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Nash Heartburn Treatment Center
a division of Nash Health Care
NHCS Mission Statement:
To provide superior quality health care services and to help improve the health of the community in a caring, efficient and
financially sound manner.
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Welcome to the Nash Heartburn Treatment Center.
Thank you for choosing the Nash Heartburn Treatment Center and for allowing us to
participate in your care.
If you have an appointment with a heartburn treatment physician, you will have a one-on-one
consultation to discuss symptoms that you are experiencing. The physician will review any past
tests and order any new tests that are needed to determine a diagnosis. Once these tests are
completed, you will have a follow–up appointment to discuss the test results and treatment
options.
If your gastroenterologists scheduled you for a heartburn test, you will follow-up with that
physician once the test(s) is completed. That physician will discuss findings and possible
treatment options with you. You may then be referred to one of the Nash Heartburn
Treatment Center physicians for an appointment.
Please review this booklet. Write down any questions you may have or notes you may need,
and bring with you to your next office visit.
Sincerely,
Nash Heartburn Treatment Center Staff
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Table of Contents
Diseases of the Esophagus .................................................................................................................................................... 3
Gastroesophageal Reflux Disease (GERD) ............................................................................................................................. 3
Hiatal Hernia ...................................................................................................................................................................................... 3
Esophageal Motility Disorders ................................................................................................................................................... 3
Esophagitis .......................................................................................................................................................................................... 3
Barrett’s Esophagus ........................................................................................................................................................................ 3
Laryngopharyngeal Reflux Disease (LPR) ............................................................................................................................. 3
Diagnostic Tests ...................................................................................................................................................................... 4
Upper Endoscopy or Esophagogastroduodenoscopy ....................................................................................................... 4
Ambulatory pH Monitoring .......................................................................................................................................................... 4
BRAVO pH Test .................................................................................................................................................................................. 4
Restech or 24-‐ hour Airway pH study ..................................................................................................................................... 5
Esophageal Manometry ................................................................................................................................................................ 5
24-‐hour Impedance Test ............................................................................................................................................................... 6
Barium Swallow ............................................................................................................................................................................... 6
Gastric Emptying Study ................................................................................................................................................................. 6
GERD Treatment Options ...................................................................................................................................................... 7
Lifestyle/Behavior Changes ......................................................................................................................................................... 7
Medications ......................................................................................................................................................................................... 7
Minimally Invasive Surgery ......................................................................................................................................................... 8
General Surgery Information .............................................................................................................................................. 8
Prior to Surgery ................................................................................................................................................................................. 8
After Surgery ...................................................................................................................................................................................... 9
Care of Surgical Sites ....................................................................................................................................................................... 9
When to Notify the Doctor or Nurse ........................................................................................................................................ 9
Surgical Risks ..................................................................................................................................................................................... 9
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Diseases of the Esophagus The esophagus is a muscular tube that contracts to propel propels food or liquid from the back of the mouth to the stomach.
Gastroesophageal Reflux Disease (GERD)
Gastroesophageal Reflux Disease, or GERD, is a digestive disorder that can cause intense heartburn, chest pain, or hoarseness. GERD occurs when the lower sphincter is not working properly. The sphincter is a ring of muscles located between the esophagus and the stomach, and it acts as a one-‐way valve to prevent stomach contents from coming back up into the esophagus or throat (regurgitation.) If GERD is not treated, over time it may cause more serious health problems such as inflammation, ulcers, and even esophageal cancer. GERD may also cause narrowing of the esophagus, which makes it difficult to swallow foods and liquids.
Hiatal Hernia
A hiatal hernia occurs when the stomach pushes up through the opening of the diaphragm into the chest cavity. The diaphragm is a muscle that separates your belly from your chest. Many people have no symptoms, but for others, a hiatal hernia may cause heartburn. One major type of hernia is called a sliding hernia. (This occurs when part of the stomach and a section of the esophagus slide up into the chest cavity through the opening in the diaphragm. This is the most common type of hernia. Hiatal hernias may be caused by stress, age, or a weakened diaphragm.
