Acid Reflux Disease

Acid reflux, or gastroesophageal reflux disease (GERD), is a common condition in which stomach acid frequently flows back into the esophagus, causing irritation and discomfort. This reflux can lead to symptoms like heartburn, chest pain, and regurgitation. Understanding acid reflux, its diagnosis, treatment options, and potential complications is key to managing the condition and improving quality of life.

Dr. Siegal proudly offers acid reflux care to all of Southwest Florida including Fort Myers, Naples, Cape Coral, Port Charlotte and happily accepts patients from anywhere including the convenience of virtual visits!

What is Acid Reflux?

Acid reflux occurs when the lower esophageal sphincter (LES), a ring of muscle at the bottom of the esophagus, relaxes abnormally, allowing stomach acid to move back into the esophagus. This acid can irritate the esophageal lining, causing a burning sensation, known as heartburn, and other symptoms. If acid reflux happens frequently, it can lead to GERD, a chronic form of reflux that may require long-term management.

Acid reflux is highly prevalent, affecting an estimated 20-30% of adults in the United States. GERD is more common among older adults, individuals with obesity, and those with certain lifestyle habits, such as smoking or a high intake of fatty foods. Acid reflux can also occur during pregnancy due to increased abdominal pressure.

What is the Diagnostic Workup?

Clinical History and Symptoms

Initial diagnosis is often based on reported symptoms such as heartburn, regurgitation, and difficulty swallowing.

Endoscopy

An upper endoscopy may be performed to examine the esophagus, stomach, and duodenum. This test helps identify inflammation, ulcers, or other structural abnormalities.

pH Monitoring

Ambulatory pH monitoring measures acid levels in the esophagus over 24 hours to confirm reflux and assess its severity.

Esophageal Manometry

Manometry tests measure the strength and coordination of esophageal muscles, which is useful in evaluating swallowing issues and LES function.

How is Acid Reflux Treated?

Lifestyle Modifications

Avoiding triggers, such as fatty or acidic foods, quitting smoking, weight management, and elevating the head of the bed can all help reduce symptoms.

Medications

• Antacids: Quick relief but temporary, neutralizing stomach acid.

• H2 Blockers: Reduces acid production, with longer-lasting effects than antacids.

• Proton Pump Inhibitors (PPIs): PPIs are the most effective for reducing stomach acid and healing esophageal inflammation.

Surgery

For severe or refractory GERD, surgical options like fundoplication or magnetic sphincter augmentation can help reinforce the LES and reduce acid reflux.

If you have a hiatal hernia, the hernia must be repaired as this is the main contributor to reflux and regurgitation.

Harmful Effects of Long-Term PPI Use

While PPIs are highly effective in managing acid reflux, long-term use may be associated with adverse effects:

• Nutrient Deficiencies: PPIs can reduce the absorption of calcium, magnesium, and vitamin B12, leading to deficiencies.

• Increased Infection Risk: Long-term PPI use may increase susceptibility to infections like Clostridium difficile and pneumonia due to changes in stomach acidity.

• Bone Fractures: Reduced calcium absorption has been linked to an increased risk of fractures, particularly in older adults.

• Kidney Disease: Chronic PPI use has been associated with an increased risk of chronic kidney disease.

• Gastric Polyps: Prolonged PPI use can lead to the development of benign stomach polyps, though these are typically harmless.

Barrett's Esophagus

Barrett’s Esophagus is a condition in which the normal esophagus cells are replaced with abnormal stomach cells, typically as a result of long-term exposure to stomach acid. This cellular change is called “intestinal metaplasia” and represents the body’s response to the chronic acid damage in the esophagus.

What Causes Barrett’s Esophagus?

The primary cause of Barrett’s Esophagus is chronic gastroesophageal reflux disease (GERD), in which acid frequently backs up into the esophagus from the stomach. Over time, this constant exposure to stomach acid can damage the esophageal lining, triggering cellular changes. Risk factors that may increase the likelihood of developing Barrett’s include:

• Chronic GERD Symptoms: Especially for individuals who have had symptoms for ten years or more.

• Hiatal Hernia: This often accompanies GERD and can exacerbate reflux.

• Lifestyle Factors: Smoking and obesity can increase risk.

• Genetics: Family history may play a role in susceptibility to Barrett’s Esophagus.

What is the Danger of Having Barrett’s Esophagus?

