One in five people in the United States suffers from gastroesophageal reflux disease (GERD), a digestive disorder that causes heartburn and acid indigestion. GERD accounts for 4-5 million physician visits per year, and 7-8 million Americans remain symptomatic despite taking heartburn medications, according to Middlesex Health gastroesophageal surgeon Jonathan Aranow, MD.
Not only does GERD affect patients’ quality of life, he says, but if inadequately treated, it can lead to more serious medical problems. In fact, 15 percent of those with GERD may go on to develop Barrett’s esophagus, or precancerous changes in the lining of the esophagus. Barrett’s, in turn, dramatically increases the risk of esophageal cancer.
Middlesex Health recently launched a comprehensive GERD program with the goal of helping patients suffering from the disorder to get the treatment they need. By dialing in to a new toll-free number – 1-833-END-GERD – patients can consult with a GI nurse, who will refer them to either the health system’s gastroenterologists or gastroesphageal surgeons, depending on their history and symptoms. Using an array of diagnostic tools, these physicians then determine the best course of treatment for each patient.
Says Dr. Aranow, who collaborated with gastroenterologist Nadeem Hussain, MD, to develop the program at Middlesex Health: “We’re the only people in Connecticut to have all this under one roof, with a foregut surgeon closely collaborating with the GI team in the evaluation and management of patients.”
A breach in the anti-reflux barrier
During healthy digestion, food passes down through the esophagus and into the stomach, where enzymes and acid break down food particles so that nutrients can be absorbed by the body from the intestines. “There is a muscle in the lower esophagus – known as the esophageal sphincter – that normally works as a one-way valve, closing behind the food as it passes through the digestive tract so that it doesn’t come back up,” explains Dr. Hussain.
There are two components to the anti-reflux barrier: the esophageal sphincter, and the esophageal hiatus – the opening through which the esophagus traverses the diaphragm (the muscle between the chest and abdomen). “GERD is a failure of the anti-reflux barrier,” notes Dr. Aranow. In some patients, the opening in the diaphragm becomes progressively wider with age, creating a hiatal hernia. “The stomach can slide up into the chest if the opening is too wide,” he explains.
Whatever the cause – a malfunctioning valve or a hiatal hernia – if the barrier isn’t working as it should, food (along with digestive acids and sometimes bile from the intestine) is regurgitated back up into the esophagus, causing heartburn and indigestion. “It’s normal to produce acid in the stomach,” says Dr. Hussain. “You need it to digest food and kill bacteria. But it’s not normal to get acid climbing up into the esophagus.” Symptoms of GERD may include a burning sensation in the chest, chest pain, “wet burps” and regurgitation, trouble swallowing or the sensation of a lump in the throat. GERD can also cause coughing and hoarseness.
While over-the-counter antacids often relieve such symptoms by reducing the acid that rises in the chest, they don’t address the bile, says Dr. Aranow. Both acid and bile can play a role in damaging the esophagus, leading, in some patients, to Barrett’s and, ultimately, esophageal cancer. “We want to catch people who have evidence of Barrett’s and prevent the changes from getting worse,” adds Dr. Hussain.
The incidence of esophageal cancer has increased 600 percent in the last 30 years, according to Dr. Aranow. He points out that the rise in esophageal cancer coincides with the adoption of antacid therapy. “So we’ve masked a lot of the disease,” he says. “But the most carcinogenic component of reflux is bile, not acid.” At the same time, there has been a rise in obesity, which increases the risk of both reflux and esophageal cancer, notes Dr. Hussain, as do smoking and alcohol consumption.
Making a diagnosis
Dr. Hussain says those who get occasional heartburn and feel better after modifying their diet and taking antacids probably do not require further treatment. “But if they have a family history of esophageal cancer, risk factors like smoking or obesity, or are having problems like unexplained weight loss, trouble swallowing, or worsening indigestion symptoms, they might want to think of further evaluation,” he says.
Dr. Aranow adds that anyone who has been dependent on antacids for six weeks or longer should also be assessed by a specialist.
There are several tests that doctors at Middlesex use to confirm a diagnosis of GERD, evaluate if there is damage to the lining of the esophagus, and determine whether a faulty valve or hiatal hernia is to blame for reflux, Dr. Hussain explains. Using upper endoscopy, in which a thin scope with a camera at its tip is inserted through the mouth, physicians can look at the esophagus, stomach and intestines. If the physician sees signs of Barrett’s (i.e. deep red coloring that involves the esophageal lining), he will biopsy the tissue to make that diagnosis.
A barium study can not only give doctors an idea of the anatomy of the upper digestive tract but can also show themhow the esophagus is working. There are two types of barium studies. During a timed barium swallow, the patient ingests a liquid metallic compound that lights up on x-ray, and the radiologist takes snapshots of the esophagus at timed intervals to see how quickly the barium is cleared. This is to ensure that the patient’s esophagus is emptying normally, ruling out a condition such as achalasia, where the esophageal sphincter doesn’t relax enough so that fluid and food remain in the esophagus rather than passing into the stomach. During an upper GI series, the patient also swallows the barium compound and doctors x-ray the esophagus, stomach and small intestine to create a “road map of what the digestive system looks like,” says Dr. Aranow. “Is there a hiatal hernia? A narrowing?”
