Acid reflux is caused by the backflow of gastric acid into the esophagus. It is common, affecting 59% of people monthly. Reflux becomes more than just heartburn when associated with symptoms like shortness of breath or chest pain, which require medical evaluation. Surgical options for reflux include various fundoplication procedures like Nissen that help restore the body's normal barriers against reflux. Long-term or severe reflux can potentially lead to complications like esophagitis, strictures, Barrett's esophagus, and even esophageal adenocarcinoma over time.

1. Answering the burning
questions of Acid Reflux
Kyle B. Vincent, MD
June 11, 2013

2. Objectives
What causes acid reflux?
When is it more than just “heartburn”?
What are the surgical options for reflux?
Can it lead to anything bad?

3. Prevalence of GERD
59% of the population has symptoms on a
monthly basis
19.8 symptoms on a weekly basis
4-7% symptoms on a daily basis
(Locke et al. Gastroenterology 1997;112:1148.)

5. What causes acid reflux?

6. Definition
Any symptoms or esophageal mucosal
damage that results from reflux of gastric
acid into the esophagus.
Classic GERD symptoms
 Heartburn (pyrosis): substernal burning discomfort
 After eating (postprandial)
 Aggravated by change in position
 Prompt relief by antacids
 Regurgitation (water brash): bitter, acidic fluid in the
mouth when lying down or bending over

7. Physiology
Acidity necessary for
digestion

8. Anatomy
The only organ to
traverse three
body cavities

9. GE Junction
squamous epithelium
columnar epithelium

10. Histology
Mucosal layer is squamous epithelium
 Through most of the course
Z-line
 Distal 1 – 2cm of esophageal mucosa
 Transition to columnar epithelium

11. Mechanisms to Prevent Injury
Clearance
Mucosal lining
LES competence
 Decrease in resting tone
 Hiatal hernia
Gastric emptying

12. Hiatal Hernia
NOT everyone with a hiatal hernia has
GERD.

13. When is it more than just
“heartburn”?

14. WARNING!
Reflux symptoms are almost never
associated with shortness of breath, difficulty
breathing, feeling like you’re going to pass
out, or a feeling of impending doom.
“Better to be in the emergency room and feel
silly than at home and feel dead”

15. Work Up
Traditional symptoms
 No further work up
 Treat empirically
Symptoms associated with complications
 Barium swallow
 Endoscopy
Prior to surgical intervention
 Ambulatory pH monitoring
 Esophageal manometry
H2 Blockers
Pepcid
Zantac
PPI
Protonix
Prevacid
Nexium

16. ENT
Hoarseness
Laryngitis
Pharyngitis
Chronic cough
Globus sensation
Dysphonia
Sinusitis
Subglottic stenosis
Laryngeal cancer
Pulmonary
Asthma
Aspiration pneumonia
Chronic bronchitis
Pulmonary fibrosis
Other
Chest pain
Dental erosion
Extraesophageal
Manifestations
Vaezi et al. Clin Gastro Hep 2003;1:333-344.

17. Treatment
Medical Options

18. Treatment
Lifestyle Modifications
 Elevate head of bed 4-6 inches
 Avoid eating within 2-3 hours of bedtime
 Lose weight if overweight
 Stop smoking
 Modify diet
 Eat more frequent but smaller meals
 Avoid fatty/fried food, peppermint, chocolate, alcohol,
carbonated beverages, coffee and tea
OTC medications as needed
Prescription medications

19. Complications
Esophagitis
Peptic Stricture
Barrett’s
Adenocarcinoma
Digestivehealth.net

20. Imaging/Diagnostics
Esophagram
Endoscopy

21. Barrett’s Esophagus
Metaplasia – One kind of fully differentiated
cell replaces another kind of fully
differentiated cell
 Usually squamous epithelium replaces a columnar
epithelium
Intestinal, columnar epithelium replaces the
stratified squamous epithelium at the distal
esophagus
 More resistant to injury
 More susceptible to developing carcinoma
 40 Fold increase in risk

22. Barrett’s Histology
Benign glands in
the lower right
Barrett's columnar
cell metaplasia with
a large goblet cell
containing blue
mucin in the lower
center
Adenocarcinoma
on the left

23. Endoscopic Views of Barrett’s
Salmon Colored Lesion

24. Barrett’s Monitoring
4 Quadrant Bx every 1cm

25. Controversy
Anti-reflux Surgery in Barrett’s
 Proponents
 Regression of metaplasia in 57% of Patients
 Controls symptoms without medications
 Opponents
 Screening becomes more difficult
 20% failure rate at 5 years in controlling symptoms

26. Treatment
Surgical Options

27. Helping???

28. When is surgery an option?
Intractable GERD
 Difficult to manage strictures
 Severe bleeding from esophagitis
 Non-healing ulcers
GERD requiring long-term PPI (10 years)
 Healthy young patient
 “…operative therapy is considered an alternative to
medical therapy rather than a treatment of last
resort.” – Sabiston’s 18th Edition
Persistent regurgitation/aspiration symptoms
Not Barrett’s esophagus alone
WARNING: Beware
the patient that does not
respond to PPI
treatment!

29. pH Probe
Medscape: General Surgery Edition

30. DeMeester Score
Measure of lower esophageal acidity
 A score of >14.72 shows significant reflux.
Scored in comparison to mean values
 Supine reflux
 Upright reflux
 Total reflux
 Number of episodes
 Number of episodes longer than 5 min
 Longest episode
Am J Gastroenterol. 1974 Oct;62(4):325-32.

31. Manometry

32. Anti-Reflux Surgery
Nissen

33. Fundoplications
Wrap tailored to
situation

34. Complications of Surgery
Collapsed lung 3%
Difficulty swallowing
(Dysphagia)
 30% Post-op
 2% after 2 months
Death
 0.5%
 8.3% for patients over age 80
Failures
 5%
GI Motility online (May 2006) | doi:10.1038/gimo56
Mechanisms of fundoplication failure.

35. Cancer of the Esophagus
Can it lead to anything bad?

36. Epidemiology
Adenocarcinoma of esophagus has the fastest
growing incidence rate of all cancers in the U.S.
 17,460 new cases per year
 15,070 deaths
Drastic shift in epidemiology
 Prior to 1970
 90-95% of all esophageal cancer was squamous cell
carcinoma
 Thoracic esophagus in African American males who
smoke & drank EtOH
 Currently Adenocarcinoma of the distal esophagus
& GE junction accounts for nearly 70%
86% mortality rate
Overall 5 year
survival rate was
16.9%

37. Symptoms
Dysphagia
 Solid food first
 2/3 of the lumen may be obstructed before
any symptoms are noted
 On average 24mm esophagus will narrow to
less than 12mm before dysphagia is noticed
Weight Loss

38. Squamous Cell Carcinoma of the
Esophagus
Upper and middle 2/3 of the esophagus
Smoking and alcohol
 Both increase risk 5 fold
 Together the risk increases to 25 fold
Nitrosamines
 Food additive to pickled & smoked foods
Long term ingestion of hot liquids

39. Adenocarcinoma of the Esophagus
Distal 1/3 of the esophagus
GERD
Western diet
 Caffeine, fats, acidic, & spicy food all
decrease LES tone

40. STAGING

41. Recap
What causes acid reflux?
When is it more than just “heartburn”?
What are the surgical options for reflux?
Can it lead to anything bad?

42. SURPRISE!
The End