Common Acid Reflux Questions
Dr. Mark Noar has personally answered the most common questions that he and other doctors have received over many years. Get the best acid reflux treatment!
In-depth answers to all your questions about REFLUX and how to cure it from Dr. Mark Noar!
Reflux Concepts
General Concepts about Reflux, LPR, Heartburn, and Regurgitation! related to your questions asked - By Dr. Mark Noar
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What is Reflux Disease? This is the most common questions we first get after giving the diagnosis. Reflux is a very complex disease and can present in many different ways. I prefer to think of Reflux as two different diseases.
The first that many people think of is GERD, is actually Gastro Esophageal Reflux Disease, where the symptoms are restricted to the middle portion of the chest area. They usually present as burning, difficulty swallowing, or chest pain.
Another more common form of this disease used to be known as Silent Reflux, which is a misnomer, because the symptoms are there, but they aren’t the standard esophageal symptoms. We’ll call that form of the disease Respiratory Reflux, or what many of you may know as LPR. In this case, the disease is in the laryngeal area, so it can involve the voice, nasal passages, the ears, lungs, and the airway passages leading into the lungs. -
With the various forms of reflux, the question really comes up as “What is the true root cause?” Today, most physicians and many people think of acid coming up from the stomach. What comes from the stomach is not solely acid. In fact, it is impossible for you to selectively decide to take the only the acid from your stomach and reflux that into your esophagus or higher.
What actually comes up is the entire gastric contents. What allows that to happen is a defect that occurs in the sphincter or the check valve that exists between the esophagus and the stomach itself. This check valve is known as the lower esophageal sphincter.
What we now know is that Reflux is a disease caused by the degeneration of the lower esophageal sphincter over time. That degeneration is caused by our dietary excesses. Increased amounts of alcohol or caffeine as well as eating late at night and going to bed immediately afterward are good examples. Stress itself can cause increased amounts of reflux. Obesity is also a very important influence over this problem. When the sphincter loosens, it allows the pressure from the stomach to force the contents from the stomach into the esophagus or even higher up into the throat area. -
In normal physiology when we think about the body, the stomach and the esophagus are connected together. The stomach contracts at a certain rate throughout the day. It creates what we’ll call the gastric yield pressure. The job of the lower esophageal sphincter is to hold that pressure back. So, as long as the sphincter is strong enough and has a basis of a minimum of 4 millimeters of mercury pressure greater than what the stomach can generate, then reflux does not occur.
But, as the sphincter weakens over time and the amount of pressure that the sphincter can generate goes down, that allows the stomach pressure to exceed the sphincter strength. That’s when you have unchallenged reflux and that’s when the disease begins. -
When a reflux event takes place, we now know that the stomach contents end up in the esophagus or in the upper airway or the larynx. But what causes the symptoms? Is it the actual contents themselves causing a direct effect on the tissue or is there another mechanism of action that could better explain what is happening?
It’s important to understand this mechanism of action because current therapy is designed towards lowering acid levels by taking a pill to reduce the amount of acid. This works variably in many people and the reason why it works variably is that it’s not the acid causing a direct effect on the tissue that causes the symptoms.
The fact is that medical evidence shows that in the wall of the esophagus there are receptors known as vanilloid receptors. We call them TRPV1 receptors for short. What these receptors do is directly interact with the nerves or they indirectly interact by allowing the secretion of different substances that are not normally present in great quantities in the wall of the esophagus. It is the presence of these substances that can lead to thickening of the wall. It can affect motility so your food cannot be swallowed as easily. It can cause pain or even the symptom that we all commonly know as heartburn.
Activation of these substances, in this particular case, platelet activating factor or PAF, can also be directly toxic to the lining. Thus the ulcers or the erosions that many people will have are actually not due to the acid touching the tissue, which is protected by a mucus layer, but actually by the production of the PAF. -
Now, let’s look at the difference between what happens in the esophagus when a reflux event takes place, compared to what happens in the larynx, or the bronchi, or the nasal passages. One of the predominant substances that causes the injury is known as pepsin, which is a normal digestive enzyme produced by your stomach. The difference is that once the pepsin enters the esophagus it cannot stick to the tissue because of the protective mucus layer. In contrast, the mucus layer in the larynx or the upper airway area is actually very thin. There the pepsin is absorbed directly into the tissue and it remains in the tissues resident without causing any damage. However, in the course of our day, we typically will eat or drink many acid type foods or beverages such as fruit juices or other fruits such as citrus, tomato based products, wine or vinegar just to name a few.
When the acid in our food or beverages comes in contact with the tissue that has the pepsin inside, the pepsin then activates, and that creates an inflammatory response. That inflammatory response can result in pain in your throat, increased mucus production, loss of voice strength or hoarseness, and even more serious conditions such as bronchitis, pneumonia, chronic nasal drip, pain into the ears, and, in some cases, sleep apnea.
