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Reflux

Basics

Reflux indicates the back flow of gastric content (lat. refluare = flow back). Acid reflux is the major cause for Heartburn. Symptomatic Acid reflux with Heartburn, coughing and vomiting affects 20% to 30% of the population (male and females with similar frequency).

Causes

Life style and eating behavior (too much, sweet, often) damage the Anti reflux mechanism in the lower portion of the esophagus. As a consequence Reflux occurs and inflames the esophagus. This in turn causes the development of the Reflux symptoms.

Symptoms

Reflux causes the symptoms of the Gastroesophageal reflux disease ( GERD). Reflux symptoms include Heartburn, acid regurgitation, wheezing, coughing and asthma.

Diagnosis and tests

Reflux inflames the esophagus ( Esophagitis) and causes the symptoms ( Heartburn, acid regurgitation, asthma). Diagnosis and tests for GERD, Heartburn and acid regurgitation are conducted as out patient procedures and assess the manifestations of Reflux in the esophagus (gullet). Gastroscopy examines tissue changes, manometry and Reflux monitoring examines the functional consequences of the Reflux.
Endoscopy is conducted under sedation and assesses esophageal inflammation ( Esophagitis) and rules out the presence of cancer risk, i.e. Barrett‘s esophagus. Barrett‘s esophagus affects the innermost layer of the esophagus and represents a special Reflux induced tissue composed of intestinal cells (goblet cells) and marks an increased risk for the development of Esophageal adenocarcinoma (0.5% annual cancer risk). The condition is diagnosed from esophageal biopsies. Therefore we follow a special Biopsy sampling protocol to exclude the presence of Barrett‘s esophagus and to accurately assess the extent of Reflux induced tissue changes (columnar lined esophagus, Esophagitis).

Esophageal manometry examines the competency of the Anti reflux mechanism (sphincter) within the lower end of the esophagus (gullet). In addition the test assesses the transport function of the esophagus. Via the locally anesthetized nostrils the spaghetti thin catheter (including 32 pressure probes) is positioned along the entire length of the esophagus. The test does not hurt and takes 15-20 min. GERD patients usually have a shortened Anti reflux mechanism with an impaired competency. The manometry data serve to tailor the treatment.

Esophageal Reflux monitoring ( Impedance pH monitoring) assesses acid and non Acid reflux and if the Reflux causes Heartburn, acid regurgitation, wheezing or asthma. Via the locally anesthetized nostrils the spaghetti thin catheter (including the pH- & Reflux sensing probes) is placed into the esophagus with the pH probe 5 cm above the upper limit of the manometric Anti reflux mechanism (lower esophageal sphincter). The test takes 24 hrs and does not hurt. The catheter is connected to a belt mounted recorder (size of a cell phone) and does not interfer with your daily activities. During the study you catalog eating times, type of food and upright and supine body position times. The Reflux monitoring data serve to individually tailor the therapy of your Reflux. Fell free to contact us for further information on the diagnosis and therapy of Reflux.

Endoscopy & Manometry

Treatment

Due to the symptoms and cancer risk GERD impairs the life quality, productivity and the well being of the patients. Therefore we therapy GERD to eliminate cancer risk (Barrett‘s esophagus) and to restore the life quality.
Cancer risk is eliminated by radiofrequency ablation (HALO®) of Barrett‘s esophagus. HALO® is a novel, endoscopic, highly effective method for the durable elimination of Barrett‘s esophagus. The therapy is conducted as a day care procedure under general anesthesia. Following the ablation you are prescribed pain killers and proton pump inhibitor (PPI, 2x40 mg p.o.). PPI therapy is to be continued for successful wound healing. After one HALO® ablation Barrett‘s esophagus is eradicated in 70% of the cases, 30% of the cases need 2-3 treatment sessions.

HALO

Treatment of GERD symptoms includes self care (life style modification, change of the eating behavior), medical and surgical therapy.
Reflux produces a large spectrum of symptoms including Heartburn, acid regurgitation, wheezing, chronic cough and asthma. The causes for Reflux include gastric distention (overeating) and dysfunction of the Anti reflux mechanism (lower esophageal sphincter). The Stomach produces gastric acid. Therefore Reflux contains acid and non-acid components. Dietary measures eliminate factors which provoke Reflux. we recommend to avoid sweeties, large volumes, carbonated beverages, alcohol and cigarette smoking. Medical therapy with antacids and proton pump inhibitors decrease the amount of Acid reflux and eliminates symptoms in 50%-60% of the patients. Failure of PPI therapy indicates that the symptoms are not due to Acid reflux or that Reflux is not the cause for the complaints. This issue is clarified by Reflux monitoring.
If Reflux is proven (manometry, Reflux monitoring) and life quality and well being are not restored by dietary measures and medical therapy, we recommend to consider Anti reflux surgery ( Fundoplication, magentic ring). The surgeries are conducted laparoscopically and restore the competency of the Anti reflux mechanism (sphincter) by enwrapping the lower end of the esophagus (gullet) within either a fundic wrap (the Fundus is a part of the Stomach) or a magnetic ring.

