HotButton TreatmentGastroesophageal reflux disease (GERD) is a condition that develops when the stomach contents reflux back into the esophagus and troublesome symptoms or complication occur. Upper endoscopy (EGD) is recommended for those with long-standing GERD as well as those who develop persistent or worsening symptoms a little later in adulthood when they never had problems in the past. Also, when alarm symptoms occur such as trouble swallowing, gastrointestinal bleeding, anemia, weight loss or recurrent vomiting, an EGD is recommended.  Additionally, those with GERD symptoms that persist, despite a therapeutic trial of a PPI for 6-8 weeks. Risk factor for Barrett’s Esophagus, which can be considered pre-cancerous, include chronic GERD, hiatal hernia, obesity, male gender, >50 years of age, and these people should be considered for a Barrett’s screening.

Initial Therapy

Our treatment approach to patients with GERD is based on the frequency and severity of the symptoms, as well as the presence of erosive esophagitis at the time of upper endoscopy (EGD).  For mild symptoms, say twice weekly and without evidence of erosive esophagitis, initiating an H2 Blocker such as Ranitidine, Famotidine, Cimetidine, in a full strength twice daily dosage is recommended. If this is not effective in managing symptoms, then after a few weeks the patient could be switched to a once-daily PPI at a low dose and then increase to standard doses if not effective. Once symptoms are controlled, treatment should continue for at least 8 weeks. At that point, the treatment could be discontinued if there was no evidence of Barrett’s Esophagus or severe erosive esophagitis, and the patient can use the PPI more on an as-needed basis.

Lifestyle Modifications

We suggest the following lifestyle and dietary modifications for all patients with GERD:

  • Elevation of the head of the bed with 4-6 inch blocks. This can prevent contents from refluxing into the chest at night when recumbent. An alternative is to place a foam wedge under the head of the bed, though this may not be as effective. Using 2 or more pillows does not work, as one rolls off the pillows during the night. In addition, avoidance of meals for 2-3 hours prior to bedtime is advisable so as not to go to sleep on a full stomach.
  • Foods to limit or avoid:  fatty foods, caffeine, spicy foods, chocolate, peppermints, carbonated beverages, citrus, garlic and onions.
  • Avoid tobacco, both smoking and especially chewing tobacco.
  • Avoid very tight fitting clothes to prevent increased intra-abdominal pressure

Antacids

Antacids do not prevent GERD, but they do help alleviate symptoms on an intermittent basis (on-demand). They usually provide some relief within 5 minutes, but have a limited duration of effect of about 60 minutes.

Surface Medications

Sucralfate (aluminum sucrose sulfate), a topical agent, adheres to the mucosal lining and can promote healing, and protects from peptic injury as well possibly by releasing protective prostaglandins in the stomach lining. Although generally not used by itself, it can be used an in addition to an acid reducing agent discussed above.

Severe or Frequent Symptoms or Erosive Esophagitis

Full dose H2 Blockers twice daily, such as Ranitidine, Famotidine or Cimetidine is started, along with lifestyle modifications. If not effective, then switching to a Proton pump inhibitor (PPI) would be the next step, such as Omeprazole, Pantoprazole or Esomeprazole.

Standard dose therapy of a PPI once daily for 4-8 weeks, and if the patient does not improve significantly, we might add an H2 Blocker med in the evening, or go to double dose therapy of a PPI.

PPIs are the most potent inhibitors of gastric acid secretion, binding to and inhibiting the cellular pump that releases acid for the stomach lining. Compared to the H2 Blockers, PPIs provide faster symptom relief and are more effective in controlling symptoms of GERD. PPIs have a higher cost as compared to H2 Blockers, and infrequent side effects that may or may not be of importance to you, and should be discussed with one of our Providers.

Barrett’s Esophagus

If one is diagnosed with Barrett’s Esophagus at the time of an upper endoscopy (EGD), treatment with a PPI long-term is recommended, as well as a periodic EGD every 2-3 years to check for any changes that may occur visually as well as microscopically on biopsy.

