What is Reflux Disease?

Reflux is the backflow of stomach contents into the esophagus. Normally, the sphincter consisting of muscles in the lowest part of the esophagus acts as a valve, preventing the stomach contents from returning to the esophagus. If the lower esophageal sphincter (LES) opens on its own or does not close properly, stomach contents begin to rise to the esophagus and reflux occurs. Gastroesophageal reflux disease is a more serious form of gastroesophageal reflux, which is common. Reflux is also called acid reflux because gastric juice is acidic.

When acid reflux occurs, the taste of food and acid liquid may return to the mouth. When stomach acid comes into contact with the esophagus, a burning sensation occurs in the chest. Reflux is common and does not necessarily mean a disease. Reflux that occurs twice a week or more is considered persistent reflux disease and can eventually lead to more serious health problems. Reflux disease can occur in people of all ages.


What are the symptoms of reflux disease?

* Heartburn, burning and burping
* Burning and tightness in the chest
* Difficulty in breathing deeply
* Pressure and palpitations on the heart with a feeling of tightness in the chest
* A bitter taste in the mouth,
* Foul breath
* hoarseness
* Chronic pharyngitis, chronic sinusitis, allergic asthma

Causes of reflux disease!

The cause of reflux disease that develops in some people is still unclear. However, studies show that in people with reflux disease and at rest, the LES is loose. Anatomical abnormalities such as hiatal hernia (stomach hernia) may also contribute to reflux formation. When a hiatal hernia develops, the LES rises above the diaphragm. Normally, the diaphragm helps the LES to keep stomach acid from returning to the esophagus. Acid reflux can occur more easily when you have a hiatal hernia. Hiatal hernia can occur at any age. It is often a normal finding in healthy people over the age of 50. Most of the time, hiatal hernias cause no symptoms. Other factors that contribute to the occurrence of GERD include:

* obesity
* pregnancy
* smoking

Foods that can worsen reflux symptoms
* citrus fruit
* chocolate
* drinks with caffeine or alcohol
* Oily and fried foods
* garlic and onion
* mint, flavorings
* spicy foods
* foods containing tomatoes, such as spaghetti sauce, salsa, peppers, and pizza


What is reflux in children?


It is important to distinguish normal reflux, physiological reflux and reflux disease in children. Reflux may develop in infants from birth, but it does not cause a disease, it is physiological. There may be reflux disease that continues after the age of one. Studies have shown that reflux disease in infants and children is common but often overlooked. For example, reflux disease can cause nausea, heartburn, cough, laryngitis, or recurrent respiratory problems such as wheezing, asthma, pneumonia. Babies and young children often experience irritability during or immediately after feeding. Babies with reflux disease may refuse to be fed and may have developmental delay. Contact your child's doctor or health care provider if their reflux-related symptoms occur regularly and cause your child to feel uncomfortable. Your healthcare provider or doctor may recommend a simple strategy to prevent reflux, such as burping the baby several times during feeding or holding the baby in an upright position for 30 minutes after breastfeeding. If the child is older, the health care provider may recommend that your child eat frequent but small portions and avoid the following foods.


* carbonated drinks containing caffeine
* chocolate
* mint
* spicy foods
* acidic foods such as oranges, tomatoes, and pizza
* fried and fatty foods

Avoiding food 2-3 hours before bedtime can also help. The healthcare provider may recommend raising bed head for your child. Just using extra pillows will not be enough. If this change does not work, your doctor may prescribe medication for your child. A child may rarely need surgery for reflux.


How is reflux disease treated?
If your reflux complaints persist despite using antacid or reflux medications for more than two weeks, your family doctor may refer you to a gastrointestinal specialist (General Surgeon or Gastroenterologist). Depending on the severity of your reflux disease, treatment may include lifestyle changes, medication, or surgical treatment options.

