in this article:
Gastroesophageal reflux is defined as the passage of gastric material into the esophagus which, within certain limits, is completely physiological. An increase in the frequency, amount and duration of this reflux is generally associated with symptoms, or less frequently, with lesions of the esophageal mucosa (erosions, ulcers, etc.). This generates the condition of gastroesophageal reflux disease (GERD).
What is GERD?
Gastroesophageal reflux has the same prevalence in both male and female sex and is preferentially around 30 – 50 years. In our country this disease affects one in three people; in the western world affects 40% of the population. The probability of the appearance of reflux increases with increasing age; it is also very common in pregnant women and newborns.
The esophagus has at its ends, proximal and distal, two ‘valves’ (sphincters) that open to the passage of the bolus, while externally it is enveloped by a muscular tunic that is contracted and released rhythmically (peristalsis) and which facilitates movement of food towards the stomach. If the lower valve (lower esophageal sphincter) is released when it should not (inappropriate releases) it may have gastroesophageal reflux.
Even the poor motility of the esophagus, which does not allow the effluent to be removed quickly, is part of the pathogenetic mechanism of reflux. The material drained into the esophagus is largely composed of hydrochloric acid, but can sometimes be associated with bile of duodenal origin.
Sometimes at the base of the reflux there is a hiatal hernia (photo) which is a slipping of the stomach into the thorax through the diaphragm. However, it should be noted that MRGE is not always caused by a hiatal hernia, as hiatal hernia is not always accompanied by MRGE.
Other factors that may favor gastroesophageal reflux differently are:
- Family and genetic predisposition
- Overweight and obesity, in particular the ‘waistline’ fat deposition, i.e. the abdominal circumference
- Diabetes mellitus (due to slowed gastric emptying)
- Smoking favors reflux with a clear dose effect: those who smoked more than 20 years have a 70% risk compared to non-smokers
- Pregnancy: the fetus increasing in volume increases the abdominal pressure and goes to compress the stomach directly.
- Unbalanced and incorrect diet: Foods with animal fats that slow gastric emptying. Abundant meals before bedtime. Abuse of alcohol, coffee, tea, chocolate, mint, strongly acidic drinks.
- Medications that infect the esophagus, such as non-steroidal anti-inflammatory drugs (NSAIDs), iron salts, potassium salts; drugs that promote the opening of the lower esophageal sphincter as some hypertensive agents, i.e. beta-blockers and calcium antagonists; drugs against anxiety and insomnia like benzodiazepines; long-lasting bronchodilators (LABA) used for asthma and chronic bronchitis; hormone replacement therapy estrogen progestogen in menopause.
- Lifestyle. Use of belts and clothes that are too tight. Sports that require efforts in ‘blocked’ inspiration (such as weight lifting).
In some subjects, especially in elderly subjects, there may be a non-specific symptomatology, usually referred to as ‘poor digestion’ (pain-discomfort-tension in the upper part of the abdomen, early satiety, sense of after-eatenness, nausea, vomiting), defined by the medical term dyspepsia.
Since reflux can also exceed the upper valve of the esophagus (upper esophageal sphincter) and affect the pharynx, larynx, and lungs, the possibility of extra-esophageal symptomatology follows. The extraesophageal symptoms, defined as ‘atypical’, can be:
– pharyngitis (recurrent sore throat); chronic laryngitis and other affections of the vocal cords or arytenoids (polyps, granulomas, etc.); sensation of a lump in the throat (sensation of a foreign body and contraction of the throat); chronic bronchitis and bronchial asthma; pathologies of the nose and the nasopharynx; habitual snoring and nocturnal apnea; laryngospasm; non-cardiac chest pain; halitosis; erosion of dental enamel. In the absence of typical symptoms, it is sometimes difficult to associate these disorders with gastroesophageal reflux and for this reason patients do not go to the specialist for whom the diagnosis is often delayed.
The continuous passage of this liquid into the esophagus can cause damage to the mucosa that is expressed by erosions, ulcers, bleeding (resulting in anemia) or with more serious complications such as stenosis (narrowing of the lumen) and Barrett’s esophagus.