Fundoplication

Feel free to contact us for further information regarding GERD treatment.

Self care

Self care starts with the change of the eating behavior. Avoid large meals, sweeties, carbonated beverages, alcoholic drinks, juices and cigarette smoking. If these measures contribute to relief your Heartburn, this proofs that you may in fact have Reflux. We recommend Gastroscopy for the assessment of the inflammation of the esophagus and the exclusion of a premalignant Barrett’s esophagus. CAVE: no self care without Gastroscopy (cancer risk).

Complications

Complications of Reflux include Esophagitis, structure, Stenosis, Barrett’s esophagus and cancer. Early diagnosis and treatment contribute to prevent the development of cancer. Therefore we recommend Gastroscopy for the exclusion of cancer risk (Barrett’s esophagus).

Prevention

Prevention of Reflux includes all measures to avoid the impairment of the Anti reflux mechanism in the lower portion of the esophagus. Avoid large meals before bed time, avoid the consumption of sweeties, carbonated beverages, alcohol, juices and cigarette smoking.

Self test

Avoid large meals, sweeties, carbonated beverages, alcoholic drinks, juices and cigarette smoking. Start medical therapy with proton pump inhibitor. If these measures relief Heartburn and Reflux symptoms this in facts proofs that you have Reflux ( GERD). CAVE: no treatment without Gastroscopy (Barrett’s esophagus, cancer risk)

Expert opinion

Ildiko Mesteri (Pathologist, Vienna). Reflux causes typical microscopic changes of the tissue: we name it columnar lined esophagus (CLE). If a Biopsy obtained from the esophagus contains CLE we know that the patient, he or she, has Reflux. However, we do not know if the Reflux impairs the life quality, if it causes symptoms. This is the job of the clinician to find out, in as much Heartburn affects the well being of a person. Finally, if we see Barrett’s esophagus this tells us: the person has Reflux and cancer risk. The good clinician knows that and offers adequate therapy: ablation, Anti reflux surgery.

Martin Riegler (Surgeon, Vienna). There should be no Reflux self care and therapy without Gastroscopy. Up to 30% of those with Reflux symptoms ( Heartburn, cough, asthma) have Barrett’s esophagus. Barrett’s esophagus has an increased cancer risk. With Gastroscopy we exclude the cancer risk. In case of Barrett’s esophagus we offer elimination with HALO ablation. This prevents cancer and saves lives.

Johannes Lenglinger (Physiologist, Vienna). Large meals provoke Reflux. The gastric distensions shorten the Anti reflux mechanism in the lower portion of the esophagus. The sphincter opens and Reflux occurs. This is why patients with Reflux and Heartburn frequently have a short sphincter. Reflux monitoring shows abnormal Reflux and esophageal Acid exposure. In addition, Reflux monitoring proofs, that the Reflux and the Acid exposure cause Heartburn. If the patient is fit for operation I recommend Anti reflux surgery. If not, the patient should continue medical treatment.

Literature

  1. Lagergren J, Bergström R, Lindgren A et al. Symptomatic gastroesophageal Reflux as a risk factor for Esophageal adenocarcinoma. N Eng J Med 1999; 340 (11): 825-31.
  2. Rieder F, Biancani P, Harnett K et al. Inflammatory mediators in Gastroesophageal reflux disease: impact on esophageal motility, fibrosis, and carcinogenesis. Am J Physiol 2010; 298: G571-81.
  3. Becher A, Dent J. Systematic review: ageing and gastro-oesophageal Reflux disease symptoms, esophageal function and Reflux oesophagitis. Aliment Pharmacol Ther 2011; 33(4): 442-54.
  4. Theisen J, Stein HJ, Feith M et al. Preferred location for the development of Esophageal adenocarcinoma within a segment of intestinal metaplasia. Surg Endosc 2006; 20(2): 235-8.
  5. Ayazi S, Tanhankar A, DeMeester SR et al. The impact of gastric distension on the lower esophageal sphincter and its exposure to acid gastric juice. Ann Surg 2010; 252: 57-62.
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