What is GERD (acid reflux)?

Gastroesophageal reflux disease, commonly referred to as GERD or acid reflux, is a

condition in which the liquid content of the stomach regurgitates (backs up or refluxes)

into the esophagus. The liquid can inflame and damage the lining (cause esophagitis) of

the esophagus although visible signs of inflammation occur in a minority of patients. The

regurgitated liquid usually contains acid and pepsin that are produced by the stomach.

The refluxed liquid also may contain bile that has backed-up into the stomach from the

duodenum. (The duodenum is the first part of the small intestine that attaches to the

stomach.) Acid is believed to be the most injurious component of the refluxed liquid.

GERD is a chronic condition. Once it begins, it usually is life-long. If there is injury to the

lining of the esophagus (esophagitis), this also is a chronic condition. Moreover, after the

esophagus has healed with treatment and treatment is stopped, the injury will return in

most patients within a few months. Once treatment for GERD is begun, therefore, it

usually will need to be continued indefinitely although it is argued that in some patients

with intermittent symptoms and no esophagitis, treatment can be intermittent and done

only during symptomatic periods.

As is often the case, the body has ways (mechanisms) to protect itself from the harmful

effects of reflux and acid. For example, most reflux occurs during the day when

individuals are upright. In the upright position, the refluxed liquid is more likely to flow

back down into the stomach due to the effect of gravity. In addition, while individuals are

awake, they repeatedly swallow, whether or not there is reflux. Each swallow carries any

refluxed liquid back into the stomach. Finally, the salivary glands in the mouth produce

saliva, which contains bicarbonate. With each swallow, bicarbonate-containing saliva

travels down the esophagus. The bicarbonate neutralizes the small amount of acid that

remains in the esophagus after gravity and swallowing have removed most of the liquid.

Gravity, swallowing, and saliva are important protective mechanisms for the esophagus,

but they are effective only when individuals are in the upright position. At night

during sleep, gravity is not in effect, swallowing stops, and the secretion of saliva is

reduced. Therefore, reflux that occurs at night is more likely to result in acid remaining in

the esophagus longer and causing greater damage to the esophagus.

Certain conditions make a person susceptible to GERD. For example, GERD can be a

serious problem during pregnancy. The elevated hormone levels of pregnancy probably

cause reflux by lowering the pressure in the lower esophageal sphincter.At the same

time, the growing fetus increases the pressure in the abdomen. Both of these effects

would be expected to increase reflux. Also, patients with diseases that weaken the

esophageal muscles, such as scleroderma or mixed connective tissue diseases, are

more prone to develop GERD.

What causes GERD?

The cause of GERD is complex. A small number of patients with GERD produce

abnormally large amounts of acid, but this is uncommon and not a contributing factor in

the vast majority of patients. The factors that contribute to GERD are lower esophageal

sphincter abnormalities, hiatal hernias, abnormal esophageal contractions, and slow or

prolonged emptying of the stomach.

Lower esophageal sphincter

The action of the lower esophageal sphincter (LES) is perhaps the most important factor

(mechanism) for preventing reflux. The esophagus is a muscular tube that extends from

the lower throat to the stomach. The LES is a specialized ring of muscle that surrounds

the lower-most end of the esophagus where it joins the stomach. The muscle that makes

up the LES is active most of the time. This means that it is contracting and closing off the

passage from the esophagus into the stomach. This closing of the passage prevents

reflux. When food or saliva is swallowed, the LES relaxes for a few seconds to allow the

food or saliva to pass from the esophagus into the stomach, and then it closes again.

Several different abnormalities of the LES have been found in patients with GERD. Two

of them involve the function of the LES. The first is abnormally weak contraction of the

LES, which reduces its ability to prevent reflux. The second is abnormal relaxations of the

LES, called transient LES relaxations. They are abnormal in that they do not accompany

swallows and they last for a long time, up to several minutes. These prolonged

relaxations allow reflux to occur more easily. The transient LES relaxations occur in

patients with GERD most commonly after meals when the stomach is distended with

food. Transient LES relaxations also occur in individuals without GERD, but they are

infrequent.

The most recently-described abnormality in patients with GERD is laxity of the LES.