Esophagitis is the typical complication of MRGE and its severity is defined on the basis of the universally recognized Los Angeles classification, which provides for 4 stages of severity:
Presence of one or more lesions
At least one mucous lesion,> 5 mm, localized in the mucosal folds, but without continuity between the tips of two mucosal folds.
At least one continuous mucous lesion between the apices of two or more folds, but not circumferential
Extensive mucosal lesions to involve at least 75% of the esophageal circumference
Most patients with gastroesophageal reflux symptoms have a negative endoscopic picture (Non Erosive Reflux Disease: NERD) and only less than half of patients have an endoscopic picture of erosive esophagitis (Erosive Reflux Disease: ERD). A possible explanation of this is due to the fact that patients undergo endoscopic control (although not essential, especially if young) after or during an antisecretory treatment that is able to control the mucosal damage in 70-90% of cases.
The evolutionary stage of erosions is ulcers and stenosis. Stenosis is formed when the esophageal walls are replaced by fibrous tissue becoming unrewarding. This finding is rarely found today because it is difficult for a patient with important symptomatology not to make the appropriate tests and the subsequent highly effective therapy.
GERD complications: chronic pharyngitis and laryngitis
Gastroesophageal reflux disease is a common condition in an otorhinolaryngology clinic, above all where a video fibroscopy of the throat is performed in the context of the visit. Laryngeal disorders are in fact traceable to at least 50%, to varying degrees, to clinical manifestations of reflux. A specialist is able to distinguish the symptoms of reflux disease pertaining to orl: symptoms of proximal reflux, distal reflux symptoms and symptoms of an unknown mechanism.
Difficulty in swallowing (dysphagia): this is an alarm symptom that should prompt an immediate endoscopic video investigation to exclude the presence of tumor diseases that may obstruct the throat.
The most important clinical characteristic of this symptom, which distinguishes it from dysphagia deriving from occlusive neoplastic pathology, is the capriciousness of the clinical picture, which is not pejorative over time, continuously changes in intensity, varying several times during the day and can present prolonged wellness intervals.
Voice changes (dysphonia): are determined by the presence of vocal cord lesions such as granulomas from prolonged exposure to irritating liquids refluxed by the alimentary canal (acid, enzymes), polyps and, in a lower percentage, carcinomas (in the neoplastic mucosa they were often documented reflux tissue damage). The hoarseness, the prolonged voice reduction, the modification of the vocal tone apparently without a documentable cause are therefore symptoms not to be underestimated and to refer to specialized ENT consultancy, preferably with endoscopic video assessment.
Hoarseness and itching in the throat: this is a symptom for which the patient generally does not receive adequate attention, since it is erroneously considered a disorder of little importance. In reality this annoyance arises in a subtle way up to become a real obsession; consequently there is a documentable damage in the life of relationship and work, especially for those professions in which the use of the voice is necessary and frequent (teachers, shopkeepers, businessmen, representatives).
In most cases these patients are entrusted to the care of the psychologist, the psychiatrist or the neurologist, with continuous – rather harmful – administration of psychotropic drugs (anxiolytics, antidepressants). In fact, a good cure against reflux has proved very often useful in bringing the patient back to a good quality of life.
Sensation of a foreign body in the throat (hysterical globe): it is an unpleasant sensation of a lump in the throat, something that ‘does not go up or down’. In these cases the use of anxiolytic and / or antidepressant drugs aggravates, due to the known relaxing action on the esophageal valve, the gastroesophageal reflux disease, as well as being ill accepted by patients who do not feel understood or adequately treated by specialists and isolated from family and acquaintances. Taking a correct anti-acid therapy leads, in many cases, to the reduction of the lump in the throat, in a reasonably short time.
Inflammation of the retronasal mucosa with mucus drip at the trachea: this is a less common symptom, however, documented in discrete association with acidic mucosal alterations. Nose, mouth, pharynx, larynx are affected in varying degrees by gastroesophageal reflux
The treatment of pharyngitis and reflux laryngitis provides a rigorous choice of the appropriate patient, after an endoscopic examination of the nosea nd of the throat. Neither diagnosis nor anti-reflux therapy should be presumed on the basis of information only reported by the patient.
