Heartburn is very common – and very unpleasant. It appears that the diaphragm that surrounds the LES is important in preventing reflux. That is, in individuals without hiatal hernias, the diaphragm surrounding the esophagus is continuously contracted, but then relaxes with swallows, just like the LES. Note that the effects of the LES and diaphragm occur at the same location in patients without hiatal hernias. Therefore, the barrier to reflux is equal to the sum of the pressures generated by the LES and the diaphragm. When the LES moves into the chest with a hiatal hernia, the diaphragm and the LES continue to exert their pressures and barrier effect. However, they now do so at different locations. Consequently, the pressures are no longer additive. Instead, a single, high-pressure barrier to reflux is replaced by two barriers of lower pressure, and reflux thus occurs more easily. So, decreasing the pressure barrier is one way that a hiatal hernia can contribute to reflux.
The second type of drug developed specifically for acid-related diseases, such as GERD, was a proton pump inhibitor (PPI), specifically, omeprazole ( Prilosec ). A PPI blocks the secretion of acid into the stomach by the acid-secreting cells. The advantage of a PPI over an go now H2 antagonist is that the PPI shuts off acid production more completely and for a longer period of time. Not only is the PPI good for treating the symptom of heartburn, but it also is good for protecting the esophagus from acid so that esophageal inflammation can heal.
Barrett’s esophagus can be recognized visually at the time of an endoscopy and confirmed by microscopic examination of the lining cells. Then, patients with Barrett’s esophagus can undergo periodic surveillance endoscopies with biopsies although there is not agreement as to which patients require surveillance. The purpose of surveillance is to detect progression from pre- cancer to more cancerous changes so that cancer -preventing treatment can be started. It also is believed that patients with Barrett’s esophagus should receive maximum treatment for GERD to prevent further damage to the esophagus. Procedures are being studied that remove the abnormal lining cells. Several endoscopic, non-surgical techniques can be used to remove the cells. These techniques are attractive because they do not require surgery; however, there are associated with complications, and the long-term effectiveness of the treatments has not yet been determined. Surgical removal of the esophagus is always an option.
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.
A new technology allows the accurate determination of non-acid reflux. This technology uses the measurement of impedance changes within the esophagus to identify reflux of liquid, be it acid or non-acid. By combining measurement of impedance and pH it is possible to identify reflux and to tell if the reflux is acid or non-acid. It is too early to know how important non-acid reflux is in causing esophageal damage, symptoms, or complications, but there is little doubt that this new technology will be able to resolve the issues surrounding non-acid reflux.