Gastroesophageal Reflux Disease

Heartburn is a burning feeling in the chest caused by stomach acid travelling up towards the throat (acid reflux). Who should consider surgery or, perhaps, an endoscopic treatment trial for GERD? (As mentioned previously, the effectiveness of the recently developed endoscopic treatments remains to be determined.) Patients should consider surgery if they have regurgitation that cannot be controlled with drugs. This recommendation is particularly important if the regurgitation results in infections in the lungs or occurs at night when aspiration into the lungs is more likely. Patients also should consider surgery if they require large doses of PPI or multiple drugs to control their reflux. It is debated whether or not a desire to be free of the need to take life-long drugs to prevent symptoms of GERD is by itself a satisfactory reason for having surgery.

The throat communicates with the nasal passages. In small children, two patches of lymph tissue, called the adenoids , are located where the upper part of the throat joins the nasal passages. The passages from the sinuses and the tubes from the middle ears (Eustachian tubes) open into the rear of the nasal passages near the adenoids. Refluxed liquid that enters the upper throat can inflame the adenoids and cause them to swell. The swollen adenoids then can block the passages from the sinuses and the Eustachian tubes. When the sinuses and middle ears are closed off from the nasal passages by the swelling of the adenoids, fluid accumulates within them. This accumulation of fluid can lead to discomfort in the sinuses and ears. Since the adenoids are prominent in young children, and not in adults, this fluid accumulation in the ears and sinuses is seen in children and not adults.

Moreover, as with any treatment, there is perhaps a 20% placebo effect, which means that 20% of patients will respond to a placebo (inactive) pill or, indeed, to any treatment. This means that 20% of patients who have causes of their symptoms other than GERD (or ulcers) will have a decrease in home their symptoms after receiving the treatment for GERD. Thus, on the basis of their response to treatment (the therapeutic trial), these patients then will continue to be treated for GERD, even though they do not have GERD. What’s more, the true cause of their symptoms will not be pursued.

When GERD affects the throat or larynx and causes symptoms of cough, hoarseness , or sore throat , patients often visit an ear, nose, and throat (ENT) specialist. The ENT specialist frequently finds signs of inflammation of the throat or larynx. Although diseases of the throat or larynx usually are the cause of the inflammation, sometimes GERD can be the cause. Accordingly, ENT specialists often try acid-suppressing treatment to confirm the diagnosis of GERD. This approach, however, has the same problems as discussed above, that result from using the response to treatment to confirm GERD.

The surgical procedure that is done to prevent reflux is technically known as fundoplication and is called reflux surgery or anti-reflux surgery During fundoplication, any hiatal hernial sac is pulled below the diaphragm and stitched there. In addition, the opening in the diaphragm through which the esophagus passes is tightened around the esophagus. Finally, the upper part of the stomach next to the opening of the esophagus into the stomach is wrapped around the lower esophagus to make an artificial lower esophageal sphincter. All of this surgery can be done through an incision in the abdomen (laparotomy) or using a technique called laparoscopy During laparoscopy, a small viewing device and surgical instruments are passed through several small puncture sites in the abdomen. This procedure avoids the need for a major abdominal incision.

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