Dr. Aranow explains that most people have some degree of reflux throughout the day – even those with healthy digestive tracts – so a barium study, which lasts only 10-20 minutes, is not definitive enough to guide the decision to perform surgery. That’s where the 96-hour Bravo capsule test comes in. It can tell the doctor the amount and duration of acid reflux that patients experience during their normal daily activities. The doctor uses endoscopy to insert and attach a capsule with a radio transmitter by suction cup to the wall of the esophagus, then withdraws the scope, leaving just the capsule inside the patient.
“We leave it in for four days and patients can have a normal day, and do the stuff that incites their symptoms,” Dr. Aranow explains. “We can then see whether heartburn events match the acid spikes. This is the gold standard for determining that a patient has reflux. I always want a Bravo before considering a patient for surgery.”
Other diagnostic testing might include a 24-hour esophageal pH test (which measures the amount of acid that flows back into the esophagus from the stomach over the course of a day) or motility testing (which uses a probe with sensors, inserted through the nose and into the stomach, to ensure that patients are, in fact, emptying their esophagus and moving food through the digestive tract normally). “We use this to rule out alternate diagnoses,” Dr. Hussain explains.
A range of treatment options
For some patients, medications and lifestyle changes are adequate to manage GERD. Proton-pump inhibitors (PPIs), like the prescription drug Nexium and the over-the-counter drug Prilosec, which bind to proton pumps in the stomach, blocking acid production, are effective in reducing heartburn. “But there are potential risks related to PPIs,” says Dr. Hussain. “They control gastric acid so well that you may not be digesting food as well, or not absorbing calcium and vitamin D, so you could be at increased risk for osteoporosis. There is also concern that people may develop other problems from lifelong, higher-dose use, but these issues are currently under study.”
That’s why people look to alternate ways of fixing the problem, he says, like non-PPI medications (Tums, Zantac, or Pepcid, for example). “Exercising and eating healthy can help too,” Dr. Hussain says. He points out that certain foods – like coffee, chocolate and tomatoes – relax the sphincter, causing reflux. Heavy, high-fat and fried foods can also increase regurgitation. Avoiding fats, carbs, large meals, late-night eating, and any foods that trigger your symptoms can all help. So can elevating the head of the bed by placing books or towels under the top of the mattress.
For some patients, the best solution is to surgically fix the underlying anatomical problem causing GERD. “Of those millions and millions of patients suffering from GERD, only 17,000 anti-reflux surgeries are done annually,” notes Dr. Aranow. “It’s a resource that is being very underutilized.”
Dr. Aranow considers four criteria to determine if a patient is a candidate for surgery: Are they taking medications long term and the drugs aren’t working? Do they find themselves increasing the dosage of these medications? Are their symptoms affecting their quality of life? And are they still having liquid regurgitation despite taking medicine?
The most common surgery for reflux is a group of procedures known as fundoplication. In the traditional Nissen fundoplication, the upper portion of the stomach is wrapped 360 degrees around the lower end of the esophagus to strengthen the esophageal sphincter. “While this is the most potent procedure, it also has the highest risk of side effects,” says Dr. Aranow. “It gives you a very good barrier to reflux, but it could be too good a barrier, causing food to get stuck or leading to the inability to vomit. I rarely offer this procedure because of the side effects.”
He is more likely to do a partial fundoplication, that is, a partial wrapping of the upper stomach around the esophagus, creating a lower-pressure valve to prevent regurgitation. “The long-term effectiveness over 10 years is 80 percent complete reflux control, as compared to 94-96 percent with the Nissen, but side effects are rare,” he says. The surgical approach typically utilizes the da Vinci robotic platform, which allows for minimal discomfort and rapid recovery. The majority of patients can be treated as outpatients. Transoral Incisionless Fundoplication (TIF) is a nonsurgical alternative to partial fundoplication for a select group of patients. Using an endoscope inserted through the mouth, Dr. Aranow tightens the esophageal sphincter using a tiny, spear-like device and sutures. He is the only surgeon in Connecticut who is credentialed to do this procedure.
Another relatively new surgical approach to GERD is the LINX procedure, which involves the laparoscopic implantation of a small ring made of interlinked magnetic titanium beads – “it looks like a Smarties bracelet,” says Dr. Aranow – that acts as a makeshift valve. “I strengthen up the diaphragm as well when I do this procedure.” (He also repairs hiatal hernias when doing partial fundoplication surgery; those with hernias are not candidates for TIF). Gastric bypass, though typically performed as a weight-loss surgery, is also effective in treating reflux, he says. “It may be the only surgical choice for those who are morbidly obese.”
Dr. Aranow, who has been at Middlesex for 21 years, also performs other bariatric, stomach and esophageal surgeries. Dr. Hussain, who has been at the institution for 14 years, has a digestive disease and liver diseases practice, and sees patients for conditions ranging from reflux, inflammatory bowel disease and liver diseases to cancers of the GI tract. Both doctors say they are excited about Middlesex Health’s new program.
“We are fully equipped to streamline the care of GERD patients in a multidisciplinary way,” says Dr. Hussain, “by optimizing a healthy lifestyle, fine-tuning medications when needed, defining the problem by imaging and specialized testing and, in certain cases, intervening surgically.”
Lori Miller Kase is a freelance writer living in Simsbury.
Allegra Anderson is a Glastonbury-based photographer and president of the Connecticut chapter of the American Society of Media Photographers.