Reflux Treatment Basic Concepts
Treating Reflux - A Collection of Brief Introductions to Several Basic Concepts on Treating Acid Reflux!
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Now that we understand that the cause of the reflux disease is a chronic degenerative change of the lower esophageal sphincter, which causes weakening and the inability of that sphincter to resist the normal pressure coming from the stomach, it helps us to begin to understand how we can best treat this disease. Treatment is a very individual concept, because each of us has caused a problem or causes problems based upon our anatomy, based upon our activities, or based upon our eating habits that have occurred over time. The most basic measures that we can follow are what we will call dietary, as well as mechanical anti-reflux measures. Some of these are very simple, and just following those measures alone may be sufficient to control your symptoms and actually limit the amount of reflux that takes place. -
The simplest measures to treat reflux would be not eating within three, four, or five hours prior to bedtime. This means that your stomach will then normally be empty, and when you lie down at night, you will not be refluxing stomach contents, up into your esophagus or your throat. Other measures are avoiding trigger foods. Trigger foods that we know that cause further weakening and therefore, lack of strength in the sphincter and causing more reflux to occur, are things like caffeine, chocolate, alcohol and peppermint. Large amounts of fatty food in the diet slow down the stomach emptying, and then this allows for more reflux to take place.
Now, we’re not really talking about eliminating these completely from your diet. It is okay, with moderation, to have for instance, a cup of coffee, eight ounces or less per day, but beyond that, we cause repetitive weakening and then repetitive episodes of reflux. Another important concept is to not lie flat in the bed at night when you’re sleeping. During the day, it’s very easy to control reflux because we’re in the upright position so gravity helps the reflux to stay down towards our stomach. However, when we lie down at night flat in the bed and especially if we’ve eaten too soon before bedtime, then what is in the stomach is going to end up in the esophagus as well as up into your throat because you no longer have the benefit of gravity helping to keep the food down in the stomach. -
Other important lifestyle measures look at factors such as obesity or being overweight.
Although many people who have reflux are quite trim there are many who are not. If you have any excess weight, particularly in your abdomen, it increases the amount of pressure within the abdomen in itself, which increases the amount of pressure on the stomach, which in turn increases the stomach yield pressure. This means that your lower esophageal sphincter has to be even stronger to hold back that extra pressure created by the extra body fat. We often find patients who lose a small amount of their body fat see significant improvements in their reflux symptoms and regain control over the disease. -
With regard to treatment the next question then becomes, “What happens when I’m following dietary measures and the mechanical measures, but I’m still having frequent reflux symptoms? Is there anything else I can do?” At that point, we try and look at minor measures to help support the lower esophageal sphincter. One of the simplest things that we can do is try and take a preparation that contains something known as Alginate, which is a derivative of kelp or seaweed. Often this is found in liquid antacid, certain ones known as Gaviscon and another called Esophageal Guardian. When we take Esophageal Guardian or Gaviscon that contains the Alginate, it forms a foam raft of one to three inches and that acts as a mechanical barrier so the food and the acid and the other gastric contents, such as bile or pepsin, cannot get up the esophagus, even in the presence of a weak sphincter. These are some of the most basic measures.
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There are many different forms of treatment for reflux, and we consider treatment for reflux that is more advanced, when you’re not responding to simple dietary measures, or lifestyles changes, or even the use of medication. I like to divide up therapy based upon the type of therapy or let’s say the sphincter location that’s going to be treated. We’ve talked before about the fact that there’s an internal lower esophageal sphincter and an external lower esophageal sphincter.
Reflux Treatment and Medicine
All the in-depth answers to your questions related to Reflux Treatment Medications!
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When the most basic measures, such as the use of antacids or alginate containing compounds or dietary mechanical measures do not work, many will often turn to medication. I think it’s very important to understand that the use of medication for the control of reflux is nothing more than a bandaid approach to the disease, the medications that we currently use are designed to do one thing. Whether it be the class known as H2 inhibitors, which you may know as Zantac or Tagamet or Pepcid, or whether you’re talking about the class known as Proton Pump inhibitors, such as Nexium, Omeprazole, Pantoprazole, Aciphex or Dexilant, all of these medications are designed to do one thing and one thing only. That is to decrease the amount of acid that your stomach produces.
However, this has no impact whatsoever on the progression of your disease, or the risk of developing more serious types of disease from reflux, such as Barrett’s esophagus or even cancer of the esophagus. Why is that? They do not eliminate all of the acid produced by your stomach. Again, the sphincter is the weak link in the chain here. Because the sphincter is weak you’re still refluxing, but you’re just not refluxing as much acid. Make no mistake, the small amount of acid as well as the bile and the pepsin that comes from the stomach can cause as much damage in the esophagus as well as in the larynx and still create significant symptoms.