Specifically, similar distending pressures open the LES more in patients with GERD than

in individuals without GERD. At least theoretically, this would allow easier opening of the

LES and/or greater backward flow of acid into the esophagus when the LES is open.

Hiatal hernia

Hiatal hernias contribute to reflux, although the way in which they contribute is not clear.

A majority of patients with GERD have hiatal hernias, but many do not. Therefore, it is

not necessary to have a hiatal hernia in order to have GERD. Moreover, many people

have hiatal hernias but do not have GERD. It is not known for certain how or why hiatal

hernias develop.

Normally, the LES is located at the same level where the esophagus passes from the

chest through the diaphragm and into the abdomen. When there is a hiatal hernia, a

small part of the upper stomach that attaches to the esophagus pushes up through the

diaphragm. As a result, a small part of the stomach and the LES come to lie in the chest,

and the LES is no longer at the level of the diaphragm.

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.

There is a second way in which hiatal hernias might contribute to reflux. When a hiatal

hernia is present, there is a hernial sac, which is a small pouch of stomach above the

diaphragm. The sac is pinched off from the esophagus above by the LES and from the

stomach below by the diaphragm. What's important about this situation is that the sac

can trap acid that comes from the stomach. This trap keeps the acid close to the

esophagus. As a result, it is easier for the acid to reflux when the LES relaxes with a

swallow or a transient relaxation.

Finally, there is a third way in which hiatal hernias might contribute to reflux. The

esophagus normally joins the stomach obliquely due to which a flap of tissue is formed

between the stomach and esophagus. This flap of tissue is believed to act like a valve,

shutting off the esophagus from the stomach and preventing reflux. When there is a

hiatal hernia, the entry of the esophagus into the stomach is pulled up into the chest.

Therefore, the valve-like flap is distorted or disappears and it no longer can help prevent

reflux.

Esophageal contractions

As previously mentioned, swallows are important in eliminating acid in the esophagus.

Swallowing causes a ring-like wave of contraction of the esophageal muscles, which

narrows the lumen (inner cavity) of the esophagus. The contraction, referred to as

peristalsis, begins in the upper esophagus and travels to the lower esophagus. It pushes

food, saliva, and whatever else is in the esophagus into the stomach.

When the wave of contraction is defective, refluxed acid is not pushed back into the

stomach. In patients with GERD, several abnormalities of contraction have been

described. For example, waves of contraction may not begin after each swallow or the

waves of contraction may die out before they reach the stomach. Also, the pressure

generated by the contractions may be too weak to push the acid back into the stomach.

The effects of abnormal esophageal contractions would be expected to be worse at night

when gravity is not helping to return refluxed acid to the stomach. Note that smoking also

substantially reduces the clearance of acid from the esophagus. This effect continues for

at least 6 hours after the last cigarette.

Emptying of the stomach

Most reflux during the day occurs after meals. This reflux probably is due to transient

LES relaxations that are caused by distention of the stomach with food. A minority of

patients with GERD, about 20%, has been found to have stomachs that empty

abnormally slowly after a meal. The slower emptying of the stomach prolongs the

distention of the stomach with food after meals. Therefore, the slower emptying prolongs

the period of time during which reflux is more likely to occur.

In addition to the above, some medications may cause or worsen GERD. Some common

medications that may have this effect include anticholinergics, antihypertensives such

as beta blockers or calcium channel blockers, bronchodilators, dopamine-active drugs,

progestin, sedatives, and tricyclic antidepressants. Individuals should not stop taking

these or any drugs that are prescribed until the prescribing doctor has discussed the

potential GERD situation with them.