Esophageal Motility Disorders
If the muscles of the esophagus are weak or do not contract correctly, food or liquid may not move easily down the esophagus. This is known as a motility or motor disorder. This may cause difficulty swallowing, chest pain, or regurgitation of food or liquids into the esophagus. Some people only complain of one of these symptoms. There are many types of motility disorders and treatment depends upon the type of disorder.
Esophagitis
Esophagitis is inflammation, swelling, or irritation of the esophagus. The severity of esophagitis is classified according to four grades (A-‐D) with Grade A being least severe and Grade D being most severe.
Barrett’s Esophagus
Barrett’s Esophagus is a complication of GERD, and it occurs when the lining of the esophagus changes in response to acid reflux. Barrett’s Esophagus may cause changes in the color of the esophageal lining. A biopsy is necessary in order to confirm the diagnosis. During a biopsy, a small tissue sample is examined under a microscope. Barrett’s Esophagus is not cancer, but those diagnosed with Barrett’s Esophagus have a higher risk of developing cancer. This disease should be monitored closely, and patients may have to have several procedures and treatments due to potential changes in the esophageal tissue.
Laryngopharyngeal Reflux (LPR)
Laryngopharyngeal reflux disease is a condition that develops when stomach acid travels back up into your throat. It is sometimes referred to as ‘silent reflux.’ The symptoms are usually hoarseness, throat clearing, chronic cough, asthma, and a feeling of a ‘lump’ in one’s throat. This type of reflux may damage the airway to the lungs if not treated. Sometimes it is hard to differentiate between allergies, vocal abuse, sleep apnea and LPR.
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Diagnostic Tests
Upper Endoscopy or EGD or Esophagogastroduodenoscopy
The upper endoscopy is a procedure that allows the physician to visualize the throat, esophagus, stomach, and the first part of small intestine. The physician uses a flexible endoscope, a thin tube with a light and camera on the end. An upper endoscopy may help diagnose ulcers, bacteria, tumors, polyps, cancers, and lesions. During the procedure, patients are sedated, receiving medicine through an IV. An EGD usually takes about 10 minutes, though patients will be at the facility for about two hours. After the procedure, the physician will provide information about his or her findings. Patients may resume normal activities the next day. If a biopsy is obtained, results will be available in about a week from your physician.
Ambulatory pH Monitoring
This test monitors pH and acid levels in the esophagus. There are two types of ambulatory pH monitoring tests:
24-‐hour pH test – For this test, a thin, flexible catheter is placed through the nose into the esophagus and secured to the face and neck with a clear adhesive. This catheter is attached to a monitor that will record pH levels over a 24-‐hour period. Our health care professionals will provide instructions for the monitor, and a diary to record symptoms, meals, and activities. After 24 hours, the patient returns to have the catheter removed. This test may be used even if the patient has a pacemaker or defibrillator. Anti-‐reflux medications should not be taken for at least 7 days prior to this test unless advised otherwise. However, Tums or Rolaids may be taken up to 24 hours prior to test.
BRAVO pH Test
During this test, a small electronic capsule is placed in the lower esophagus to record pH readings. The procedure should be painless, but some patients report a pinching sensation when the capsule is swallowed and attached. A wireless receiver will record your pH levels in the esophagus for at least 48 hours.
Our health care professionals will provide instructions regarding the buttons on the monitor as well as a diary for recording symptoms, meals, and activities. This capsule may be placed during an EGD (see previous page) or alone if an EGD has already been completed. The capsule will fall from the esophagus in 4-‐7 days and will pass through the body through bowel movements. Do not have a MRI within 30 days of a BRAVO capsule placement. Do not take any anti-‐reflux medications for at least 7 days prior to this test unless advised otherwise. However, Tums or Rolaids may be taken up to 24 hours prior to test. Once the BRAVO test is
Do not eat or drink anything after midnight the night before your test.
Bring a list of medications you are taking with you.
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completed, return the monitor and diary as instructed.
