What is reflux?

Gastroesophageal reflux disease (GERD), generally known as acid reflux, is a condition where acid from the stomach discomfortingly leaks up into the esophagus for a long time. This leak may temporarily occur in every individual depending on the food that we normally eat and drink. In order to call it reflux disease, it should occur more than twice a week, affect our daily life or cause damage to the esophagus.Many people can control reflux disease by avoiding foods that discomfort them and by rarely taking drug.

At this point, a very famous saying in medicine “There is no disease, there is patient” is true. Although the name of the disease is the same, the symptoms and treatment modality vary greatly from person to person.

How does reflux occur?

There is a valve system between the stomach and esophagus which is opened by swallowing and then closed. However, this valve system begins not to function in some cases. When the pressure in the stomach rises, the valve loosens and causes the stomach content to rise up into the esophagus. In general, the stomach content is acidic and the stomach has the capability to protect itself against this acid. However, the protective mechanisms against this acid are not present in the esophagus. Rise up of this acidic fluid into the esophagus causes damage to that area, resulting in pain and burn. The stomach contents may also be bilious and the bile is harmful to the esophagus even though it has an alkaline content.In the long term, if not treated, this condition can lead to esophageal inflammation (esophagitis), bleeding, esophageal stricture, tissue changes (Barrett’s esophagus), and even malignant diseases.

What are the symptoms?

  • Burn in the upper middle part of the abdomen and the spread of this burn to the chest. (these patients may even be exposed to long-term examinations and tests, considering as a cardiac patient)
  • Bitter taste in the mouth, especially after meals
  • Dry cough (sometimes so severe to wake you up at night)
  • Hoarseness and sore throat (meaning that the acidic fluid risen up has reached the vocal cords)
  • Polyp or nodule on the vocal cords
  • Persistent laryngitis and pharyngitis despite treatment
  • Recurrent pneumonia
  • Painful and difficult swallowing

The abovementioned complaints may vary in frequency and severity.

What are the risk factors?

There are a variety of diseases that cause gastroesophageal reflux or increase its severity. Obesity is at the top of these. In obese individuals, it can be seen that the symptoms of reflux completely disappear with weight loss. Stomach (hiatal) hernia is a condition that causes reflux by itself. In addition, asthma, diabetes, and some connective tissue diseases may increase your reflux.There is almost no one experiencing reflux during pregnancy. Reflux may arise since the space occupied by the uterus, which grows inside the abdomen, pushes the intraabdominal organs up. Sometimes, this condition may force mother candidates a lot, since we have a limited right in terms of drugs. Generally, reflux disappears when the pregnancy ends (or, with the excitement of the child, the mother forgets herself).

What are the foods that increase reflux?

It should be kept in mind that not every food disagrees with every patient. The patient should determine the foods and drinks that have a negative effect on themselves and increase their reflux, and avoid these foods. Foods most commonly complained about by patients are tea, coffee, alcoholic beverages, acidic beverages, chocolate, mint, excessively oily foods, yeasted pastries (such as pastry, savory bun bought from outside), salami, sausage, bologna sausage, raw tomato, onion, and garlic.

How is it diagnosed?

Actually, a clinician can most of the time diagnose gastroesophageal reflux by only listening to the patient’s complaints and asking a few questions. However, one or a few tests are needed to choose treatment methods.

  1. Endoscopy (Gastroscopy): This method visualizes the inner surfaces of the esophagus, stomach, and duodenum utilizing a device that has a camera at the tip. In the presence of reflux, it is important in terms of observing changes that may occur in the esophagus and diagnosing gastric hernia.
  2. 24-hour esophageal pH monitoring: This method aims to measure the times when the esophagus is exposed to acid over a 24-hour period with a very fine small probe placed in the esophagus. The information that is decisive in the treatment, such as a number of reflux episodes in the course of a day, the level it rises up, duration, are recorded throughout the day.
  3. Barium-contrast imaging of the stomach (barium swallow test): In this method, a substance called barium is swallowed by the patient and a series of x-rays are then taken from the patient. During this study, the movement of the barium visualized in a bright color on the images is followed. The amount of reflux can be seen during or immediately after swallowing.
  4. Esophageal Manometry: It is a device that measures the motility of esophagus. If esophageal motility disorder is detected, the treatment of reflux may be completely changed.

NOTE: Not all of these tests are required for each patient. The philosophy of medicine is based on “administration of the most effective treatment with the fewest tests possible”. However, in the case of suspicion, even additional tests may be necessary.

What is the treatment?

The most important step in the treatment of reflux disease is a lifestyle change. In other words, it is necessary to find foods and behaviors that increase reflux and eliminate them.

  • Obese individuals must regain their normal weights to prevent reflux.
  • There should be a minimum of 4 hours between dinner time and bedtime.
  • Lying on the left side with the head slightly elevated during sleep may partially prevent the stomach content from rising up. For this purpose, a large variety of wedge pillows for reflux are available in the market. (figure)
  • Smaller, more frequent meals should be eaten.
  • Tight clothes that tighten the waist region should be avoided.
  • Smoking is known to increase reflux. Smoking should be discontinued.

Patients whose symptoms do not resolve with these measures need drug therapy in the second step. Drug therapies cannot prevent the stomach content from rising up into the esophagus, but prevent this reflux from damaging the esophagus by reducing the amount of acid in the stomach. Therefore, in order to benefit from drug therapy, it is necessary to use it for life. Unfortunately, the use of these drugs for many years increases the risk of occurrence of some dangerous side effects.

The best treatment method is surgery for patients who cannot achieve the expected benefit from drug therapy or who benefit from drug therapy but do not want to use gastroprotective drugs for life. In reflux surgery, the space in which the esophagus passes through the diaphragm is narrowed and the stomach is rotated around itself by giving an inkwell shape, thus reflux is prevented. The surgery is entirely performed laparoscopically (closed). In this method, special instruments inserted into the abdomen through incisions smaller than 1 cm are used.

What is the success rate of the surgery?

The success rate of the surgeries performed by experienced surgeons is above 90%. Patients are relieved of all of the symptoms after the surgery. Another factor in the success of surgery is the right patient selection. Each patient may not be an eligible candidate for reflux surgery. For this reason, preoperative examinations should be meticulously interpreted by a physician experienced in this field.

What is the chance of recurrence after the surgery?

Recurrence may occur after reflux surgery performed in any hospital in the world. At this point, surgical technique is of importance. With the development of modern methods, the rate of postoperative recurrence has decreased. The rate of recurrence is less than 5% in laparoscopic surgeries using mesh. In the case of recurrence, the symptoms of these patients are usually milder than before the surgery.

What are the endoscopic treatments?

In all gastric and esophageal diseases, endoscopic treatment (orally entering the stomach) has always been remarkable. The point of attracting patients and physicians is that they do not require general anesthesia, there is no need for any incision and they do not require prolonged hospital stays. Hence, the medical world conducts extensive research on these methods. However, many methods that have been developed as of now could not be an alternative to surgery. It has been found that both their risks were more than that of surgery and their benefits were less than that of surgery. According to our knowledge now, endoscopic treatment methods are experimental methods.
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