Symptoms of GERD

More common symptoms are:

Feeling that food may be left trapped behind the breastbone

Heartburn or a burning pain in the chest (under the breastbone)

Increased by bending, stooping, lying down, or eating

More likely or worse at night

Relieved by antacids

Nausea after eating

Less common symptoms are:

Cough or wheezing

Difficulty swallowing

Hiccups

Hoarseness or change in voice

Regurgitation of food

Sore throat

Complications of GERD

Barrett's oesophagus (a change in the lining of the oesophagus that can increase the risk of cancer)

Bronchospasm (irritation and spasm of the airways due to acid)

Chronic cough or hoarseness

Dental problems

Oesophageal ulcer

Inflammation of the oesophagus

Stricture (a narrowing of the oesophagus due to scarring from the inflammation)

Diagnosis

Symptoms and response to treatment (therapeutic trial)

The usual way that GERD is diagnosed—or at least suspected—is by its characteristic

symptom, heartburn. To confirm the diagnosis, physicians often treat patients with

medications to suppress the production of acid by the stomach. If the heartburn then is

diminished to a large extent, the diagnosis of GERD is considered confirmed. This

approach of making a diagnosis on the basis of a response of the symptoms to treatment

is commonly called a therapeutic trial.

There are problems with this approach, however, primarily because it does not include

diagnostic tests. For instance, patients who have conditions that can mimic GERD,

specifically duodenal or gastric (stomach) ulcers, also can actually respond to such

treatment. In this situation, if the physician assumes that the problem is GERD, he or she

will not look for the cause of the ulcer disease. For example, a type of infection

called Helicobacter pylori, or non-steroidal anti-inflammatory drugs (for

example, ibuprofen), can also cause ulcers and these conditions would be treated

differently from GERD.

Endoscopy

Upper gastrointestinal endoscopy (also known as esophago-gastro-duodenoscopy or

EGD) is a common way of diagnosing GERD. EGD is a procedure in which a tube

containing an optical system for visualization is swallowed. As the tube progresses down

the gastrointestinal tract, the lining of the oesophagus, stomach, and duodenum can be

examined.

The oesophagus of most patients with symptoms of reflux looks normal. Therefore, in

most patients, endoscopy will not help in the diagnosis of GERD. However, sometimes

the lining of the oesophagus appears inflamed (esophagitis). Moreover, if erosions

(superficial breaks in the esophageal lining) or ulcers (deeper breaks in the lining) are

seen, a diagnosis of GERD can be made confidently. Endoscopy will also identify several

of the complications of GERD, specifically, ulcers, strictures, and Barrett's esophagus.

Biopsies also may be obtained.

Finally, other common problems that may be causing GERD like symptoms can be

diagnosed (for example ulcers, inflammation, or cancers of the stomach or duodenum)

with EGD.

Biopsies

Biopsies of the esophagus that are obtained through the endoscope are not considered

very useful for diagnosing GERD. They are useful, however, in diagnosing cancers or

causes of esophageal inflammation other than acid reflux, particularly infections.

X-rays

Before the introduction of endoscopy, an X-ray of the esophagus (called an esophagram)

was the only means of diagnosing GERD. Patients swallowed barium (contrast material),

and X-rays of the barium-filled esophagus were then taken. The problem with the

esophagram was that it was an insensitive test for diagnosing GERD. That is, it failed to

find signs of GERD in many patients who had GERD because the patients had little or no

damage to the lining of the esophagus. The X-rays were able to show only the infrequent

complications of GERD, for example, ulcers and strictures.

Examination of the throat and larynx

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.

Esophageal acid testing

Esophageal acid testing is considered a "gold standard" for diagnosing GERD. As

discussed previously, the reflux of acid is common in the general population. However,

patients with the symptoms or complications of GERD have reflux of more acid than

individuals without the symptoms or complications of GERD. Moreover, normal

individuals and patients with GERD can be distinguished moderately well from each other

by the amount of time that the esophagus contains acid.

The amount of time that the esophagus contains acid is determined by a test called a 24-

hour esophageal pH test. (pH is a mathematical way of expressing the amount of acidity.)

For this test, a small tube (catheter) is passed through the nose and positioned in the

esophagus. On the tip of the catheter is a sensor that senses acid. The other end of the

catheter exits from the nose, wraps back over the ear, and travels down to the waist,

where it is attached to a recorder. Each time acid refluxes back into the esophagus from

the stomach, it stimulates the sensor and the recorder records the episode of reflux. After

a 20 to 24 hour period of time, the catheter is removed and the record of reflux from the

recorder is analyzed.

Typical symptoms, response to treatment, or the presence of complications of GERD in

combination with pH testing are required for the correct diagnosis of GERD. GERD also

may be confidently diagnosed when episodes of heartburn correlate with acid reflux as

shown by acid testing.