It is important to remember that these medications are temporary bridges to more definitive therapy. What we like to encourage people to try is to take medication for a day or two, or a week or two, or maybe from time to time. However, once you are chronically dependent on the need to take a medication to control your symptoms, at that point there has been sufficient degeneration of the lower esophageal sphincter that your reflux disease is not going to get any better, increasing your risk from more serious symptoms. -
Often I’m asked by patients, “Why can’t I just take a medication the rest of my life and control my symptoms? Is that not sufficient in order for me to feel better?” Certainly, if the goal is to do nothing but not feel symptoms, you can take medication the rest of your life. You can take medication, mostly safely, throughout your lifetime, but it’s important to understand that medication is really only a band aid and it only affects how you feel. The importance of controlling your reflux is that reflux is a chronic inflammatory condition and that chronic inflammation that affects the tissues of the esophagus is what causes the real threat as time goes on.
Continued inflammation can lead to ulceration or erosions that, when they heal, create scar tissue or what we call strictures, which can impede the ability to swallow and then, makes the ability of your body to control reflux even more difficult. More seriously, is the development of a chronic inflammatory pre-malignant condition known as Barrett’s Esophagus. This occurs because the cells that normally are replaced in the esophagus are so inflamed that they create another type of tissue, which is considered more resistant to acid. This is known as Barrett’s tissue. Barrett’s tissue is a pre-malignant condition and felt to be a precursor for cancer of the esophagus. Another very important point is that, even in the absence of Barrett’s tissue, just that chronic inflammation alone can develop into esophageal cancer, one of the most lethal types of cancer in the upper GI tract.
Non-Surgical Treatment Options for Reflux
All the in-depth answers to your questions related to Non-Surgical Treatment!
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When thinking of types of therapy, it’s convenient to think of a particular therapy based upon the anatomy. When we think about the internal sphincter of the lower esophageal sphincter, there really is only one therapy available these days, and that’s known as the Stretta procedure. This is a procedure that’s been around since the year 2000, and it was developed specifically to not damage tissue, but to rather reinforce tissue. What the Stretta procedure does is, through an endoscopically directed catheter, radio-frequency energy is directed into the lower portion of the esophagus where the intrinsic lower esophageal sphincter resides in the wall of the esophagus. By shooting the radio-frequency energy into the esophageal muscle, the muscle begins to heat. The molecules will vibrate, creating some heat, and this causes a stimulus effect with regeneration of the tissue.
What we see over a very short period of time, beginning at two weeks, and extending upwards of 12 to 13 months after the procedure, is the muscle fibers and the muscle within each muscle fiber bundle will begin to increase in size, resulting in a net increase in the strength. Think of a weightlifter who lifts weights for a long period of time, and as their muscles begin to grow, the strength of the muscle begins to grow. -
I’m often asked how effective is the Stretta procedure for medically refractory reflux disease. I usually divide my answer based upon the type of reflux disease for the particular individual. Esophageal reflux, which involves the refluxing of gastric, mostly liquid contents, is actually much easier to treat, and we see a more rapid response and a higher percentage of improvement. Typically, in the first year we’ll see 92% to 92.5% of patients asymptomatic and off medication. When we go out to four years, that number decreases slightly to between 78 and 85%, and then when we look at the ten year data, which was published recently, we see that 72 to 75% of patients are still asymptomatic, most of them still not taking any medication even out to ten years.
When looking at other type of reflux, laryngeal reflux, or respiratory reflux, the numbers are slightly different. In the first year, we typically see between 86 and 88% of patients asymptomatic and off medication with regard to their laryngeal or respiratory reflux. This number decreases down to approximately 83% by the time we get to the third or fourth year, and at ten years it stays pretty much equal with the patients who have esophageal reflux, again between 70 and 75% efficacy long-term.
Because the Stretta procedure is what would be called a simple outpatient endoscopic procedure, patients will usually be present in the facility for approximately an hour, and then perhaps another hour of recovery time. Afterwards, most people can then leave and resume relatively normal activities, especially the next day after anesthesia has worn off. -
The safety and the efficacy of the technology allows the Stretta procedure to be offered to almost anyone, even for those that cannot undergo other types of reflux procedures. So, for example, patients with significant abnormal motility conditions who are having trouble swallowing, or who are not responding to medications, or having any type of reflux will respond. Stretta is equally effective as well in patients who are overweight, as well as in those who may have a laryngeal as opposed to esophageal form of reflux disease.
