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Acid Reflux

Linx Device

What is Acid Reflux or GERD?

Acid reflux or “heartburn” occurs when stomach contents leak back, or reflux, into the esophagus. Refluxed stomach acid creates a burning sensation in the chest or throat called heartburn or indigestion. Occasionally, people describe reflux as a burning sensation in the back of the mouth. Heartburn that occurs more than twice a week may be considered gastro-esophageal reflux disease (GERD). Some people have GERD without heartburn. In other words, it is a “silent’’ reflux. This may present as a chronic cough or throat clearing, chronic sinus drainage, or hoarseness of the voice.

What Causes Acid Reflux?

The esophagus is the muscular tube that carries food from the mouth to the stomach. At the end of the esophagus there is a valve called the lower esophageal sphincter (LES). The function of the lower esophageal sphincter (LES) is to keep stomach contents from refluxing back into the esophagus. Minor reflux that happens infrequently is normal and usually does not cause any symptoms. Chronic reflux, however, can cause ulcers, an erosion of the lining of the esophagus, a stricture, or severe inflammation.

Reflux is a mechanical problem. It is caused by the lower esophageal sphincter (LES) being dysfunctional. Many times, this is associated with a hiatal hernia preventing the sphincter from working properly. A hiatal hernia is an enlargement of the natural opening in the diaphragm where the esophagus enters the abdomen. If this opening gets too large, a portion of the stomach may begin to protrude through the diaphragm into the chest. This can weaken the LES and result in acid reflux. Foods, chemicals and certain medications can weaken the function of the sphincter (LES). Examples include:

  • Peppermint
  • Chocolate
  • Tobacco
  • Alcohol
  • Certain Medications
  • Anticholinergic drugs ( urinary tract disorder medications)
  • Antihistamines
  • Asthma Medications
  • Calcium Channel Blockers (High Blood Pressure)
  • Diazepam (anxiety disorders and seizure medication)
  • Nitrates (Angina)
  • Opioid Analgesics ( Prescription pain medications)
  • Some Antidepressants

Other conditions can lead to higher pressures in the abdominal cavity which can overwhelm the sphincter LES causing it to become ‘weakened’ and incompetent. Examples include the following:

  • Pregnancy
  • Obesity
  • Chronic cough or straining
  • Bending over

Over time chronic acid reflux can lead to changes in the cells that line the esophagus. This is known as Barrett’s Esophagus. Patients can also develp pre-cancerous changes (dysplasia) as a result of chronic reflux. Once a patient develops these findings, careful and close follow-up is mandatory with an annual upper endoscopy and/or esophageal tissue ablation therapy to help prevent and to rule out the development of cancer.

Treatment

In most cases reflux can be managed with simple strategies. If you are experiencing reflux you should visit with your doctor for diagnosis and treatment. Pain in the chest can also signify serious conditions such as heart disease so a professional medical consultation is required to distinguish heartburn from something more significant.
Once diagnosed properly, reflux can be managed with several strategies including lifestyle changes and medical therapy

  • Avoid causative agents (STOP SMOKING and ALCOHOL CONSUMPTION)
  • Weight loss
  • Avoid over eating and late night meals
  • Elevate the head of the bed a few inches
  • Medications
  • Antacids (Tums, Gaviscon, Pepto-Bismol)
  • H2 blockers (Zantac, Pepcid)
  • Proton pump inhibitors (Prilosec, Prevacid, Zegerid, Nexium, Dexilant)
  • Your physician may order additional testing including: x-ray (upper gi series or video esophagram), upper endoscopy (EGD) esophageal manometry, BRAVO pH testing or Impedance pH testing, Endoflip Impedance Planimetry, or Esoguard testing.

Preparation for Reflux Testing

Upper Endoscopy is a brief outpatient procedure accompanied with IV based anesthesia. The patient should refrain from eating within 8 hours prior to the procedure. During the procedure the patient is sedated and an endoscope is passed through the mouth and down the esophagus and is used to visually inspect the esophagus, stomach, and the first portion of the small intestine. Superficial, painless biopsies are often taken during the procedure to evaluate for changes within the esophagus concerning for Barrett’s esophagus. Biopsies of the stomach are also taken to evaluate for the presence of a bacteria called H. pylori that can increase the risk of stomach ulcers. 

Bravo pH testing is a procedure typically performed at the time of an endoscopy in which a small capsule the size of a small pill is temporarily implanted in the wall of the esophagus that can continuously measure pH levels within the esophagus for 72 hours (about 3 days). The capsule communicates via a Bluetooth type technology with a small recording device the patient carries with them for 72 hours. The Bravo capsule typically falls off and is passed in the stool within 5 days.  (No, patients do NOT need to retrieve the device from their stool)  In preparation for Bravo pH testing, patients will need to hold all Proton pump inhibitor medications or H2 blocker medications for 3 days prior to the procedure, and all antacids such as Tums for 24 hours prior to the procedure. 

