Gastric reflux, also called gastro-esophageal reflux disease (GERD), is a condition where the stomach's contents (food or liquid) rise up from the stomach into the esophagus, a tube that carries food from the mouth to the stomach. Food mixed with the stomach's digestive acids can irritate and damage the esophagus.

Causes

Normally, the stomach's contents are retained in the stomach with the help of the lower esophageal sphincter (LES), a muscle that contracts and relaxes to maintain the one-way movement of food. However, gastric reflux occurs when the LES weakens. The exact cause of this is not known, however certain factors including obesity, smoking, pregnancy and possibly alcohol, may contribute to GORD. Common foods such as spicy foods, onions, chocolates, caffeine containing drinks, mint flavorings, tomato-based foods, citrus fruits and certain medications can worsen gastric reflux.

Impact

Living with gastric reflux is inconvenient as symptoms can severely interfere with your life. You may have to follow certain dietary restrictions and reflux occurring in the night can hinder a good night's sleep, thereby affecting alertness and productivity the next day.

Anatomy

Food travels from the mouth through the esophagus, a long, narrow tube that opens into the stomach. This food pipe is lined by muscles that expand and contract to push food down the tube, a process called peristalsis. The stomach secretes acid and other digestive enzymes for the digestion of food and stores food before it enters into the intestine.

A band of muscles called the lower esophageal sphincter (LES) are present at the junction of the esophagus and the stomach. This acts as a valve, preventing the reflux of acid and chyme (food mixed with acid and digestive enzymes) from the stomach into the food pipe.

Symptoms

Heartburn is usually the main symptom of GERD, characterized by a burning-type pain in the lower part of the mid-chest, behind the breast bone. Other symptoms include a bitter or sour taste in the mouth, trouble swallowing, nausea, dry cough or wheezing, regurgitation of food (bringing food back up into the mouth), hoarseness or change in voice and chest pain.

Diagnosis

Your doctor may order some of the following tests to diagnose gastric reflux:

• Endoscopy: allows the doctor to examine the inside of your esophagus, stomach and portions of the intestine with an instrument called an endoscope, a thin flexible lighted tube
• Barium X-rays: involves swallowing a barium preparation, which can be detected through X-rays
• Twenty four-hour pH monitoring: involves inserting a tube through your nose into the esophagus, and positioning it above the LES. The tip of the tube contains a sensor which can measure the pH of the acid content refluxed into the esophagus. The tube will be left in place for 24 hours.
• pH capsule: allows measuring acid exposure in the esophagus. A small wireless capsule is introduced into the esophagus by a tube through the nose or mouth. The tube is removed after the capsule is attached to the lining of the esophagus. The pH sensor transmits signals to a computer which collects the data about the acid exposure over the next24 hours. The capsule eventually falls off of the esophagus lining and is safely passed in the stool.
• Impedance study: requires two probes; one is placed in the stomach and the other just above the stomach. The dual sensor helps to detect both acidic and alkaline reflux.

Treatments

Treatment aims at reducing reflux, relieving symptoms and preventing damage to the esophagus. Some of the treatment options include:

• Antacids: over-the-counter medicines that provide temporary relief to heartburn and indigestion by neutralizing acid in the stomach
• Other medications: reduce the production of acid in the stomach
• Endoluminal gastroplication or endoscopic fundoplication technique: minimally-invasive method that requires the use of an endoscope with a sewing device attached to the end, known as an EndoCinch device. This instrument places stitches in the stomach below the LES to create a plate which helps reduce the pressure against the LES and strengthen the muscle.
• Nissen's fundoplication: is a surgical procedure in which the upper part of the stomach is wrapped around the end of your esophagus and esophageal sphincter, where it is sutured into place. This surgery strengthens the sphincter and helps prevent stomach acid and food from flowing back into the esophagus.

Esophageal achalasia is a condition in which the esophagus (tube carrying food from the mouth to the stomach) is unable to move food into the stomach. The muscles at the lower end of the esophageal sphincter fail to relax and allow food to pass into the stomach, resulting in reflux.