A newer method for prolonged measurement (48 hours) of acid exposure in the

esophagus utilizes a small, wireless capsule that is attached to the esophagus just above

the LES. The capsule is passed to the lower esophagus by a tube inserted through either

the mouth or the nose. After the capsule is attached to the esophagus, the tube is

removed. The capsule measures the acid refluxing into the esophagus and transmits this

information to a receiver that is worn at the waist. After the study, usually after 48 hours,

the information from the receiver is downloaded into a computer and analyzed. The

capsule falls off of the esophagus after 3-5 days and is passed in the stool. (The capsule

is not reused.)

The advantage of the capsule over standard pH testing is that there is no discomfort from

a catheter that passes through the throat and nose. Moreover, with the capsule, patients

look normal (they don't have a catheter protruding from their noses) and are more likely

to go about their daily activities, for example, go to work, without feeling self-conscious.

Because the capsule records for a longer period than the catheter (48 versus 24 hours),

more data on acid reflux and symptoms are obtained.

Capsule pH testing is expensive. Sometimes the capsule does not attach to the

esophagus or falls off prematurely. For periods of time the receiver may not receive

signals from the capsule, and some of the information about reflux of acid may be lost.

Occasionally there is pain with swallowing after the capsule has been placed.

Esophageal motility testing

Esophageal motility testing determines how well the muscles of the esophagus are

working. For motility testing, a thin tube (catheter) is passed through a nostril, down the

back of the throat, and into the esophagus. On the part of the catheter that is inside the

esophagus are sensors that sense pressure. A pressure is generated within the

esophagus that is detected by the sensors on the catheter when the muscle of the

esophagus contracts. The end of the catheter that protrudes from the nostril is attached

to a recorder that records the pressure. During the test, the pressure at rest and the

relaxation of the lower esophageal sphincter are evaluated. The patient then swallows

sips of water to evaluate the contractions of the esophagus.

Esophageal motility testing has two important uses in evaluating GERD. The first is in

evaluating symptoms that do not respond to treatment for GERD. The abnormal function

of the esophageal muscle sometimes causes symptoms that resemble the symptoms of

GERD. Motility testing can identify some of these abnormalities and lead to a diagnosis

of an esophageal motility disorder. The second use is evaluation prior to surgical or

endoscopic treatment for GERD. In this situation, the purpose is to identify patients who

also have motility disorders of the esophageal muscle. The reason for this is that in

patients with motility disorders, some surgeons will modify the type of surgery they

perform for GERD.

Gastric emptying studies

Gastric emptying studies are studies that determine how well food empties from the

stomach. As discussed above, about 20 % of patients with GERD have slow emptying of

the stomach that may be contributing to the reflux of acid. For gastric emptying studies,

the patient eats a meal that is labeled with a radioactive substance. A sensor that is

similar to a Geiger counter is placed over the stomach to measure how quickly the

radioactive substance in the meal empties from the stomach.

Information from the emptying study can be useful for managing patients with GERD. For

example, if a patient with GERD continues to have symptoms despite treatment with the

usual medications, doctors might prescribe other medications that speed-up emptying of

the stomach. Alternatively, in conjunction with GERD surgery, they might do a surgical

procedure that promotes a more rapid emptying of the stomach.

Symptoms of nausea, vomiting, and regurgitation may be due either to abnormal gastric

emptying or GERD. An evaluation of gastric emptying, therefore, may be useful in

identifying patients whose symptoms are due to abnormal emptying of the stomach

rather than to GERD.

Acid perfusion test

The acid perfusion (Bernstein) test is used to determine if chest pain is caused by acid

reflux. For the test, a thin tube is passed through one nostril, down the back of the throat,

and into the middle of the esophagus. A dilute, acid solution and a physiologic (normal)

salt solution are alternately poured (perfused) through the catheter and into the

esophagus. The patient is unaware of which solution is being infused. If the perfusion

with acid provokes the patient's usual pain and perfusion of the salt solution produces no

pain, it is likely that the patient's pain is caused by acid reflux.