Barrett’s Esophagus is considered a pre-cancerous condition because the abnormal cells have the potential to progress to esophageal adenocarcinoma, a type of esophageal cancer. While only a small percentage of those with Barrett’s develop this cancer, it is a serious and potentially life-threatening condition. The risk of progression is higher for individuals with advanced changes, known as dysplasia, within the Barrett’s tissue.

How Should Barrett’s Esophagus be Monitored?

Monitoring and treatment are critical to managing Barrett’s Esophagus and preventing progression to cancer:

Regular Surveillance with Endoscopy: Endoscopic exams every 3-5 years are common for those without dysplasia. Individuals with dysplasia may require more frequent surveillance, sometimes every 6-12 months.
Biopsies During Endoscopy: Tissue samples are often taken to assess for any changes or progression to dysplasia.

How Should Barrett’s Esophagus be Treated?

Acid-Suppressing Medications: Proton pump inhibitors (PPIs) are commonly prescribed to reduce stomach acid, minimizing further irritation and inflammation.
Endoscopic Treatments: For cases with dysplasia, non-invasive treatments to remove or alter the abnormal cells can reduce cancer risk.
Surgery: It is important to know that if you have a hiatal hernia and acid reflux, your hernia is causing the GERD and thus the Barrett's. Hiatal hernia repair is recommended to stop the further acid exposure in the esophagus.

Acid Reflux Surgery

Acid reflux surgery has two main components. The first and most important is to address any hiatal hernia, if present. Once the stomach is herniated above the diaphragm (hiatal hernia), the anti-reflux barrier is broken. This hernia must be repair by bringing the stomach back down below the diaphragm, into the abdomen, and the defect (gap) in the diaphragm is closed snugly around the bottom of the esophagus.

Secondly, the lower esophageal sphincter is reinforced to prevent reflux and regurgitation of stomach acid either by a fundoplication or a LINX(TM) magnetic sphincter augmentation device. Both methods aim to strengthen the lower esophageal sphincter (LES) to prevent acid reflux, but they differ in approach, technology, and clinical outcomes. Below is a comparison of fundoplication and the LINX device, including their pros and cons, study outcomes, and guidelines for choosing each option.

Fundoplication

Fundoplication is a surgical procedure where the upper part of the stomach (fundus) is wrapped around the lower esophagus to reinforce the sphincter, creating a tighter valve that helps prevent acid reflux.

Pros:

Effective and Established: Fundoplication has been a standard GERD surgery for decades, with extensive data showing long-term symptom relief and reduction in acid exposure.

Durable: Typically provides lasting results, particularly for patients with severe GERD or large hiatal hernias.

Adaptable to Patient Needs: Surgeons can adjust the tightness of the wrap (e.g., Nissen, partial wrap) to balance symptom control and minimize side effects.

Cons:

Potential for Side Effects: Side effects can include difficulty swallowing (dysphagia) or gas-bloat syndrome.

Longer Recovery: Patients may need more time than the LINX to fully recover from surgery and get used to swallowing solid food

LINX(TM)

The LINX device is a ring of small, magnetic titanium beads implanted around the LES to reinforce it. The magnetic force helps the LES close after swallowing while still allowing for natural movements.

Pros:

Quick Recovery: The LINX procedure typically involves a faster recovery, and patients often experience symptom relief soon after surgery.

Reduced Side Effects: Fewer patients experience gas-bloat syndrome, and normal functions like belching and vomiting are usually preserved.

Cons:

Foreign Body: Since the LINX device is an implant, there is a risk of device migration, erosion, or malfunction over time.

Limited by Magnetic Interference: Patients with a LINX device cannot undergo MRI scans above 1.5 Tesla.

Watch Dr. Siegal perform a linx

Fundoplication vs. LINX(TM)

Studies have directly compared fundoplication and the LINX device to assess efficacy, durability, and patient satisfaction:

Symptom Relief: Studies show that both procedures are effective in reducing GERD symptoms, with the LINX device providing similar rates of symptom control as fundoplication for mild to moderate cases.

Quality of Life: Patients with LINX often report fewer side effects related to gas-bloat syndrome and dysphagia compared to fundoplication.

Long-term Durability: Fundoplication is well-established in terms of long-term outcomes, with symptom relief lasting beyond 10 years for many patients. While LINX data is still emerging, current studies show symptom relief and patient satisfaction up to 10 years post-procedure.