Esophageal manometry testing is a short procedure which measures the esophagus’ ability to properly contract and move food down it. It is performed by placing a small catheter down the nose and then having the patient drink several small swallows of liquid. The catheter can measure the muscle strength of the esophageal contractions as the liquid is pushed down. Patients should avoid eating 8 hours prior to the procedure.  

Esoguard testing is a quick screening procedure that is often performed in the office. During the procedure, the patient swallows a small capsule attached to a thin catheter. The capsule contains a small balloon with ridges that can be inflated once it reaches the stomach. The balloon is pulled back into the esophagus a few inches which allows the ridges of the ballon to collect some superficial tissue from the esophagus. The balloon is deflated, removed from the mouth, and then sent off for molecular testing of the tissue to look for early tissue changes that can be associated with Barrett’s esophagus or esophageal cancer. A positive test result does not always mean that a patient has Barrett’s esophagus or cancer but should typically be followed by an endoscopy to further evaluate. A negative test result would indicate a low risk for Barrett’s esophagus or esophageal cancer

Surgical Treatment of Acid Reflux

Many GERD symptoms will respond to lifestyle changes and medical management. People who do not respond to conservative management should consider surgery. Over time the cost of the medicines can be significant, and some patients will elect to have surgery to correct the condition. Studies have shown that results are better if the surgery is done before the patients GERD becomes severe (maximum medical therapy). Any patient who has developed Barrett’s esophagus or pre-cancerous changes (dysplasia) in the lower esophagus should strongly consider anti-reflux surgery. There are recent studies that report the regression of these findings in some patients who undergo an operation. Patients with Barrett’s esophagus or dysplastic changes who undergo surgery should continue to have close follow-up including endoscopy regularly until the condition resolves. 

There are multiple surgical options for the treatment of GERD. After thoroughly reviewing your history and clinical symptoms, your surgeon may recommend one of the following:

Fundoplication (Nissen or Toupet) is a common surgical treatment for GERD. In this operation, the upper part of the stomach is wrapped either partially or completely around the lower end of the esophagus and the hiatal hernia is repaired.

Implantation of a LINX Magnetic Sphincter Augmentation Device is an alternate FDA approved device that is recommended for patients whose symptoms are not controlled with medication or lifestyle changes. LINX offers similar efficacy in resolution of GERD as fundoplication and can also be a good option for patients who may not be candidates for fundoplication. These could be patients that have a sleeve gastrectomy or a gastric bypass.

Linx

At BMI of Texas, Dr. Englehardt is a nationally recognized leader in the field of reflux surgery. He performs clinical evaluations and surgery to address the increasing prevalence of GERD in San Antonio by offering a full spectrum of reflux surgery options including LINX surgery. Dr. Englehardt has been involved in many significant multi-institution research projects to help advance the field of reflux surgery and treatment of GERD.  

The LINX Magnetic Sphincter Augmentation (MSA) device is an FDA-approved device for the treatment of gastroesophageal reflux disease (GERD) and is FDA approved for treatment of GERD in sleeve gastrectomy patients.  Studies show that 90% of patients are able to stop anti-reflux medications and over 80% had maintained resolution of bothersome heartburn at 5 years. 

How does LINX work?

The Linx device is a flexible ring of magnetized titanium beads that is placed in a specific position on the esophagus.  It is like a magnetic bracelet placed around the esophagus.  The device acts as a helper to the lower esophageal sphincter (LES) muscle allowing it to prevent reflux of stomach contents into the esophagus. 

Is there any workup prior to a Linx procedure?

Specific testing to determine if you are a candidate for linx can include:

  • upper endoscopy
  • esophageal manometry
  • bravo pH testing
  • Endoflip impedance planimetry
  • Video Esophogram

Am I a candidate for LINX?

Ideal candidates are those with one or more of the following:

  • Patients with symptoms of GERD despite taking 2 or more daily medications for the treatment of GERD.
  • Presence of a hiatal hernia
  • Abnormal pH testing
  • Normal esophageal function
  • Reflux following sleeve gastrectomy or RNY gastric bypass

What is the recovery process?

The LINX surgery is a minimally invasive laparoscopic surgery performed on an outpatient basis. Patients are ambulatory and able to perform light activities following surgery. Patients will be able to consume a regular diet modified to have small frequent meals.

In general, patients can return to work within 1-2 weeks of surgery. By working collaboratively with your surgeon, you will be able to wean off any medical therapies for GERD over time.