Causes

Esophageal achalasia is caused by damage to the nerves supplying the esophagus, which affects:

• Muscles lining the esophagus that rhythmically contract to push food towards the stomach
• Muscles of the lower esophageal sphincter that act as a gate for the one-way movement of food into the stomach

The cause of damage is not clear, but may be associated with an earlier viral infection or autoimmune condition, such as lupus and uveitis, where the body attacks healthy cells.

Impact

Achalasia can have a significant impact on your health with respect to the act of eating and drinking. With the advancement of the condition you may lose considerable amount of weight and suffer from malnutrition. If the obstruction lasts for a long time, there are chances of developing esophageal cancer.

Anatomy

The esophagus is a long, narrow tube that allows the passage of food from the throat to the stomach. It extends behind the windpipe and heart and in front of the spine, and passes through the diaphragm before joining the stomach. The food pipe is lined by muscles that expand and contract to push food down the tube. A valve called the upper esophageal sphincter prevents the accidental movement of food into the windpipe. Another valve called the lower esophageal sphincter, located at the junction of the stomach and esophagus, allows the passage of food to the stomach and prevents the backflow of food and stomach acids into the esophagus. The sphincter is controlled by muscles that relax and contract to open and close the passage.

Symptoms

Common symptoms of achalasia include difficulty swallowing (dysphagia) both solid and liquid foods, and experiencing the sensation of food getting stuck in the chest. To facilitate swallowing you may make changes in the way you eat. Other symptoms include regurgitation of food, heartburn, sensation of fullness and chest pain. In advanced stages of the disease, you may experience weight loss and suffer from malnutrition (although this is rare).

Diagnosis

Your doctor may order the following tests to diagnose achalasia:

• Barium swallow test: involves swallowing a barium preparation, which can be detected through X-rays
• Endoscopy: allows the doctor to examine the inside of your esophagus, stomach, and portions of the intestine, with an instrument called an endoscope, a thin flexible lighted tube
• Manometry: measures changes in pressureexerted by the esophageal sphincter

Treatments

Treatment aims at opening or relaxing the lower esophageal sphincter muscles for easy passage of food into the stomach. Some of the options for relieving symptoms include:

• Medications: Medications help relax the lower esophagus sphincter muscles and provide temporary relief.
• Botox injection: Botulinum toxin injection can be administered to help relax the sphincter muscles. It provides temporary relief only and has to be repeated after a few months or years.
• Balloon dilation (pneumatic dilatation): A small balloon is positioned at the lower esophagus sphincter and inflated to widen the opening.Although this procedure improves swallowing, it is not a permanent solution and needs to be repeated.
• Myotomy surgery: Myotomy is a surgical procedurein which the sphincter muscle is cut to open up the esophagus. This surgery provides a permanent solution to swallowing.

The esophagus is a tube that carries food and liquid from the mouth to the stomach. Peptic stricture is a condition in which the esophagus narrows causing difficulty or pain while swallowing, regurgitation of food (backflow of the food from stomach into the esophagus or mouth) and unexplained weight loss.

Peptic stricture can be caused due to:

• Gastro esophageal reflux disease: condition in which the stomach contents leak back from the stomach into the esophagus
• Injury while undergoing an endoscopy (diagnostic procedure that involves the insertion of a narrow tube through your mouth to examine the digestive tract)
• Extended use of a nasogastric (NG) tube: feeding tube inserted through your nose, into your stomach
• Swallowing household cleaners or battery acid that may harm the esophagus lining
• Treatment of esophageal varices: enlarged esophageal veins that bleed

Peptic stricture can be diagnosed with the help of an endoscopy or by barium swallow, which involves the ingestion of a barium solution followed by X-ray imaging.

Treatment involves relieving symptoms by administration of acid-blocking medication. Dilation of the esophagus is also a procedure for treating peptic stricture. Surgery may be advised if medications and dilation are unsuccessful in treating peptic stricture.

Endoscopic Management of Barret's Esophagus

Barret's esophagus is a condition characterized by changes in the lining of the esophagus to resemble that of the intestine. It usually occurs as a complication of prolonged gastroesophageal reflux disease where the acidic contents of the stomach spill upwards into the esophagus. Barret's esophagus does not cause any symptoms; however, it does increase your risk of developing esophageal cancer.