The category of drugs of first choice is represented by the so-called antacids (proton pump inhibitors, ppi); in the otorinolaringoiatriche manifestations of the reflux disease the initial dosage should be doubled compared to the usual one and protracted for at least a month, with regular endoscopic verifications of therapeutic efficacy. Other complementary controls include: drugs that facilitate stomach emptying (prokinetic), drugs that they protect the mucous membranes (magaldrates). A correct alimentary behavior is finally always recommendable.
A complication, however, that can be found with relative frequency, compared to the stenosis, in the chronic reflux is Barrett’s esophagus. This condition consists in the replacement of the squamous esophageal epithelium cells with characteristics more similar to those of the intestine. In practice it is a defense mechanism of the esophagus that ‘covers’ with a mucosa that is resistant to acid. Therefore, the diagnosis cannot be only endoscopic (evidence of a pinkish flame rising over the squamocolumnar junction) but also requires histological confirmation with evidence of intestinal columnar epithelium, i.e. with presence of goblet cells (intestinal metaplasia).
Barrett’s Esophagus, although with a relatively low incidence (approximately 2-5% of cases), may predispose to esophageal cancer, so it is a pathological condition to be kept under strict control.
For this reason, patients with long-standing gastroesophageal reflux symptoms should perform a gastroscopy at least once to evaluate the severity of the inflammation and the possible presence of a Barrett.
Diagnosis of GERD
The esophagus-gastro-endoscopy. Endoscopic exploration allows us to evaluate the state of the esophageal mucosa (erosions, ulcers) and possible complications (stenosis, Barrett). Biopsies can be useful for defining the characteristics of Barrett, but also for excluding other forms of esophageal disease (eosinophilic esophagitis, for example). A pemphigoid of the esophagus that can simulate reflux oesophagitis (with erosions and fibrin) is rarely found. Gastroscopy, of course, is the test that all patients must absolutely perform before a possible evaluation of the surgical correction of the reflux.
The stationary esophageal manometry: studies the esophageal peristalsis, evaluating amplitude duration and coordination of esophageal motor waves to the deglutitive stimulus. It also evaluates the reflexive relaxation capacity of the lower esophageal sphincter. It is a fundamental method to exclude motor pathologies of the esophagus, such as achalasia and scleroderma, which can sometimes simulate a reflux and which are contraindications to a surgical management of the reflux.
The esophageal pH-impeditometry / 24 hours (pH-IIM 24): dynamically evaluates in 24 hours both the (acid and non-acidic) composition and the nature of gastroesophageal reflux (gaseous, liquid, mixed). It is a new method that has gradually replaced the esophageal pH-metry / 24 hours, in the diagnosis of reflux, becoming the new gold standard significantly improving the amount of reflux, the correlation between reflux and symptomatology, and the extent of the reflux in proximal esophagus.
For this last aspect it is of paramount importance in all atypical reflux manifestations, especially in pulmonary and otolaryngology symptoms from possible gastro-esophageal etiology. It also allows identifying those patients with a so-called acid esophageal hypersensitivity. In other words, they are subjects with a reflux in the esophagus still within the normal limits but with an excellent correspondence between symptoms and reflux. The identification of this type of subjects allows a better therapeutic and management approach.
Barium radiography can be useful for evaluating the esophagus-gastric anatomy, especially in large hernias. This examination is required above all in anticipation of a surgical procedure.
How to get a pin-point GERD diagnose
Classically, reflux disease is represented as an iceberg in which the emerging part corresponds to the proportion of patients (20-40%) with typical and frequent symptoms (retro-sternal pyrosis, regurgitation, etc.), while the submerged part represents the share of patients with occasional symptoms and who rarely come to the doctor.
The diagnosis of MRGE is based on a meticulous collection of symptoms and the prompt response to a short cycle of therapy with proton pump inhibitors (PPI test). However, there are clinical situations in which it is not easy to identify patients with true MRGE as, for example, in subjects with typical symptomatology but who do not present mucosal lesions on endoscopic examination (non-erosive esophageal reflux disease – NERD) or in subjects who do not respond to medical therapy.