We’ve been able to demonstrate over the past 10 years worth of published research that this procedure is equally effective for all of these groups, and especially effective in those patients who may have had prior surgical therapy, like Nissen fundoplication, that then failed over time. -
From a safety perspective, it is an extremely safe procedure because the device was designed to vigorously protect any damage to the tissue. There’s no damage to the surface or deeper tissues or the possibility of scarring. There’s no restriction or stricture that develops, but what does happen is the muscle becomes stiffer and stronger to resist the gastric pressure thereby preventing reflux from taking place. We see very, very few side effects from this procedure. The more common things that may happen following the procedure include: 1) in approximately 2 to 5% of patients, they may experience some mild chest pain that is usually treated easily with some oral pain medication and 2) some patients may develop what we call dyspepsia, or a feeling of fullness and bloating often with loss of appetite. This develops in between 5 and 8% of patients, and is usually gone two weeks after the procedure.
By the second or third week after the procedure, most people are beginning to already feel less reflux or if they’re still feeling reflux, it becomes less intense. This effect begins to grow and gets better and better and better as time goes on, up to approximately one year. The nice thing about the Stretta procedure compared to other anti-reflux procedures is that it does not require significant modification of diet or medication use afterwards. In fact, as soon as the procedure is over, you may begin immediately drinking fluids and eating soft foods. We ask that patients not eat food such as nuts or pretzels or chips, foods that are often not chewed very well before they’re swallowed. -
How Does The Stretta Procedure Work?
What the Stretta procedure does, is use radio frequency energy, much like you see on the spectrum of harmless radio waves. The energy is well controlled by the device to keep the temperature low enough to not damage tissue. What it does do, is stimulate the water molecules within the muscle tissue in the lower esophageal sphincter to vibrate. With vibration, that creates heat. The heat effect causes the muscle to grow.
When we look at the muscle, the muscle is composed of bundles of fibers and then actual muscle tissue within the muscle fiber bundle. By stimulating these areas with radiofrequency waves, usually one minute at a time for a series of eight treatments in the esophagus and six treatments in the stomach side of the lower esophageal sphincter, we get a net doubling in the number of muscle fiber bundles as well as the amount of muscle within each fiber bundle. What this does is increase the strength, the goal being to get above that magic four millimeters of Mercury of pressure higher than what the stomach generates, and this effectively just shuts down reflux. This effect is not immediate. It begins and takes approximately two weeks and then upwards of a year to see the full doubling effect of the muscle.
This is really a very simple endoscopically administered procedure. In fact, the total amount of treatment time is only 14 minutes. At the end of 14 minutes, you’ve administered treatment to the lower esophageal sphincter and the sphincter then begins to grow. -
What, More Reflux Medication after The Procedure?
Continued medication use is often a concern after having had an anti-reflux procedure. With a Stretta procedure it is important that we maintain the same medications, for the first two months. This is because it’s during this period of time that the initial swelling takes place in the esophagus. Then with the reabsorption of that swelling, known as edema, we hope to see accelerated muscle growth effect. It is normally around that second month that that muscle growth effect starts to really become its strongest. Until then we like to try and keep patients on medications for the first two months, and if there’s a good response, slowly taper those medications off over several weeks. Of course, if there is a slower response and the muscle grows a little bit slower, which it does in many patients, medications may be needed for anywhere between three months and an additional six months before it is best to try and take the medications away.
Reflux Treatment: Surgical
All the in-depth answers to your questions related to Surgical Treatment!
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The indications for considering a surgical therapy are actually very easy to define. One easy indication is the size or presence of an hiatal hernia. A hiatal hernia is a large gap in the diaphragm that allows a portion of your stomach to move from the positive pressure area of the abdomen into the negative pressure area of the chest, causing retention of the stomach contents there. In fact, it facilitates the movement of stomach contents into the chest area, where it’s much easier to result in serious complications of reflux.
The repair of the hiatal hernia becomes very important, and there are two methods to fix approach an hiatal hernia. One is known as the Hill procedure, in which case they will pull the stomach back down under the diaphragm, close the diaphragm with a mesh reinforcement, and then stitch the stomach to the tissues in the back of the abdomen, so it will no longer be able to go back up into the chest. That’s the simplest of the procedures.
More commonly done, however, is a procedure known as the Nissen fundoplication, where they will perform the same elements as the Hill procedure but, in addition, they will take the upper portion of the stomach, which is known as the fundus, and wrap that in a circular fashion around the esophagus. This essentially forms an external barrier that will impede gastric contents from coming back up into the esophagus.