There are different endoscopic methods for the management of Barret's esophagus. The goal of these methods is to avoid cancer or the need for open surgery. The various options include:

• Radiofrequency Ablation: An electrode mounted on an endoscope is used to deliver thermal energy to the mucosal lining that has undergone changes consistent with Barret's esophagus. This has proven to be a very safe and effective method of eradicating Barret's esophagus.
• Endoscopic Mucosal Resection: A snare is delivered through the endoscope to the suspicious area in the esophagus. The mucosal lining is then removed using the snare. This method is only indicated for patients with focal areas of Barret's esophagus as treating widespread areas of Barret's esophagus using this method can result in complications.
• Photodynamic Therapy: A drug is first injected into the vein which makes the diseased mucosal lining sensitive to laser light. After 24 to 48 hours, laser light is then delivered to the Barret's esophagus through an endoscope resulting in specific destruction of the diseased tissue.
• Cryotherapy: Cold nitrogen or carbon dioxide gas is supplied to the diseased mucosal lining of the esophagus resulting in freezing and destruction of the abnormal cells. This is a relatively new treatment method.

In the past, surgery was performed to treat Barret's esophagus before it advanced to cancer which could require more complicated surgery. Over the last few years, however, endoscopic management has become the treatment of choice for advanced Barret's esophagus and early stages of esophageal cancer.

Anti-reflux surgery, also known as Nissen Fundoplication surgery is a procedure to treat gastro esophageal reflux disease (GERD).

Acid reflux, also called gastro-esophageal reflux disease (GERD), is a condition where the stomach contents (food or liquid) rise up from the stomach into the esophagus, a tube that carries food from the mouth to the stomach.

Normally the stomach contents do not enter the esophagus due to constricted LES. But in patients with acid reflux stomach content travels back into the esophagus because of a weak or relaxed lower esophageal sphincter (LES). Lower esophageal sphincter is a ring of muscle fibers that surrounds the lower-most end of the esophagus where it joins the stomach. LES acts like a valve between the esophagus and stomach preventing food from moving backward into the esophagus.

Heartburn is usually the main symptom; a burning-type pain in the lower part of the mid-chest, behind the breast bone. Other symptoms such as a bitter or sour taste in the mouth, trouble in swallowing, nausea, dry cough or wheezing, regurgitation of food (bringing food back up into the mouth), hoarseness or change in voice, and chest pain may be experienced.

The exact cause of what weakens or relaxes the LES in GERD is not known, however certain factors including obesity, smoking, pregnancy, and possibly alcohol may contribute to GERD. Common foods that can worsen reflux symptoms include spicy foods, onions, chocolates, caffeine containing drinks, mint flavorings, tomato based foods and citrus fruits. Certain medications can also worsen the reflux.

There are several tests that can be performed to diagnose acid reflux and they include:

• Endoscopy: This test allows the doctor to examine the inside of the patient's esophagus, stomach, and portions of the intestine, with an instrument called an endoscope, a thin flexible lighted tube.
• Barium X-rays: These are diagnostic x-rays in which barium is used to diagnose abnormalities of the digestive tract. You are asked to drink a liquid that contains barium. The barium coats the walls of the esophagus and stomach and makes the abnormalities visible more clearly. Then X-rays are taken to see if there are strictures, ulcers, hiatal hernias, erosions or other abnormalities.
• Twenty four-hour pH monitoring - In this procedure, a tube will be inserted through the nose into the esophagus and positioned above the LES. The tip of the tube contains a sensor which can measure the pH of the acid content refluxed into esophagus. A recorder, strap-like device that can be worn on wrist, will be connected to record the pH of the acid content. The tube will be left in place for 24 hours. Patients can also go back home and perform their regular activities and can record the pH of the acid content when they experience the symptoms. On the next day the recorder will be connected to a computer and the data will be analyzed.
• PH Capsule: It is a new method of measuring acid exposure in the esophagus. A small wireless capsule which is introduced into the esophagus by a tube through the nose or mouth. The tube is removed after the capsule is attached to the lining of the esophagus. The pH sensor transmits signals to a computer which collects the data about the acid exposure over the usual 24 hours. The capsule falls off of the esophagus with time and is passed in the stool.
• Impedance study: This test is similar to pH test but requires two probes; one is placed in the stomach and the other just above the stomach. The dual sensor helps to detect both acidic and alkaline reflux.

