GERD is detectable, reflux treatment with proton pump inhibitors (PPI) is necessary. In most cases, this therapy can alleviate reflux symptoms and avoid surgery.

Fundoplication – GERD surgery

Fundoplication (GERD surgery) is necessary in:

• Advanced stages of esophagitis
• Lack of effect or intolerances of reflux medication
• Aspirations
• Biliary reflux
• Large hiatal hernias (to avoid complications)

Only GERD surgery can restore the anatomically correct position of the stomach and the function of the lower esophageal sphincter. The fundoplication is performed gently (minimally invasive, laparoscopically) through small skin incisions. The GERD surgery takes about 1 hour. On the day of the fundoplication, the patient is allowed to drink, and the next day the diet buildup begins. The hospital stay lasts 2 to 4 days.

What complications can arise from GERD?

With gastroesophageal reflux disease, ulcers (ulcerations) can develop in the esophagus. Less commonly, there may be bleeding or penetration of stomach contents into the lungs (aspiration) and stenosis (narrowing of the esophagus).

5% of patients with GERD develop Barrett's esophagus (Barrett syndrome). Here, the normal squamous epithelium of the esophageal mucosa is replaced by specialized mucosa from the stomach. This phenomenon is called metaplasia. Barrett's mucosa is a precancerous condition (precancer). Up to 10% of these patients develop neoplastic esophageal carcinoma (esophageal cancer). The cancer risk for long-segment Barrett (length of mucosal transformation over 3cm) is estimated at 0.5% per patient year.

Autor: Dr. Andreas Franczak, Facharzt für Chirurgie, Gefässchirurgie und Visceralchirurgie