GERD treatment

Lifestyle changes

To prevent heartburn, avoid foods and beverages that may trigger your symptoms. For many people, these include:

Alcohol

Caffeine

Carbonated beverages

Chocolate

Citrus fruits and juices

Tomatoes

Tomato sauces

Spicy or fatty foods

Full-fat dairy products

Peppermint

Spearmint

If other foods regularly give you heartburn, avoid those foods, too.

Also, try the following changes to your eating habits and lifestyle:

Avoid bending over or exercising just after eating

Avoid garments or belts that fit tightly around your waist

Do not lie down with a full stomach. For example, avoid eating within 2 - 3 hours of bedtime.

Do not smoke.

Eat smaller meals.

Lose weight if you are overweight.

Reduce stress.

Sleep with your head raised about 6 inches. Do this by tilting your entire bed, or by using a wedge under your body, not just with normal pillows.

One novel approach to the treatment of GERD is chewing gum. Chewing gum stimulates

the production of more bicarbonate-containing saliva and increases the rate of

swallowing. After the saliva is swallowed, it neutralizes acid in the esophagus. In effect,

chewing gum exaggerates one of the normal processes that neutralize acid in the

esophagus. Nevertheless, chewing gum after meals is certainly worth a try.

Antacids

Despite the development of potent medications for the treatment of GERD, antacids

remain a mainstay of treatment. Antacids neutralize the acid in the stomach so that there

is no acid to reflux. The problem with antacids is that their action is brief. They are

emptied from the empty stomach quickly, in less than an hour, and the acid then re-

accumulates. The best way to take antacids, therefore, is approximately one hour after

meals, which is just before the symptoms of reflux begin after a meal. Since the food

from meals slows the emptying from the stomach, an antacid taken after a meal stays in

the stomach longer and is effective longer. For the same reason, a second dose of

antacids approximately two hours after a meal takes advantage of the continuing post-

meal slower emptying of the stomach and replenishes the acid-neutralizing capacity

within the stomach.

Antacids may be aluminum, magnesium, or calcium based. Calcium-based antacids

(usually calcium carbonate), unlike other antacids, stimulate the release of gastrin from

the stomach and duodenum. Gastrin is the hormone that is primarily responsible for the

stimulation of acid secretion by the stomach. Therefore, the secretion of acid rebounds

after the direct acid-neutralizing effect of the calcium carbonate is exhausted. The

rebound is due to the release of gastrin, which results in an overproduction of acid.

Theoretically at least, this increased acid is not good for GERD.

Though, treatment with calcium carbonate has not been shown to be less effective or

safe than treatment with antacids not containing calcium carbonate. Nevertheless, the

phenomenon of acid rebound is theoretically harmful. In practice, therefore, calcium-

containing antacids such as Tums and Rolaids are not recommended.

Aluminum-containing antacids have a tendency to cause constipation, while magnesium-

containing antacids tend to cause diarrhea. If diarrhea or constipation becomes a

problem, it may be necessary to switch antacids or alternately use antacids containing

aluminum and magnesium.

Histamine antagonists

Although antacids can neutralize acid, they do so for only a short period of time. For

substantial neutralization of acid throughout the day, antacids would need to be given

frequently, at least every hour.

The first medication developed for more effective and convenient treatment of acid-

related diseases, including GERD, was a histamine antagonist,

specifically cimetidine (Tagamet). Histamine is an important chemical because it

stimulates acid production by the stomach. Released within the wall of the stomach,

histamine attaches to receptors (binders) on the stomach's acid-producing cells and

stimulates the cells to produce acid. Histamine antagonists work by blocking the receptor

for histamine and thereby preventing histamine from stimulating the acid-producing cells.

Because histamine is particularly important for the stimulation of acid after meals, H2

antagonists are best taken 30 minutes before meals. The reason for this timing is so that

the H2 antagonists will be at peak levels in the body after the meal when the stomach is

actively producing acid. H2 antagonists also can be taken at bedtime to suppress night-

time production of acid.

H2 antagonists are very good for relieving the symptoms of GERD, particularly heartburn.

However, they are not very good for healing the inflammation (esophagitis) that may

accompany GERD. In fact, they are used primarily for the treatment of heartburn in

GERD that is not associated with inflammation or complications, such as erosions or

ulcers, strictures, or Barrett's esophagus.