These procedures have been done for decades and have a very high safety margin. In fact, they’re some of the safest surgical procedures that can be done, and some of the most effective, especially for those patients who suffer from hiatal hernias. -
When dealing with a problem with the external sphincter, this is often where we see something known as a hiatal hernia. This means that the opening in the diaphragm that is defined by this external sphincter becomes wider and wider, larger and larger, allowing your stomach to protrude up from the positive pressure cavity of the stomach into the negative pressure cavity of your chest. When this occurs, that allows gastric contents to be held up high in the negative pressure area of your chest and it facilitates more reflux. When the hiatal hernia is three centimeters or larger, roughly a little bit larger than an inch in size, we know that unless we fix that defect in the diaphragm, the hiatus, and bring the stomach back down, fix it in place eliminating the hiatal hernia, and tighten up the external sphincter, then no matter what we do, you will continue to reflux and your disease will continue to advance.
A large hiatal hernia, larger than three centimeters, is often is actually best treated surgically with a Nissen fundoplication, to close that area back down and reestablish the normal anatomy. On the other hand, if the external sphincter is normal, as it is in the majority of people with reflux, we’re really dealing with chronic degeneration of the lower esophageal sphincter – internal portion. When that occurs, we have completely different modalities that we can begin to look at. In particular, there’s one modality, known as the Stretta procedure, which allows us to naturally stimulate that internal sphincter to grow, reestablishing the pressure gradient and then preventing the pressure from the stomach from creating a reflux event. -
The efficacy or the success rate for Nissen fundoplication is actually quite good, and we know that when we look at the long-term studies out as far as 10 years, we can expect between 35 and 65% of people who undergo this surgery to remain asymptomatic and off of medication. However, the remainder of that group will be back on medication within a three to five-year period, although their symptoms will still be better controlled than prior to having surgery.
Once you have had a Nissen fundoplication, if your reflux returns again, the options are to either: 1) repeat the Nissen fundoplication, which is often avoided because the complication rates are higher during the repeat, 2) perform a different procedure known as a Roux-en-Y procedure, which is a complete rerouting of stomach and intestinal tract to avoid reflux, or 3) more commonly these days is to undergo an endoscopic therapy known as a Stretta procedure, which by modifying and improving the the internal sphincter of the lower esophageal sphincter helps to reestablish the prior effect of the Nissen fundoplication on the external sphincter. -
Common side effects that often occur after a Nissen fundoplication, especially in the early few months, which are often found to be disagreeable, is the inability to belch, and many will not be able to vomit. This then results in the unfortunate side effect of having increased flatulence with the passage of increased intestinal gas.
The good news about these side effects is that over a period of time, as the Nissen fundoplication site loosens up and becomes more pliable, those problems tend to attenuate, or become less of a problem for people over time. They should never be regarded as a reason not to do the procedure, especially in those patients with refractory reflux disease and a large hiatal hernia.
Diagnostic Testing For Reflux
How to best characterize the extent of your illness and to have a precise understanding of the specific type of Reflux - Dr. Mark Noar
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There are many questions concerning what is necessary to best characterize the extent of your reflux in order to have a precise understanding of the specific type and factors affecting your disease. We have a number of tools that we use. In particular, we may use a probe to measure the amount of reflux that comes up into your throat or into your esophagus, known as a pH Probe study. This helps gauge the severity of your reflux and what type of contents may be effecting your disease and how we may better treat it.
Another important tool is esophageal motility, which is usually measured by a small catheter placed through your nostril, which you then swallow into the esophagus. This gives us the opportunity to measure the sphincter pressures as well as to measure the disorder of swallowing. The most important thing about esophageal motility is to make sure you do not have another condition, which is actually the opposite of reflux known as Achalasia. In this particular case, the sphincter muscle is actually too tight, and we wouldn’t want to try and correct your reflux, but rather fix the problem of an overly tight sphincter muscle leading to retention in the esophagus and simulating reflux type symptoms.
Other tests that are very important, because the weakened lower esophageal sphincter can be overcome by the gastric pressure, include studies of gastric motility or gastric emptying. In the case of gastric emptying, you may be asked to eat an egg preparation, and this is measured leaving your stomach over a four hour period of time. We’re looking for a condition known as gastroparesis, which is present in 40 to 45% patients with reflux disease.
Another very important test is the electrogastrogram. This is a test that measures electrical activity and motility. Approximately 20-25% of patients will have a problem with the emptying of their stomach caused by a faulty sphincter at the bottom of the stomach, known as the pylorus. Very often in these cases we can improve the pyloric sphincter function at the bottom of the stomach, which will make the reflux either disappear or come under better control. -
Let’s talk about the gastric emptying scan, an important marker for reflux disease. The gastric emptying scan can be done in one of two ways. You can either be in a radiological facility where you will be asked to eat a radioactive nuclear egg, and then they’ll watch that leave your stomach over four hours. Another more common test that we’re doing these days is called the gastric emptying breath test, where you eat basically a mixture of eggs and Spirulina, which is a type of algae which is labeled with Carbon-13, and some Saltines. However instead of being in a machine to detect radioactivity in this case you will be asked to breathe into a tube for a few seconds over approximately four hours.