Lifestyle Changes
* If you smoke, quit it.
* Avoid foods and drinks that increase your complaints.
* Lose weight if needed.
* Eat frequently but small portions.
* Wear loose clothing.
* Avoid lying down for 3 hours after a meal.
* Raise the head of your bed 15-20 degrees, just using extra pillows will not be enough.


Medicines

Your doctor may recommend antacids, drugs that stop acid production and speed up stomach emptying. However, be sure to seek your doctor's advice before starting a drug treatment.
Antacids are often the first medication recommended to relieve heartburn and other mild reflux symptoms. Many brands on the market contain different combinations of the three basic salts, magnesium, calcium, aluminum hydroxide, or bicarbonate ions to neutralize stomach acid. However, antacids can have side effects. Magnesium salt can cause diarrhea, and aluminum salt can cause constipation. Aluminum and magnesium salts are often combined in a single product to offset these side effects.
Antacids containing calcium carbonate can also be an additional source of calcium, but these antacids can cause constipation.
Gaviscon is very effective in preventing reflux as it forms a layer on the lower esophageal mucosa by standing like a foam on the stomach contents.
Drugs such as H2 blockers, cimetidine (Tagamet), famotidine (Famodin), nizatidine (Axid), ranitidine (Ranitab, Zantac) reduce acid production. These drugs provide short-term relief and are effective in about half of patients with reflux symptoms.
Proton pump inhibitors include drugs such as omeprazole (Omeprol), lansoprazole (Lansor), pantoprazole (Panthec, Pantpas), rabeprazole (Pariet), and esomeprazole (Nexium). These drugs inhibit (suppress) acid secretion. Proton pump inhibitors are more effective than H2 blockers. In the vast majority of patients, improvement or relief of reflux symptoms can be achieved with these drugs.
Prokinetics cause LES augmentation and rapid gastric emptying. This group of drugs includes betanechol (Urecholine) or metoclopramide (Metpamide). Metoclopramide also increases the motility of the digestive tract. However, prokinetics have common side effects such as fatigue, drowsiness, depression, anxiety, and decreased physical activity. Sucralfate (Antepsin) forms a protective layer on the esophageal mucosa and thus acts as a protective barrier against acid, bile salts and enzymes in the stomach.
Because the mechanisms of action of drugs are different, the use of varying combinations of drugs may be more effective in controlling symptoms. People with heartburn and burning after a meal can take antacids and H2 blockers together. Antacids initially neutralize stomach acid, and then H2 blockers block acid production. Of course, the best thing to do is to use medication in accordance with the doctor's recommendation for each patient. Treatment combinations may differ for each patient according to the symptoms and complaints.



What if reflux symptoms persist?

If symptoms do not improve with lifestyle changes or medications, you may need additional testing.
* Esophageal-stomach passage radiography is performed using x-rays to aid in the diagnosis of hiatal hernia and anatomical and structural abnormalities in the esophagus. With this examination, strictures and ulcers in the esophagus can be diagnosed. However, it has no diagnostic value for superficial irritation and erosions.
* Upper endoscopy has more accurate diagnostic value in esophagus-stomach radiography. It can be carried out in a hospital or doctor's office. First, a spray is applied to numb the throat. The procedure is followed by minimal sedation, in which a thin, flexible plastic tube with a light and lens (camera) at the end, called an endoscope, is passed down the throat. The endoscope acts like a small camera, allowing the doctor to see the surface of the esophagus and stomach. If moderate to severe symptoms are present and this is detected by endoscopy by visualizing damage to the esophageal surface, other tests are not required to confirm reflux disease. If your doctor deems it necessary, he or she may also perform a biopsy. Precision tweezers, called forceps, are passed through the endoscope and used to pick up small pieces of tissue from the esophagus. The tissue pieces are then examined by the pathologist to look for damage (inflammation, dysplasia) caused by acid reflux.
* pH monitoring is performed by inserting a small tube or a small device into the esophagus. The device or tube is placed so that it stays there for 24 to 48 hours. The device records when and how much acid comes back into the esophagus while the person continues his/her normal activities. This test can be useful if combined with the recording of the carefully completed diary. The doctor can detect the presence of a relationship between symptoms and reflux attacks by comparing the recording and the time of symptoms. This procedure can also sometimes be useful in determining if respiratory symptoms such as wheezing and coughing are triggered by reflux. There is no completely accurate and definitive diagnosis method for reflux disease. Tests have not shown a direct relationship between acid exposure in the lower part of the esophagus and damage to the esophageal wall.