Antacids are over-the-counter medicines that provide temporarily relief to heartburn or indigestion by neutralizing acid in the stomach. Other medications such as proton pump inhibitors and H2 antagonists may be prescribed to reduce the production of acid in the stomach.

Anti-reflux Surgery may be an option for patients whose symptoms do not go away with the medications. Nissen's fundoplication is a surgical procedure in which the upper part of the stomach is wrapped around the end of your esophagus and esophageal sphincter, where it is sutured into place. This surgery strengthens the sphincter and helps prevent stomach acid and food from flowing back into esophagus.

Surgical Procedure

Nissen Fundoplication is performed as day surgery either in the hospital or outpatient surgery center usually with the patient under general anesthesia.

The surgeon uses a needle to inject a harmless gas into the abdominal cavity near the belly button to expand the viewing area of the abdomen giving the surgeon a clear view and room to work. The surgeon makes a small incision in the upper abdomen and inserts a tube called a trocar through which the laparoscope is introduced into the abdomen. Additional small incisions may be made for a variety of surgical instruments to be used during the procedure.

With the images from the laparoscope as a guide, your surgeon wraps the upper part of the stomach, the fundus, around the lower esophagus to create a valve, suturing it in place.

The hole in the diaphragm through which the esophagus passes is then tightened with sutures. The laparoscope and other instruments are removed and the gas released.

The tiny incisions are closed and covered with small bandages.

Laparoscopy is much less traumatic to the muscles and soft tissues than the traditional method of surgically opening the abdomen with long incisions (open techniques).

Specific complications for Nissen Fundoplication include:

• Post-operative fever and infection
• Surgical injury to blood vessels
• Surgical injury to stomach or esophagus
• Swallowing difficulties
• Gas embolism - If gas is used to distend the abdominal cavity for better viewing there is a risk of gas embolism or gas bubbles in the bloodstream.
• Adhesions - Extensive scar tissue formation can form in the surgical area.

Esophageal stricture is narrowing or tightening of the esophagus, (a tube that carries foods and liquids from the mouth to the stomach) which leads to pain and difficulty in swallowing, vomiting, and loss of weight. Some of the factors that can cause narrowing include congenital defects, radiation therapy, sclerotherapy, esophageal surgery, stomach narrowing, and scar tissue formation. Stricture is relieved by dilatation technique.

Esophageal dilatation: It is a procedure to widen or clear the blockage in esophagus. It relieves difficulty in swallowing. It is done under local anesthesia. Patient should not take food for 4 to 6 hours before the procedure.

This treatment uses dilators along with an endoscope (a narrow tube with a tiny light and camera at the end). It is inserted through the mouth into the esophagus. Dilators are passed to the blocked site. Endoscope enables viewing the inside of esophagus and dilators pass down the esophagus to increase the size.

Various types of dilators are available for use in esophageal dilatation.

Simple Dilators (Bougies): These are series of flexible dilators. One or more of these bougies are passed down through the esophagus which helps in opening the esophagus.

Guided wire bougie: During endoscopy, a flexible wire is passed across the stricture. The wire is left in place and endoscope is removed. A small tube that is wider at one end is passed down the esophagus through the stricture. The wire is removed at the end of the procedure. Guided wire bougies are used to treat all kinds of strictures.

Balloon dilators: Deflated balloon is passed through the endoscope across the stricture. The deflated balloon is then inflated which breaks the stricture. It is used to treat achalasia, a rare swallowing disorder of the lower sphincter muscle of the esophagus. A larger balloon type dilator is inserted into the lower esophagus through an endoscope. The muscle fibers are stretched and broken. This procedure helps in easy passage of food into the stomach.

Some of the complications of esophageal dilatation procedures include perforation, bleeding, and infection. Perforation causes a hole in the lining of esophagus which is surgically repaired.