With either of these tests, we’re trying to see how fast or how slow the stomach empties. This is very important since we know that approximately 40 to 45 percent of patients with refractory reflux disease will have this problem with slow emptying, otherwise known as gastroparesis. -
One of the most important things that we have to consider when faced with reflux disease that is not responding to simple dietary measures is what type of testing do we need to do to fully characterize that disease. On the surface that seems like a fairly simple concept, but unfortunately, because we’re dealing with the esophagus as well as the stomach and a number of sphincters that intervene in between, it’s important that we fully characterize the motility and the contents of those organs. This will provide a better idea of what’s really causing the reflux, what are the crucial outside influences, and what complications the reflux disease has created affecting other organs. Testing as a group may be divided into motility tests, tests of emptying , and pH testing. A typical test is the esophageal motility study, which provides a view how the upper esophageal sphincter works, how the lower esophageal sphincter works, and how does the body of the esophagus contract. Has reflux caused an abnormality or is there an abnormality that actually is contributing to the reflux. Another important study is going to be a pH study, which helps confirm exactly how much and to what location the reflux is taking place.
We know that there is alkaline type reflux, and acid type reflux, which can be divided into both weakly acid and strongly acid types. There is also the refluxing of digestive enzymes called pepsin in particular, which is very important when we talk about laryngeal reflux or LPR. In addition, because the stomach is involved in this entire reflux picture, we want to know does the stomach empty normally. We need to make sure that the stomach is either emptying normally or abnormally. Either way, we’ll be able to then judge how to better treat your reflux. And then the final test, which is very important, which is becoming more and more important these days, is something called the electrogastrogram. The electrogastrogram is something that will determine if the stomach contracts normally or if there perhaps an obstructive change contributing to the reflux, that if addressed first might make the reflux better. That is typically the full family of tests. Of course, you would undergo an upper endoscopy or perhaps a direct laryngoscopy to look more directly at the tissues to evaluate the damage. Do we have ulceration? Do we have inflammation? Are the vocal cords involved? These are some of the important questions that we’ll be looking at when we do your diagnostic evaluations. -
Another important test that’s becoming more and more important as we learn more and more about reflux, is known as the electrogastrogram, or what we call the EGG for short. In this test, three electrodes will be placed on your abdomen on the left, mid, and right portions of your upper abdomen, and you’ll be asked to sit still for approximately 10 minutes. After this 10 minute baseline period, you’ll be asked for five minutes, to drink water until you feel you are completely full. Then for the next 30 minutes, the equipment will monitor the contraction of your stomach. What we’re looking for specifically here are disorders in the contraction or the motility of your stomach.
We can call these different motility disorders either slow stomach emptying, or slow stomach contraction, known as bradygastria, fast stomach contraction known as tachygastria, a mixture of the two, which we’ll called mixed-type. The most important condition that we’re really concerned about is called functional outlet obstruction. In this condition, even though your stomach contracts normally, it cannot contract well enough. Instead the stomach contracts against a closed pyloric sphincter. This causes your gastric contents to back up, making your reflux worse. When we consider correcting reflux, we want to make sure that the people who have the reflux do not have this obstructive change because it needs to be fixed first, so as to not get worse once the reflux is fixed. -
Esophageal manometry is a very common test that’s performed when we evaluate patients who have refractory reflux. It really is important because sometimes the lower esophageal sphincter is actually too tight rather than too loose. This would be known as achalasia. In upwards of between five and 15% of patients who have classic reflux symptoms, they may really have achalasia, which is the sphincter being too tight. In this case that would be treated in a completely different way because it’s not reflux. What we’re looking for in the non-achalasia patient, the standard refluxing patient, is how high is the pressure at the lower esophageal sphincter and that is a reflection of how little or how much muscle you may still have to resist the gastric pressure in order to not reflux.
We get this information from the manometry study. We also get information about the upper esophageal sphincter. Often people with reflux have an overly tight upper esophageal sphincter as a reaction to protect the larynx against reflux. The other component we look at is the actual peristalsis, or normal contraction in a rhythmic fashion from top to bottom of the esophagus. The disorder of peristalsis, which is reflected as a percentage of normal verus spasm versus just simply non-conducted contractions becomes very important because it reveals the severity of the damage caused by the reflux and how much the reflux has adversely affected the esophagus. -
The esophageal pH study, or rather the pH study in general, comes in two types. One of them is a laryngeal pH study, where a probe is placed through your nostril, which you will wear for approximately 24 hours. That will sit in the back of your throat where it’s very comfortable. This is important especially for patients with respiratory reflux, or LPR. This specific test is essential so that we can document what and how much is coming up into the larynx, and how it relates to the reflux symptoms. This helps your doctor confirm whether your disease is actually related to what you’re feeling, and what the best treatment would be.
