February 5, 2009
Heartburn belies reflux’s complex causes, subtle symptoms
By Brian Donohue
News & Community Relations
One curly fry and energy drink at a time, Americans are feeling the sting of acid reflux. It’s estimated to affect 15 million nationwide, and 90 percent of the folks who seek medical care will be prescribed an antacid.
Nearly every general practitioner will treat gastroesophageal reflux disease, or GERD, at some point. Cases begin routinely: Patients complain of heartburn and regurgitation of acid. First-line therapies are medications that reduce acid, such as proton-pump inhibitors (PPIs), which frequently resolve heartburn.
But in 30 percent or more of patients, reflux persists and/or other symptoms emerge.
These cases keep practitioners busy at UW Medical Center’s Swallowing Center, which opened in 1995. Its esophageal-function lab evaluated more than 1,000 people last year, most of whom were patients referred for GERD. Of that group, the physicians saw about 250 patients in clinic, and operated on about 150, said Dr. Brant Oelschlager, who, with Dr. Carlos Pellegrini, directs the center.
“GERD is complex,” Oelschlager said. “Signs may be subtle. Patients may not present just with heartburn, and many have problems that aren’t obviously related.”
For example, patients who seem to have asthma, a bad cough, a voice change or hoarseness might have reflux and not know it. Even in the absence of the telltale heartburn, GERD can play a role in lung disease, asthma, laryngitis and other disorders.
“It seems to be the action of the reflux, regardless of the acidity, and the potential aspiration into the vocal cords or lungs that irritates those organs and perpetuates those problems. Medication does not address those issues,” Oelschlager said.
UW Medicine’s esophageal surgeons consult with gastroenterologists, otolaryngologists and pulmonary specialists to sort through these complexities. Sophisticated diagnostics such as high-resolution manometry and impedance, which measures any type of reflux, help reveal a patient’s problem and tailor treatment.
Surgery and other emerging endoscopic techniques can address structural deficits that foster reflux. These procedures mostly target the lower esophageal sphincter (LES), which, working correctly, keeps acid in the stomach. For years the standard surgical fix has been laparoscopic fundoplication: The top of the stomach is wrapped around, or cinched against, the esophagus to compensate for a failing LES.
Oelschlager, who has performed fundoplications for 10 years, now also offers patients with chronic reflux an incisionless version — EsophyX. The surgeon inserts a stapling device into the patient’s stomach through his/her mouth. With an endoscope as visual guide, the surgeon retracts the device’s clamp end to a V-shape, pinches a fold of tissue against the device itself, and implants staples in a 270-degree arc to create a hinged flap about 4 centimeters in diameter.
“This is the first endoscopic procedure to truly re-create what we do surgically with a fundoplication. There’s no incision, almost no pain, and the outpatient procedure takes about an hour,” Oelschlager said.
The approach is directed at the patients whose reflux symptoms are not adequately resolved with medication but aren’t so severe that surgery is the sole option.
For those in-between patients, the minimally invasive EsophyX is “really fitting the treatment strategy more to the severity of the problem,” Oelschlager said.
“Most new patients we see are being managed with PPIs for reflux. They don’t always hear about options,” he said. “Many should be referred for evaluation and a discussion of the alternatives.”
To learn more, call the Swallowing Center at (206) 598-4477.
