GERD and LPR

Gastroesophageal Reflux Disease (GERD) is a chronic digestive disease that occurs when stomach acid or, occasionally, bile flows back (refluxes) into your food pipe (esophagus). The backwash of acid irritates the lining of your esophagus and causes GERD signs and symptoms that are generally referred to as heartburn or reflux. In addition to heartburn symptoms, severe GERD can also cause problems with worsening asthma, recurrent pneumonia, or chronic laryngitis. The treatment for GERD is usually begun with lifestyle modification and diet changes. When this is insufficient, medications can be added to manage the symptoms. For some patients these treatments might not be enough and surgery may be indicated.

Laryngopharyngeal Reflux (LPR), also known as extraesophageal reflux disease, silent reflux, and supra-esophageal reflux, is caused by the flow of stomach contents back up through the esophagus and back into the larynx, oropharynx and/or the nasopharynx. The stomach fluids that cause LPR symptoms can be either acidic or non-acidic. In fact, even gas coming up from the stomach can cause the same problems. The diagnosis of LPR can often be very difficult as patients often have minimal heartburn symptoms. It only takes three episodes of reflux per week into the proximal esophagus and throat to cause chronic symptoms. Patients with LPR often require extensive evaluations to confirm the diagnosis.

SYMPTOMS:

Heartburn, also called as acid indigestion, is the most common symptom of GERD and usually feels like a burning chest pain which begins behind the breastbone and moves upwards to the neck and throat. Some people experience acidic or bitter taste. Other symptoms of GERD include:

  • Chest Pain
  • Difficulty in Swallowing (dysphagia)
  • Dry Cough
  • Hoarsness or Sore Throat
  • Regurgitation of Food or Sour Liquid (acid refulx)
  • Sensation of a Lump in Your Throat (globus)

DIAGNOSIS:

  • Laryngoscopy – Typically, your ENT doctor will perform this procedure as part of your initial evaluation to evaluate the features of your throat. It is often the first sign that you may have LPR if the ENT doctor finds that your tissues are irritated. Once other causes of your symptoms are excluded, the ENT doctor may refer you to have further testing to see if you truly have LPR caused by reflux of stomach contents.
  • Upper Endoscopy Your doctor inserts a thin, flexible tube equipped with a light and camera (endoscope) down your throat, to examine the inside of your esophagus and stomach. Test results can often be normal when reflux is present, but an endoscopy may detect inflammation of the esophagus (esophagitis) or other complications. An endoscopy can also be used to collect a sample of tissue (biopsy) to be tested for complications such as Barrett’s esophagus.
  • Ambulatory Acid (pH) Probe Test A monitor is placed in your esophagus to identify when, and for how long, stomach acid regurgitates there. The monitor connects to a small computer that you wear around your waist or with a strap over your shoulder. The monitor might be a thin, flexible tube (catheter) that’s threaded through your nose into your esophagus or a clip that’s placed in your esophagus during an endoscopy and that gets passed into your stool after about two days.
  • Esophageal Manometry This test measures the rhythmic muscle contractions in your esophagus when you swallow. Esophageal manometry also measures the coordination and force exerted by the muscles of your esophagus.
  • X-Ray of Your Upper Digestive System X-rays are taken after you drink a chalky liquid that coats and fills the inside lining of your digestive tract. The coating allows your doctor to see a silhouette of your esophagus, stomach, and upper intestine. You may also be asked to swallow a barium pill that can help diagnose a narrowing of the esophagus that may interfere with swallowing.
  • Gastric Emptying Study – This test is used to determine if the stomach is emptying normally. It involves eating a light meal, such as eggs and toast, that contains a small amount of radioactive material. A scanner that detects the movement of the radioactive material is placed over your abdomen to monitor the rate at which food leaves your stomach.

TREATMENT OPTIONS:

Surgery is considered the best solution for patients with severe GERD and LPR. Both are considered to be a mechanical problem due to the fact that stomach contents overcome the lower esophageal sphincter muscle that separates the esophagus and throat from the stomach. Acid-reducing medications can help a bit. However, they only mask the acidity of the stomach contents. Therefore, they do nothing to stop the material from coming into the upper esophagus and throat and causing irritation.

  • Trans-Oral Incisionless Fundoplication (TIF): The TIF® procedure is an endoscopic anti-reflux procedure. The procedure utilizes the EsophyX device to reconstruct the gastroesophageal valve (GEV) and help restore the GEV’s function as a reflux barrier. A flexible video endoscope is inserted into the central lumen of the EsophyX device to provide direct visualization throughout the TIF procedure. The result is the creation of a 2-3 cm, 270° esophagogastric fundoplication. The device is a fastener delivery system and utilizes tissue manipulating elements to deploy approximately 20 SerosaFuse fasteners.
    The TIF reconstruction of the GEV can be used in patients with no hiatal hernia as a stand- alone procedure. Alternatively, it can be used in conjunction with a laparoscopic hiatal hernia repair to restore both the anatomy of the hiatus and the anatomy of the GEV.
  • LINX Procedure: LINX magnetic sphincter augmentation involves implanting a small device (LINX) to tighten the opening of the lower esophageal sphincter (LES) and stop reflux while allowing the patient to eat normally. The LINX is a small implant comprised of interlinked titanium beads with magnetic cores.
  • Toupet 270 Degree Partial Fundoplication: In a Toupet fundoplication, the fundus of the stomach is brought posterior to the esophagus. The repair involves securing the stomach to the edge of the lower esophagus at the 10:00 position on the right and the 2:00 position on the left creating a partial wrap or fundoplication.
  • Nissen 360 Degree Fundoplication: This is an older procedure reserved for patients who are not able to have a LINX procedure. In a Nissen fundoplication, the gastric fundus (upper part) of the stomach is wrapped, or plicated, around the lower end of the esophagus and stitched in place, reinforcing the closing function of the lower esophageal sphincter.
  • Revision Anti-reflux Surgery: There is a small sub-group of patients who undergo anti-reflux surgery for GERD who initially do well and then experience recurrent symptoms or complications because of a recurrent hiatal hernia or issues related to their wrap or Linx Device. These patients are candidates for a laparoscopic revision procedure to address their issues.

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