In such circumstances, targeted diagnostic tests such as pH-multichannel esophageal pH (MII) impedance 24 hours are necessary. The multi-channel esophageal pH-potentiometer overcomes some of the limitations presented by the traditional 24-hour pH-meter because:
The main indication of this method appears to be the study of:
- endoscopically controlled patients with symptoms resistant to proton pump inhibitor therapy;
- patients with atypical symptoms, such as chest pain or extraesophageal symptoms (e.g. bronchial asthma, chronic cough, ENT symptoms) not otherwise justified;
- patients in whom indication is given to surgical treatment of reflux disease.
The clinical relevance of the functional diagnostics of pH MII / 24h is evident from recent observations that suggest:
a. that up to 30% of cases with peptic esophagitis and up to 65% of cases with reflux disease without esophageal lesions (NERD) persist subjective disorders despite antisecretive therapy.
b. Ph-impedanceometry is pathological in 40% of cases and normal in 60% of subjects resistant to antisecretory therapy.
c. 90% of subjects with pathological examination improve with increasing dosage of antisecretory drugs, while only 43% of those with normal pH-MII / 24h respond to a higher dose; therefore in about 60% of cases resistant to a standard dose of antisecretives the continuation of therapy with high doses (double-triple) is probably useless.
Therefore, the application of this functional method allows not only a better selection of patients who are candidates for long-term therapy, but also to identify cases with apparently reflux symptoms, but which are actually an expression of a functional disease of the upper gastrointestinal tract.
The exam is performed on an outpatient basis. Fasting is recommended from midnight on the previous day. It is necessary to suspend drugs that can interfere with gastric acidity (lansoprazole, pantoprazole, esomeprazole, rabeprazole, omeprazole) for at least 15 days. If suspension is not possible, it will be taken into account when reporting. Discontinue 24 hours prior to the examination for prokinetic drugs, antacids (alginates, sucralfate), H2 antagonists (based on ranitidine or famotidine).
The survey is performed by positioning a tube of approximately 2 mm by trans-nasal after local anesthesia of the nasal mucosa with a contact anesthetic. This tube will be connected to a small laptop, entrusted to the patient, by which a prolonged recording of the acidity of the contents in the esophagus will be carried out for 24 hours. The recorder is equipped with keys: standing / supine position, start / end of meal, symptoms.
The following morning the user will have to return to remove the tube. The patient in these 24 hours must follow the usual daily habits, avoid excessive rest, feed as usual, without particular restrictions. Since the introduction of the probe is practiced without direct vision by the operator, it is useful to have anamnestic knowledge of any known anatomical abnormality of the patient, eventually discovered through previous radiographs or endoscopies.
Nutrition and lifestyle
The first ‘therapy’ is proper nutrition and an adequate lifestyle that, in the case of minor reflux, can in itself be sufficient. While in the most severe cases of the disease, as well as the dietary rules, only adequate anti-secretive therapy can allow effective control of symptoms and the treatment of injuries. However, food rules are rules that the patient should follow.
It is important, as a first rule, the ‘way’ to eat which means to avoid eating quickly while it is good to chew slowly. In fact, the first stage of digestion takes place in the mouth because saliva contains a substance the salivary amylase (produced by the salivary glands) which works the digestion of the starch; moreover the shredding and the mincing of the food facilitates the gastric activity of digestion and absorption of the nutritive principles.
As far as food is concerned, it must be borne in mind that a more intense reflux can be caused by certain foods that can stimulate gastric secretion, slow gastric emptying or even reduce the tone of the valve between the esophagus and the stomach.
Milk can be consumed because, being an alkaline food, it neutralizes the acidity of the reflux. But skimmed milk is preferred because whole milk is rich in fats, proteins and calcium that increase gastric acidity and slow stomach emptying. So, after an immediate benefit there is a rapid reappearance of the symptoms. Yogurt is fine but, even for this food, remember to always prefer those low in fat.
Avoid fatty meats (pork) and smoked meats and avoid sausages, while all types of fish are suitable (both fresh and frozen). Avoid boiled or fried eggs and prefer soft-boiled ones. At risk the very fat or fermented cheeses (gorgonzola, taleggio, mascarpone and brie) because they slow down the gastric emptying, while the fresh ones (such as ricotta or mozzarella) are more suitable. It is good to avoid (or not exaggerate) with sour fruit such as citrus fruits, lemons, mandarins, oranges, cedar, pomegranate, currant and pineapple. while you can safely eat apples, blackberries, raspberries, melons, bananas, pears, peaches
As for the ‘drinking’ are absolutely to avoid hard liquor, fasting. say ‘no’ to white wine, better a glass of red. Limit the use of tea, coffee, sodas, caffeinated drinks, fruit juices (orange, grapefruit, lemon, pineapple, tomato). Mint is to be avoided because it seems to reduce the tone of the valve between the stomach and the esophagus. Attention, finally, not to take too hot drinks (tea, coffee, herbal teas, etc.)
