January 2019, Volume XXXII, No 10
Individualizing diagnosis and treatment
atients with heartburn often begin a lengthy journey of diagnosis and treatment before their conditions are accurately identified and their symptoms resolved. A new, comprehensive, personalized approach to diagnosing and managing patients with heartburn is necessary, taking into account the unique needs and issues of each patient.
The incidence of conditions causing heartburn symptoms, including acid reflux and gastroesophageal reflux disease (GERD), is growing, according to the American Society for Gastrointestinal Endoscopy (ASGE). Up to 40 percent of the U.S. population experiences GERD, a chronic digestive disorder in which stomach acid flows back into the esophagus, causing heartburn and irritation in the lining of the esophagus.
Today, proton pump inhibitors (PPIs) are among the top selling drugs in the U.S. While they often are the first line of treatment for patients with acid reflux, about 30 percent of GERD patients do not respond to standard dose PPI medications. In addition, long-term use of PPIs can sometimes mask the symptoms of heartburn. PPIs may make the patient feel better, but they might not be treating the cause of the discomfort. If left untreated, heartburn can result in more serious esophageal disorders, such as dysphagia, chronic reflux damage, adult-onset asthma, Barrett’s esophagus, and esophageal cancer.
Through our Heartburn Center, we specialize in caring for patients with esophageal and digestive disorders that frequently present as heartburn. In addition to GERD, these can include:
Because the symptoms of GERD are so diverse, diagnosis can be difficult. Reflux testing is a reimbursed procedure that enables providers to definitively diagnose esophageal disorders and determine the best course of treatment for their patients. Here are the most common diagnosis options available today.
Esophagram. An esophagram is often the first choice of physicians when seeing patients with an initial concern of heartburn. It provides X-ray imaging of the esophagus and upper stomach, including the anatomy and motility of the esophagus. We use it to evaluate swallowing problems, as well as reflux. Allergic reactions to the barium patients drink are uncommon.
Endoscopy or esophagogastroduodenoscopy (EGD). An endoscopy or EGD enables providers to visualize the esophagus, stomach, and duodenum, spotting conditions such as ulcers, erosions, and Barrett’s esophagus. EGDs are performed in our procedure centers and involve only a slight risk of sore throat, bleeding, or perforation of the upper GI tract. While this is a good diagnostic tool, the ASGE reports that up to 70 percent of patients who do not respond to optimized PPI therapy have a negative EGD.
High resolution impedance manometry (HRIM). HRIM measures pressures and fluid movement in the esophagus, helping to diagnose esophageal motility disorders. Performed in the office, the procedure involves placing a small, flexible catheter into the esophagus through the nose. Patients are asked to swallow small amounts of salt water 10 to 12 times during the test. Some patients have difficulty with gagging, but with relaxation most patients can complete the procedure.
24-hour esophageal impedance pH test. This test evaluates the extent of gastric reflux that flows into the esophagus during 24 hours. Sensors on a catheter measure the level of acidity at various levels in the esophagus, as well as the reflux of stomach contents up into the esophagus. The catheter is connected to a pocket-sized recording device worn by the patient. It is the most accurate test to document gastroesophageal reflux and is generally our preferred test because it measures acidity at different levels, as well as non-acid reflux events.
Bravo capsule esophageal pH test. The Bravo capsule test measures and records the level of pH in the esophagus over 48 to 96 hours, enabling providers to document relationships between symptoms and acid reflux events. The device consists of a capsule about the size of a vitamin pill that attaches to the esophagus via a catheter and transmits information wirelessly to a pocket-sized receiver that the patient carries. The Bravo usually is placed during an endoscopy procedure while a patient is under sedation. The capsule dislodges itself in about three to seven days and passes out with the stool. In rare cases, patients can experience chest pain, the capsule may not fall off spontaneously, or food may become lodged on the capsule. Patients should not undergo an MRI if they suspect the capsule is still in the body.
Lifestyle and medication treatment options
Each patient is unique and deserves a personalized treatment approach. In some cases, lifestyle changes can make significant improvements to a patient’s heartburn symptoms. Maintaining a healthy weight, learning what foods aggravate the heartburn, and avoiding large meals, especially late at night, sometimes can solve the problem. Avoiding carbonated and caffeinated beverages also can be helpful, as can avoiding clothes that fit tightly around the waist.
We also remind patients that smoking and drinking alcohol can both decrease the esophageal sphincter’s ability to close properly, thus increasing reflux and heartburn. Some patients also find that elevating the head of their bed or placing a wedge between the mattress and box spring makes a difference in their ability to be symptom free at night.
If lifestyle changes are not helpful, we often turn to short-term use of medications. There are three classes of medications prescribed for heartburn:
In some cases, medications other than those specifically aimed at treating heartburn may be useful, including muscle relaxants, steroids, anti-anxiety medications, and pro-motility agents.
Up to 40 percent of the U.S. population experiences GERD.
Treating patients with heartburn can be complex.
Surgery is often the best option for patients with severe esophageal disease who have failed to respond to short-term medication use. Today, we have a wide range of surgical options available to us:
Nissen or partial fundoplication. This procedure wraps the top of the stomach around the lower esophagus to reinforce the lower esophageal sphincter, creating a new sphincter between the esophagus and stomach.
Hiatal hernia repair. Most hiatal hernias require surgery to pull the stomach down, reduce the opening in the diaphragm, and reconstruct the esophageal sphincter.
LINX. The LINX procedure is a relatively new way to treat heartburn with implanted magnetic beads that tighten the esophageal sphincter. Designed for patients diagnosed with GERD through abnormal pH testing, the device is about the size of a quarter and is implanted around the outside of the lower esophageal sphincter through a minimally invasive laparoscopic procedure. Despite the fact that the beads are magnetic, patients with a LINX device can continue to have MRIs.
Bariatric weight loss surgery. Nissen or LINX procedures may be ineffective and too high risk for patients who are severely overweight. In these cases, we often recommend bariatric weight loss surgery, such as Roux-en-Y gastric bypass and gastric sleeve (gastrectomy) surgeries. Roux-en-Y is the most common gastric bypass procedure. Surgeons divide the stomach to create a small pouch to which a portion of the small intestine is attached, causing food to bypass a large section of the stomach and intestine. With a gastrectomy, a portion of the stomach is actually removed, creating a narrower stomach called a sleeve. Both make long-term changes to the digestive system by limiting the amount of food a patient can eat or reducing the absorption of nutrients. Like other major surgeries, bariatric surgery carries a number of serious risks and should only be considered when less extensive options have failed.
Minimally invasive esophagectomy. During this surgical procedure, surgeons remove part of the esophagus and reconstruct it using a piece of another organ, usually the stomach. It typically is reserved for esophageal cancer, but also may be used for Barrett’s esophagus if aggressive precancerous cells are found.
Radiofrequency ablation. This minimally invasive procedure uses electrical energy and heat to remove irregular cells as part of a treatment for Barrett’s esophagus. Once the diseased tissue is removed, a patient’s body will regenerate new tissue in the esophagus. This is often followed by surgery to treat the underlying cause of Barrett’s esophagus to prevent recurrence of irregular cells.
Many esophageal surgeries can be performed robotically. We have the largest number of robotic-trained surgeons in the Upper Midwest and have found that treating esophageal diseases with minimally invasive robotic surgery results in improved outcomes with less pain and faster recovery time.