The esophageal pH probe is a longer probe, and remains, again, for at least 24 hours, but goes through the upper esophageal sphincter and all the way down to just above where the stomach is. This gives us an idea of how much acid, whether it be strongly acidic or weakly acidic, is coming up into the esophagus, and how it relates to your symptoms. We sometimes add a study known as impedance, which tells us directionality. Again, this just gives us an idea of how much reflux you have, and how well it relates to your symptoms, and therefore how to best treat you.
Reflux Lessons In Anatomy
All the in-depth answers to your Reflux questions related to Anatomy!
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The truth about LES. With regard to esophageal motility, one of the issues that many patients often bring up is, “My esophageal sphincter pressure of the lower esophageal sphincter is normal, why is it I still have symptoms?” There is a very simple explanation for this phenomenon. Everything is about the relative strength of the sphincter compared to the pressure coming from the stomach known as the gastric yield pressure. Your LES sphincter needs to be able to generate four millimeters of mercury worth of pressure above the gastric yield pressure. This means that you could technically have a normal pressure of the LES sphincter, but it’s not normal enough to prevent reflux, because of an even higher gastric yield pressure.
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In order to further understand how we make treatment decisions, let’s go back again into the lower esophageal sphincter. Now, we have already discussed the fact that the disease is caused by a progressive degeneration.
But what are we really talking about when we refer to the LES, or the lower esophageal sphincter? Many think that it’s a single sphincter, but in reality, it is actually a dual sphincter mechanism. So there is what is commonly thought of as the lower esophageal sphincter, which is a specialized muscle layer that we refer to as the muscularis propria, that is within the wall of the esophagus and the upper portion of the stomach known as the cardia. This specialized muscle is what’s responsible for contracting and maintaining the pressure.
However, that’s just what we call, now, the internal sphincter. There is also an extrinsic or an external sphincter that works in coordination with that same internal sphincter. The external sphincter is actually made up of a portion of the diaphragm, which wraps around the bottom of the esophagus, just above the stomach.
The vagus nerve, which enervates the esophagus and helps determine motility in the esophagus and the stomach, as well as things like your heart rate, coordinates the action between the external and the internal portions of the sphincter, so that when one contracts, the other one contracts simultaneously. Similarly when one loosens, the other will loosen simultaneously. This is what allows us to swallow normally.
It is the coordinated action of these two sphincters that helps to prevent reflux. Thus it is important when we think about treatment to decide which of these two sphincters, either the internal or the external or perhaps both of the sphincters, are malfunctioning, so we can better design the treatment for your reflux disease.
This is known as personalized medicine, or subtyping the disease, so that we can decide what is the best treatment.
Reflux Types And Causes
All the in-depth answers to your question about Reflux Types and Causes!
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When we think about the two forms of Reflux disease, Esophageal Reflux versus respiratory or LPR symptoms of reflux, the reason why the symptoms are different is because these diseases are caused by two different problems. In Esophageal Reflux, we are dealing more with stomach contents, whether that be basic contents like bile or acidic contents like acid, or digestive enzymes coming up and reacting within the esophagus to cause symptoms.
What’s really unique about the respiratory or LPR type of reflux which makes it so different from Esophageal Reflux is that it’s mostly aerosolized or more like a gaseous spray form of gastric contents that is predominantly going to be dominated by pepsin, which is absorbed into the tissues in the upper airways or larynx and then is reactivated not by acid coming from the stomach, but rather acid that we ingest as part of our diet. This is what accounts for the differences in the symptoms. -
Reflux is a very common disease and what’s interesting about reflux is it actually can be caused by, or cause other diseases that go unrecognized.
In particular, the stomach emptying is very important as a normal way that your body functions that creates the gastric pressure that impacts the development of the reflux. If the stomach is emptying slowly, which we would call gastroparesis, the gastric yield pressure is elevated which may either cause reflux, and in many cases it can be caused by reflux.
We know that up to 45% of patients who have reflux will have gastroparesis. Interestingly, of that group, maybe 25% percent of them it’s actually the gastroparesis that causes the reflux. What about the other 75% where it’s actually the reflux causing the gastroparesis?
This occurs because the stomach cannot contract normally and push the food out through the bottom of the stomach because the lower esophageal sphincter valve is so loose, that gastric contents constantly move up into the esophagus, and pressure cannot develop in the stomach to allow emptying.
The positive thing is when we make that connection that it’s actually the reflux causing the gastroparesis, by correcting the reflux either by Nissen fundoplication or a Stretta procedure, we know that either these two procedures will also correct the gastroparesis at the same time.