Helicobacter Pylori Treatment

If H. Pylori is diagnosed in the setting of GERD and/or gastritis, then eradication treatment with 10-14 days of an antibiotic regimen is recommended. This has been associated with an improvement of symptoms, as well as possibly preventing peptic ulcer disease from occurring.

Pregnancy and Lactation

Initial management of reflux symptoms in pregnancy consists of lifestyle and dietary modifications. In those with persistent symptoms, medical management should start with antacids as well as sucralfate which is topical in nature. In patients who fail to respond, an H2Blocker such as ranitidine is recommended. PPIs can be used as well and studies suggest it is likely safe in pregnancy, however there is less available. They should not be used during lactation if possible as this has not been well studied.

Upper endoscopy(EGF) during pregnancy should only be performed if there is a strong indication (such as gastrointestinal bleeding). Whenever possible, it should be postponed until the second trimester.

Endoscopic Treatment (non-surgical) of Gerd

Plication of tissues in the lower esophageal sphincter with sutures, fasteners or staples (EndoCinch, EsophyX) have been tried and have generally been discarded due to the complexity of performing this procedure as well as potential complications.

Injection of a biopolymer into the lower esophageal sphincter (Enteryx) was approved a number of years ago, but due to numerous complications, this device was recalled from the market and is no longer performed.

Radio frequency or RF (Stretta). Stretta is an endoscopic procedure applying a low energy current to the lower esophageal sphincter, and its advantage is that is does not change the anatomy of the esophagus. RF energy induces the mucosa surface collagen to contract, thereby increasing lower esophageal sphincter tone, preventing reflux. Candidates for this procedure might be those that have ongoing daily reflux symptoms, less than a 2 cm hiatal hernia, positive 24 hour PH monitor results, and either haven’t responded well to PPIs or wish to discontinue PPIs. An Esophageal Motility (manometry) Study must be performed prior to this procedure in order to assure that the patient has adequate esophageal peristalsis (motility) as well as normal relaxation of the lower esophageal sphincter muscle.

Surgical Treatment of Gerd

Surgical treatment of chronic reflux is generally reserved for those patients who have failed medical management of GERD and have ongoing symptoms or complications. We work with many talented and well-trained surgeons who can offer our patients state-of-the-art surgical treatments for GERD/reflux when indicated. Several indications for surgery in the patient with GERD include:

  • Failed optimal medical management
  • Persistent erosive esophagitis
  • Medium to large size hiatal hernia
  • Barrett’s Esophagus, with columnar-lined mucosa cells without severe dysplasia or carcinoma
  • Benign esophageal stricture
  • Persistent respiratory symptoms related to GERD (chronic cough, asthma, laryngitis)
  • A desire to stop or avoid all acid-reducing medications due to either cost, potential long term side effects or intolerance to the medications

Before considering a surgical approach to treatment for GERD, certain preoperative tests for evaluation are required.

  • Upper Endoscopy (EGD). In order to assess the esophageal and gastric mucosa for signs of malignancy, severe scarring or other anatomical changes that could preclude one from being a candidate for surgery.
  • Esophageal manometry. This test is necessary to assure that the patient has adequate motility or peristaltic contraction of the esophagus. Also to exclude other conditions such as Achalasia or Scleroderma, which could make a surgical approach contraindicated or need for modification.
  • Gastric Emptying Study (GES).  A four-hour gastric emptying study is performed when the patient’s symptoms suggest that there is delay in the empting of food from the stomach. A combination of antireflux surgery and significantly impaired gastric emptying can lead to increased abdominal bloating and discomfort.

Linx® Procedure

A novel new FDA-approved magnetic device that is surgically placed at the gastroesophageal junction that prevents regurgitation of acid into the lower esophagus. < More ino

Midwest Heartburn Center
Midwest Gastroenterology
3601 NE Ralph Powell Rd.
Lee’s Summit, Missouri 64064
816-836-2200