Restech or 24-‐hour Airway pH Study (Oropharynx)
This test measures and records airway pH levels by inserting a small catheter through the nose until it reaches the back of the throat. This procedure should not cause gagging. The catheter will be secured with a clear adhesive to your face and neck. This test is used to diagnose laryngopharyngeal reflux disease. Do not take any anti-‐reflux medications 7 days prior to test unless advised otherwise. However, you may eat prior to this test since the catheter only advances to the back of the throat. You will be given instructions regarding the buttons on the monitor as well as a diary for recording symptoms, meals, and activities for 24 hours. When you return the next day, the catheter will be removed and the information will be downloaded into the computer system to generate a report. This information will be directed to the physician for a final interpretation.
Esophageal Manometry
This test measures the pressure and muscle tone of the esophagus during swallowing and at rest. It also evaluates how well the upper and lower esophageal sphincters are functioning.
The sphincters are muscles that close the natural opening of the esophagus to allow food to progress to the stomach. This test is essential to determine if you are a candidate for heartburn treatment surgery. During the procedure, a numbing medication will be placed in the nose, and a small catheter will be passed through the nose to the lower esophageal sphincter and on to the stomach. This catheter has sensors that measure pressure during swallowing. The test requires 10 single swallows of water, and then the catheter may be removed. The results will be directed to your physician for a final interpretation. You should expect to be at the facility for at least one to one and a half hours. After the procedure, you may drive yourself home and resume normal activities, since no sedation is required.
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24-‐ Hour Impedance Test
This 24-‐hour test measures the flow of liquid while on or off acid suppression medications. The test also provides reflux episodes event detection, determines the length of the episode, and direction of flow. During the procedure, a small catheter is inserted through the nose into the lower portion of esophagus. The catheter will be secured with a clear adhesive to the face and neck. You will be given instructions regarding the buttons on the monitor, as well as a diary for recording symptoms,
meals, and activities. When you return the next day, the catheter will be removed and the information downloaded into the computer system to generate a report. This information will be directed to the physician for a final interpretation. Anti-‐reflux medications should be continued during this test, unless advised otherwise.
Barium Swallow
This test requires that you swallow a chalky, white drink-‐-‐ called barium-‐-‐ while an X-‐ray technician takes several images. Because the test requires a series of images to be taken, a barium swallow test takes approximately 30 minutes to 1 hour. This test will detect abnormalities such as reflux, hiatal hernia, masses, and motility problems. Do not eat or drink anything after midnight the night before the test. Also, do not take any medications the morning of your test as well unless otherwise advised, but bring them with you to the appointment.
Gastric Emptying Study
This test determines if there is a delay emptying food from the stomach into the intestines. You will be asked to eat a substance such as oatmeal that contains a dye that can be seen on X-‐ray images. A series of images will be taken, following the substance as it passes through the stomach into the intestines until the stomach is completely empty. This test takes about one to two hours. Remember, do not eat or drink after midnight the night before the test.
Do not eat or drink anything after midnight the night before
your test.
Bring a list of medications you are taking with you.
REMEMBER: Do not eat or drink anything after midnight the night before your test.
Bring a list of medications you are taking with you.
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GERD treatment options
GERD can be managed in three different ways.
These include:
1. Lifestyle / Behavioral changes
2. Medications
3. Minimally invasive surgery
Lifestyle /Behavioral Changes:
• Avoid spicy, fried or fatty foods.
• Avoid foods that can cause GERD. These may include alcohol, coffee, tea, chocolate, ice cream, peanut butter, peppermint, and whole milk.
• Eat smaller portions.
• Maintain a healthy weight.
• Avoid all food and beverages 2 to 4 hours before lying down.
• Raise the head of your bed 6 to 8 inches by placing a block or brick under each headboard.
• Do not overeat.
• Relieve stress (tension may contribute to GERD).
Medications:
GERD is a chronic disease that can be effectively treated through long-‐term medical therapy. There are several different kinds of medications; however one may work better than another. If you have consistent reflux symptoms that require medications over the course of several months, you should to be evaluated by a physician. Because there are other conditions associated with GERD, it is important to be tested to confirm a diagnosis of GERD.