Reflux & Esophageal Cancer
All the in-depth answers to your questions about Reflux & Esophageal Cancer
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Even though you may control the symptoms of reflux, you may be disguising the development of a more serious condition such as Barrett’s Esophagus or esophageal cancer. Esophageal cancer occurs in approximately 16,000 plus new patients, every year. Previously thought to be due to alcohol or tobacco use, we now know that most of the cases now-a-days, are due to chronic reflux disease. Approximately 15,000 people per year will die of this disease, and the reason they will die is because their symptoms of esophageal cancer are often disguised until the very last moment when the esophagus is obstructed.
When this occurs, it’s often too late for adequate treatment and unfortunately, people cannot survive the diagnosis of the disease. If we can succeed in controlling the reflux disease, there are studies that now show that with devices such as the Stretta Procedure, which controls reflux, or the surgical procedure known as Nissen fundoplication, there can be actual reversal of the reflux related complications such as Barrett’s Esophagus and perhaps even reduction in the incidence of adenocarcinoma or esophageal cancer, long term. This is the importance of proper diagnosis and treatment directed towards fixing the defect in the lower esophageal sphincter. -
I want to make an important point about your case, which is the fact that you have Barrett’s esophagus. An important question is, “Where does Barrett’s esophagus come from?” It actually is due to reflux. When reflux causes tissue erosion, the normal tissue is replaced by other types of tissue. This other type tissue is a more specialized tissue, and that’s felt to be the precancerous tissue that develops called Barrett’s.
The great thing we realized when we published the 10 year data about the Stretta procedure is that by reducing your reflux we know that about 85% of the time, the Barrett’s will spontaneously regress or disappear.
When we achieve the control of your reflux and the Barrett’s regresses, you will not need the follow ups. You will not need to have to continue to look at this endoscopically. We will see over time, usually it’s going to happen within the first few years.
I would not be surprised if a couple of years from now, we see this tissue has just gone ahead and disappeared. How is this possible? The reason is that your lining of your gut sloughs away and is replaced by new lining every three to five days. By controlling the reflux we get rid of the inflammation at the basal lamina layer of cells, where the tissue develops and moves up from the bottom. If the Stretta procedure works and you’re not refluxing anymore, there’s no more inflammation in what we call the basal lamina, where there are stem cells. Thus if the stem cells are not inflamed any longer, they grow normal tissue as opposed to Barrett’s tissue or cancer tissue. That is why the abnormal tissue disappears spontaneously after a Stretta procedure.
Respiratory Reflux - LPR
All the in-depth answers to your questions related to Respiratory Reflux or LPR!
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An important respiratory manifestation of reflux that often goes undiagnosed is asthma or bronchitis. This pertains particularly to late onset asthma or bronchitis that occurs not as a child, but rather in adulthood or as a teenager. When we see this type of asthma or bronchitis present, it is most often going to be associated with uncontrolled or unsuspected reflux. It’s important that this diagnosis be considered because once we fix the reflux, no matter what procedure is used to fix the reflux, further damage can be presented which is caused by the asthma or the bronchitis. Often patients will be treated with antibiotics or medication specifically for asthma or bronchitis when really the underlying cause just continues, that being reflux.
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Other manifestations of reflux disease that often go unnoticed that are critical are diseases that involve the respiratory system or the upper airway. In particular, we now know reflux, which then causes spasm of the larynx and aspiration or the breathing-in of stomach contents into the lungs, can cause sleep apnea. In fact, it is suspected at this time that up to 50% of those patients who have sleep apnea actually have reflux as the cause for their sleep apnea. This can be determined by doing a simultaneous pH study and sleep study, and when we match up the episodes of reflux with the episodes of apnea, it is possible to make a definitive diagnosis. Then by controlling the reflux it is possible to fix the sleep apnea by fixing the reflux allowing the patients to no longer have to use those nighttime positive pressure breathing devices known as CPAP machines. It’s very important whenever sleep apnea is present to look for reflux.
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Another very common set of symptoms, we’ll call extra-esophageal symptoms, that are associated with reflux, include vocal fatigue or hoarseness, post nasal drip, and increased mucous production. All of these symptoms are often secondary to reflux, and not due to what has been assumed in the past to be a recent viral illness, or chronic allergies.
It is very important if you have any of these chronic symptoms, especially if you’re being treated for allergic conditions, or sinus drainage, sinusitis, and you’re not getting better, to have your physician consider reflux as the primary disease. Again, by fixing the reflux, and not allowing reflux of gastric contents into the ear canals, or the larynx, or into your nasal passages, or sinuses, it is possible to stop the disease, and you’ll be treated more personally, or more accurately. -
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