Surgical treatment
If medical treatment and lifestyle changes do not improve reflux symptoms, surgery is another option. Surgery may also be a reasonable alternative to the constant use of medication and constant discomfort. Fundoplication is the standard surgical treatment for reflux disease. Generally, the technique called Nissen fundoplication is applied. During Nissen fundoplication, the upper part of the stomach is wrapped around the lower esophageal sphincter to strengthen the sphincter, prevent acid reflux, and also repair hiatal hernia.

Nissen fundoplication technique


Nissen fundoplication technique (subtitle of the diagram)

The Nissen fundoplication procedure is usually performed laparoscopically. The doctor uses a camera and small instruments to look at the abdomen and pelvis. When performed by experienced surgeons, laparoscopic fundoplication is a safe method for people of all ages, including children. This procedure has the same results as a standard (open) fundoplication. However, hospital stay (1-3 days) and return to work (2 weeks) are shorter. The success rate of Nissen fundoplication surgery in patients diagnosed with reflux disease is over 90%. What is meant by the success of the surgery is the cessation of daily medication use, the disappearance of symptoms such as pain in the chest, burning and bitter water in the mouth. Endoscopic techniques used in the treatment of reflux disease are the Bard EndoCinch system, NDO Plicator and Stretta system. In these techniques, the anti-reflux procedure is performed using an endoscope. The EndoCinch and NDO Plicator systems are performed by placing sutures into the lower esophageal sphincter to create pleats that aid muscle strengthening. Small burns are created in the lower esophagus using electrodes in the Stretta system. The scar tissue formed as a result of burn healing helps to harden the muscle. These three procedures have just begun to be implemented, however long-term consequences are not yet known.

What are the complications of reflux?

Chronic reflux disease can cause serious complications if left untreated. As a result of inflammation caused by the reflux of stomach acid into the esophagus, mucosal damage, bleeding or ulceration, ie esophagitis, may develop. The scar caused by tissue damage can lead to difficulty in swallowing and esophageal-stenosis. Some people develop Barrett's esophagus (abnormal progression of gastric mucosal cells into the esophagus). Over time, these cells can develop esophageal cancer, which is often fatal. Therefore, patients who develop reflux disease and its complications should be closely monitored by a doctor. Studies have shown that reflux can worsen symptoms of asthma, chronic cough, and pulmonary fibrosis.

SUMMARY
* Heartburn, agita and indigestion are the most common symptoms of reflux disease in adults. A person may have reflux disease if they have heartburn and agita twice a week or more.
* There may be reflux disease without burning. Dry cough, asthma symptoms and difficulty swallowing are other symptoms.
* If you are using antacids for more than 2 weeks, you should consult a health institution (doctor). Doctors can treat most reflux diseases. However, it is better to consult a gastroenterologist, internist or a general surgeon.
* Your doctor may recommend that you change your lifestyle and eating habits. He or she may prescribe medication to relieve reflux symptoms. In cases where the above fails, surgery may be considered a treatment option.
* Babies can develop reflux from the birth, but it does not cause a disease. There may be reflux disease that continues after 1 year of age.
* In older children, irritability, abdominal and chest pain may be seen due to reflux. Reflux disease can cause persistent and recurrent vomiting, coughing and breathing problems, which are common in infants and children.



Assoc. Prof. Ahmet Tekin

General Surgeon