Medications usually improve the symptoms of GERD by reducing the production of acid; however, acid suppression does not stop reflux. It is normal to have acid in the stomach, but not in the esophagus. When
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stomach acid refluxes into the esophagus due to malfunction of the lower sphincter, irritation causes heartburn and other symptoms. Medications either neutralize acid or decrease acid production in the stomach.
There are 3 classes of GERD medications:
• Antacids -‐ Antacids neutralize the stomach acidity. (examples: Tums, Rolaids, Mylanta)
• H2 Blockers -‐ H2 blockers decrease the acid production by blocking acid-‐producing cells. (examples: Tagamet, Zantac, Axid, Pepcid)
• Proton Pump Inhibitors (PPI) -‐ PPIs block the production of acid in the stomach, and therefore are usually more effective than H2 blockers. (examples: Nexium, Prilosec, Prevacid, Protonix)
Minimally Invasive Surgery:
Laparoscopic Nissen Fundoplication
This surgery is performed while you are “asleep” under general anesthesia. Several small incisions are made in the abdomen where the laparoscope (a slender camera) and small instruments are inserted. The camera allows the surgeon to view the procedure on a video monitor. Your abdomen is inflated with air, which provides more space for the surgeon to work. During this procedure, the malfunctioning valve is reconstructed by wrapping the top of the stomach around the lower part of the esophagus to prevent reflux. If a hiatal hernia is present, it will also be repaired at this time. This surgery usually takes one to two hours to perform.
After Laparoscopic Nissen Fundoplicaton Surgery
After surgery, you will be on a special diet. You will be limited to soft foods, and for at least 2 weeks, you should eat six small meals a day, chew your food thoroughly, and eat slowly. In addition, you should avoid the following foods: meats, breads, carbonated beverages, cookies, raw fruits and vegetables, and cakes.
After surgery, some patients may experience some mild side effects such as the inability to vomit or belch, difficulty swallowing for short periods of time, diarrhea, increased gas and bloating.
General Surgery Information After discussing your options with your physician, the surgery will be scheduled. You will also be scheduled to see the patient educator/ coordinator within two weeks of your surgery date to discuss the time of your surgery, to receive any specific instructions, and to obtain lab results.
Prior to Surgery:
• Do not eat or drink anything after midnight the night prior to surgery
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• You may be instructed to take certain medication(s) with a sip of water
• Bring a family member or someone the physician may speak with after the surgery
• You may be an outpatient or stay overnight. Be prepared to have someone available to drive you home and stay with you for 24 hours.
• You will be instructed to arrive 2 hours prior to surgery for a pre-‐operative assessment; please be on time.
After Surgery
• Upon discharge, you will be given a prescription to treat pain and nausea
• Do not drive if you are taking medications that cause drowsiness or impair your judgment; make sure you will be able to control your car in an emergency situation.
• You may experience some gas pain in your shoulders, chest, or abdominal area. This should gradually go away within three to five days.
• Avoid any strenuous activity or heavy lifting for four to six weeks.
Care of Surgical Sites
You will have Dermabond or “skin glue” on your incisions. You may take a shower the day after surgery. Wash the area with soap and water, and pat it dry. Do not take tub baths, soak in hot tubs, or swim for at least one week after surgery. The Dermabond usually peels off in one to two weeks.
Notify the doctor or nurse if you have:
• Pain not controlled by pain medication
• Nausea or vomiting not controlled by prescription medication
• Fever greater than 100.4
• Chills
• Severe swallowing difficulties
• Incisions that have become open, inflamed, oozing, or bleeding
You may call the Heartburn Treatment Center Coordinator at 252-‐962-‐6500 during normal business hours, 8 a.m. to 4:30 p.m. Monday – Friday. After hours, weekends, or holidays, you may contact the on-‐call physician at 252-‐962-‐8822.
Surgical Risks
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There are potential risks and complications with any surgical procedure. The risks and benefits of surgery should be discussed with your physician.
Notes / Questions