Four different H2 antagonists are available by prescription, including

cimetidine (Tagamet), ranitidine (Zantac), nizatidine (Axid), and famotidine, (Pepcid).

Proton pump inhibitors

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 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.

PPIs are used when H2 antagonists do not relieve symptoms adequately or when

complications of GERD such as erosions or ulcers, strictures, or Barrett's esophagus

exist. Five different PPIs are approved for the treatment of GERD,

including omeprazole (Prilosec,

Dexilant), lansoprazole (Prevacid),rabeprazole (Aciphex), pantoprazole (Protonix),

and esomeprazole (Nexium). A sixth PPI product consists of a combination of

omeprazole and sodium bicarbonate (Zegerid). PPIs (except for Zegarid) are best taken

an hour before meals. The reason for this timing is that the PPIs work best when the

stomach is most actively producing acid, which occurs after meals. If the PPI is taken

before the meal, it is at peak levels in the body after the meal when the acid is being

made.

Pro-motility drugs

Pro-motility drugs work by stimulating the muscles of the gastrointestinal tract, including

the esophagus, stomach, small intestine, and/or colon. One pro-motility

drug, metoclopramide (Reglan), is approved for GERD. Pro-motility drugs increase the

pressure in the lower esophageal sphincter and strengthen the contractions (peristalsis)

of the esophagus. Both effects would be expected to reduce reflux of acid. However,

these effects on the sphincter and esophagus are small. Therefore, it is believed that the

primary effect of metoclopramide may be to speed up emptying of the stomach, which

also would be expected to reduce reflux.

Pro-motility drugs are most effective when taken 30 minutes before meals and again at

bedtime. They are not very effective for treating either the symptoms or complications of

GERD. Therefore, the pro-motility agents are reserved either for patients who do not

respond to other treatments or are added to enhance other treatments for GERD.

Foam barriers

Foam barriers provide a unique form of treatment for GERD. Foam barriers are tablets

that are composed of an antacid and a foaming agent. As the tablet disintegrates and

reaches the stomach, it turns into foam that floats on the top of the liquid contents of the

stomach. The foam forms a physical barrier to the reflux of liquid. At the same time, the

antacid bound to the foam neutralizes acid that comes in contact with the foam. The

tablets are best taken after meals (when the stomach is distended) and when lying down,

both times when reflux is more likely to occur. Foam barriers are not often used as the

first or only treatment for GERD. Rather, they are added to other drugs for GERD when

the other drugs are not adequately effective in relieving symptoms. There is only one

foam barrier, which is a combination of aluminum hydroxide gel, magnesium trisilicate,

and alginate (Gaviscon).

Surgery

The drugs described above usually are effective in treating the symptoms and

complications of GERD. Nevertheless, sometimes they are not. For example, despite

adequate suppression of acid and relief from heartburn, regurgitation, with its potential for

complications in the lungs, may still occur. Moreover, the amounts and/or numbers of

drugs that are required for satisfactory treatment are sometimes so great that drug

treatment is unreasonable. In such situations, surgery can effectively stop reflux.

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.

Surgery is very effective at relieving symptoms and treating the complications of GERD.

The most common complication of fundoplication is swallowed food that sticks at the

artificial sphincter. Fortunately, the sticking usually is temporary. If it is not transient,

endoscopic treatment to stretch (dilate) the artificial sphincter usually will relieve the

problem.

Endoscopy

Very recently, endoscopic techniques for the treatment of GERD have been developed

and tested. One type of endoscopic treatment involves suturing (stitching) the area of the

lower esophageal sphincter, which essentially tightens the sphincter.

A second type involves the application of radio-frequency waves to the lower part of the

esophagus just above the sphincter. The waves cause damage to the tissue beneath the

esophageal lining and a scar (fibrosis) forms. The scar shrinks and pulls on the

surrounding tissue, thereby tightening the sphincter and the area above it.

A third type of endoscopic treatment involves the injection of materials into the

esophageal wall in the area of the LES. The injected material is intended to increase

pressure in the LES and thereby prevent reflux.

Endoscopic treatment has the advantage of not requiring surgery. It can be performed

without hospitalization. Experience with endoscopic techniques is limited.