Do not overdo desserts especially with those stuffed with creams or chocolate. Chocolate, although very good, has the effect of reducing the tone of the esophagus-gastric valve. Avoid the use of spices (cinnamon, nutmeg and curry) and avoid fried and fried. Always prefer light cooking, then choose cooking on the grill, boiling and sautéed cooking.
- keep your weight because the excess pounds worsen the symptoms of the disease and increase the abdominal pressure (and, therefore, the reflux)
- reduce stress and tensions that daily life entails;
- never skip meals, but these should not be abundant and frequent.
- quit smoking: nicotine has a hypotonic effect on cardias, determines an hypersecretion of hydrochloric acid and reduces the production of bicarbonate which has the purpose of protecting the gastric mucosa from the corrosive action of gastric juice.
- drink lots of water to dilute acids making them less effective.
- avoid post-meal positions such as relaxing on the couch, which facilitate reflux, while a good walk facilitates the digestion process.
The primary goal of medical treatment of MRGE is full control of symptoms, (heartburn with or without regurgitation) accompanied by improved patient quality of life.
To counteract the gastroesophageal reflux, today we have available some particularly effective drugs able to reduce stomach acid secretion. From the milder anti-secretants of the past, like the H2-antagonists (ranitidine), today we have passed to the most powerful proton pump inhibitors (IPP): 15mg and 30mg lansoprazole; omeprazole 10mg and 20mg; pantoprazole 20mg and 40mg; rabeprazole 10 mg and 20 mg; esomeprazole 20 mg and 40 mg. Such drugs, generally equivalent as efficacy among themselves, reducing the amount of gastric acid available for reflux into the esophagus, relieve the symptoms and allow healing of the esophageal lesions, if present. These drugs should be taken on an empty stomach, 30-60 minutes before the meal (remember that it is important not to crush or chew the tablets).
With regard to prokinetic drugs there is no proven efficacy unless there is also an altered gastric motility (slowed emptying). Antacids and alginate, often taken by the patient in the form of self-medication when needed, are certainly helpful in achieving rapid symptomatic relief in occasional situations.
When setting up the therapy it must be taken into account that there is a poor correlation between the intensity of the symptoms and the severity of the lesions endoscopically found on the esophageal mucosa. In most cases, when there are mucous lesions, full control of the symptoms is accompanied by the resolution of the lesions, which instead tend to persist if the asymptomaticity is not reached.
GERD therapeutic schemes
It is one of the most interesting and important chapters not always properly followed by doctors and patients. The therapeutic scheme is diversified from patient to patient based on its symptoms, the presence of esophagitis or complications, or the presence of atypical disorders.
For a patient with a typical symptomatology of recent onset of age 50 years old, which presents disorders typical of GERD (heartburn, acid regurgitation), but without symptoms or signs of alarm such as dysphagia, weight loss, bleeding… it is advisable to start a treatment with full-dose IPP (i.e. the maximum dose for each drug), for 4-8 weeks, to be reduced to the minimum effective dose once full control of symptoms is achieved.
This type of treatment (‘downward’ or ‘stepdown’ scheme that differs from the ‘up’ or ‘up-step’ pattern that starts with the minimum dose of therapy and is triggered in the event of a lack of symptom control) begins with the maximum dose of the drug is the most indicated and followed as it allows a rapid resolution of symptoms (and of any esophagitis) by offering the best results in a shorter time and avoiding further investigation.
Once the symptoms have completely regressed, treatment may be suspended to assess the subsequent course of the disease, but if the disorders recur early and tend to continuity, treatment should be continued with the minimum effective dose. In cases where symptoms resume after longer or shorter periods of well-being, IPP therapy can be resumed according to the ‘on demand’ pattern, i.e. the drug is taken only to the eventual resumption of symptoms and for the period strictly necessary to disappeared (and in any case not less than 15 days). Patients who do not respond to therapy should be evaluated by the specialist for further diagnostic investigation.
Patient with a long history (more than 5 years) of MRGE, even if responding to previous cycles of therapy with IPP and without warning signs or symptoms, especially if over the age of 45 years are indicated an endoscopic assessment to assess the state of esophageal mucosa. Therapy will be established based on the result of gastroscopy that may have detected: 1) lack of esophageal lesions; 2) signs of esophagitis; 3) Barrett’s esophagus.
- In the absence of esophageal lesions can be formulated the diagnosis of NERD (Non Erosive Reflux Disease, i.e. Non-Erosive Reflux Disease). The indicated therapy is the daily administration of a full dose IPP according to the ‘step-down’ scheme until the symptoms have completely disappeared. In patients with NERD there may be less response to the drug, due to a concomitant ‘receptorial hypersensitivity’ of the mucosa or due to the simultaneous presence of a dyspeptic-functional syndrome. Therefore, if there is not an effective response to the cycle with IPP it is good to evaluate the actual role of acid reflux by performing an esophageal pH-impedance measurement. This survey will give us the actual data on the presence, extent, quality, extension of reflux and an estimate of the probability of association between symptoms and acid reflux.
- In the presence of an esophagitis therapy will be established according to the degree of inflammation. In the presence of a type A and B esophagitis, an IPP therapy for 4-8 weeks will be prescribed, whereas in the presence of grade C or D oesophagitis the course of therapy will be prolonged from 3 to 6 months.
- In patients with Barrett’s esophagus therapy should be maintained at full dose regardless of symptoms that may also be absent. The risk of neoplastic degeneration in Barrett’s esophagus is modest and the onset is slow so without any alarmism, it is indicated to perform endoscopic checks that will be programmed on the basis of histological damage and with such cadence.
a. Patients without dysplasia are appointed esophagus-gastro-duodenoscopy every 2-3 years
b. Patients with low-grade dysplasia. Recent studies have shown that the possibility of cancer development of low-grade dysplasia is comparable to the condition of absence of dysplasia. For this reason it is reasonable to bring the range of control endoscopies in these patients to 2 years.
c. Patients with high-grade dysplasia. Review of histological preparations by an expert pathologist of gastro-intestinal pathology and subsequent clinical-pathological evaluation to evaluate the therapeutic intervention strategy (endoscopic or surgical).
The atypical manifestations of MRGE
The atypical manifestations of MRGE include chronic cough, pharynodynia, dysphonia (ENT district), asthma, cough (pulmonary district) and chest pain not of cardiac origin (cardiology district). Patients who have the symptoms described above must arrive at the gastroenterologist only after the specialists in the sector have excluded diseases of their exclusive competence. It is therefore always desirable that the diagnosis of reflux (and consequently the therapy) is managed by the gastroenterologist specialist.
The atypical manifestations of reflux certainly have a gastroenterological genesis if they are accompanied by the typical symptoms of reflux (burning and regurgitation). Therefore they must be treated with antisecretory drugs, often with double dose, and for long times. Particular attention should be paid when atypical symptoms are the only manifestation of reflux. In these cases, also in terms of pharmacoeconomics, it is preferable to subject the patient to physiopathology studies (manometry and pH-impedance) to arrive at the most correct diagnosis, instead of setting up therapies often with long-term PPIs, of poor therapeutic efficacy.
The possible presence of hiatal hernia associated with MRGE does not change the criteria for the treatment of clinical manifestations related to reflux. As previously stated, hiatal hernia is not always associated with reflux as not all patients with reflux have a hiatal hernia. Ultimately, what directs you to therapy (medical or surgical) are the symptoms of pathological gastroesophageal reflux and not hiatal hernia.
When talking about acid pathologies related to the upper digestive tract, it is inevitably also referred to as Helicobacter Pylori. It is well known that the infection of H. pylori is a cofactor in the development of three important gastrointestinal diseases: gastric or duodenal ulcer, gastric cancer and gastric lymphoma. The eradication of the bacterium is therefore indicated in the presence of gastric and / or duodenal ulcers, gastric lymphoma, in the families of the first degree of patients with gastric cancer and in patients with superficial gastric cancer. There is, however, no role for HP in patients with gastroesophageal reflux, which is linked to other mechanisms (hiatal hernia, etc.), so that the eradication of the bacterium should not therefore be part of the usual pattern of treatment of MRGE.
Surgical therapy for GERD
The number of surgical procedures to control gastroesophageal reflux is clearly decreasing worldwide thanks to the efficacy of the powerful drugs available that inhibit gastric secretion. However, there are some conditions in which the patient (or the same doctor) would like to evaluate the surgical solution, wrongly or rightly. Let’s see what the situations are where a surgical evaluation is most required.
Young patients under 40 years who respond well to medical therapy, but who are not available, considering their young age, to take the drug ‘for life’. They are ideal candidates for surgery.
Patients who do not respond to medical therapy. It is the least possible category of a surgical treatment. In fact, very often in these patients the symptoms are not attributable to reflux, while other causes come into play: cardiac respiratory musculoskeletal, irritable bowel, other disorders of gastrointestinal motility, etc. So they are patients who must be properly studied otherwise the surgical failure is obvious.
Patients intolerant to anti-reflux therapy (IPP). Some patients may be intolerant (due to adverse drug reactions), partially or totally to PPIs. Obviously, before opting for surgery, it must be ruled out that there are no concomitant diseases that can somehow simulate the symptoms of reflux disease (see previous situation). Moreover, in some subjects there is a missed or reduced absorption of the drug so it is useless to continue to change the molecule.
Patients with persistent regurgitation. PPIs are able to control gastric acidity, but not regurgitation. It may therefore happen that some individuals manage with PPIs to control reflux symptoms (heartburn, retro sternal pain, etc.) but not the regurgitation that can be persistent and disabling. This condition is correctly indicated for surgery.
Patients with respiratory complications
A reflux that exceeds the upper esophageal sphincter may give rise to an important laryngeal and pulmonary symptomatology (laryngitis, chronic cough, asthma, bronchopulmonary outbreaks, etc.) and not always the therapy with IPP is effective. Before thinking about the surgical solution it is necessary that the specialists of the sector exclude the real broncho-pulmonary diseases (responsible for the symptomatology). It is also important to confirm the ‘high’ reflux from the targeted instrumental findings (esophageal pH-impeditometry)
Patients with complications of reflux disease
The complications that deserve to be evaluated for a surgical solution are Barrett’s stenosis and esophagus. Esophageal strictures are less and less frequent and are linked to ineffective medical therapy or unsuitable treatment. Before deciding for surgery, other possible causes must be ruled out (impaired esophageal motility, such as in achalasia and scleroderma).
Regarding Barrett’s esophagus, it should be noted that the mere presence of such pathology is not an indication of surgery (with a view to preventing cancer of the esophagus), but this decision must be taken in order to correct the reflux when the patient falls into one of the previously listed categories (young age, treatment intolerant, regurgitation, etc.). Obviously, the surgical indication becomes absolute in the presence of a Barrett esophagus complicated by invasive cancer.
Surgery aims to correct the esophageal sphincter, that is, the valve that regulates the passage of food into the stomach and avoids the pathological reflux of gastric secretions in the esophagus. The most popular intervention is the Nissen fundoplication which consists in bringing stomach and cardias into the abdomen, closing the hernial breccia of the diaphragm and packaging a 360 ° antireflux plastic that provides a stomach portion positioned ‘to tie’ around the esophagus.
This intervention is performed with a minimally invasive technique (video laparoscopy) based on the insertion of micro-cameras and special surgical instruments through some small incisions made on the abdomen. With this intervention the post-operative hospitalization generally does not exceed 48-72 hours and within a week the patient can resume normal activities, maintaining a soft diet for 20-30 days and refraining from heavy work for at least 2 months after intervention.
In order to overcome the risks and disadvantages of surgical therapy, different endoscopic techniques for the control of reflux have been developed over the last decade with different methods of approach: injective therapy, radiofrequency and suture. None of these techniques, however, has shown to date to be able to compete with surgery because they were either not very effective (radiofrequency) or unsafe (injective techniques) or impractical (sutures). Endoscopic reflux therapy, pending its definitive placement, is currently proposed in some research protocols.