Diagnosis and Treatment Options for GERD

Nearly 21 million Americans suffering from Gastroesophageal Reflux Disease (GERD) use over-the-counter H2 receptor blockers or are prescribed proton pump inhibitors (PPI) to control their symptoms. Although the major symptoms of GERD; heartburn, sour mouth, hoarseness with throat pain and chest pain, can usually be managed effectively with medications and lifestyle changes, continuously exposing the esophagus to harsh stomach acid can lead to more serious conditions and complications.

While many patients have GERD symptoms, our Center for Complex Digestive Disease Motility Program has the technology and expertise to diagnose a symptom’s root cause. Comprehensive testing allows diagnoses of complex problems such as paraesophageal hernias, diffuse esophageal spasm or achalasia and identifies candidates for endoscopic or laparoscopic repairs of these serious conditions. As a comprehensive foregut motility center, we offer state-of-the-art diagnostic and treatment options.

Medical Interventions

Read our Procedure Profile on GERD pdf

For many people who suffer from GERD or GERD-like symptoms, H2 blockers or PPI medications have been extremely successful in suppressing stomach acid production. Additionally, diagnosing and treating Helicobacter pylori (H. pylori) bacteria has helped to relieve GERD-like symptoms in many patients. However, the suppression of acid in conjunction with lifestyle modifications and weight loss treats only the symptom and not the cause and medications can be an expensive lifetime treatment option. Complications from GERD that go untreated can increase a patient’s chances for more serious problems including inflammation, ulcers, strictures, dysphagia, asthma or esophageal cancer. For many medically refractory patients, surgical intervention is the only option available that will bring relief from GERD.
Back to top

Diagnosing GERD

Diagnosing GERD is the first step in identifying the most appropriate treatment option for patients. Historically diagnosis was made using an upper GI or 24-hour pH test. However, the Motility Program offers an innovative diagnostic tool for patients with severe chronic reflux disease known as the Bravo pH test. Traditionally, a patient’s pH is tested with a trans-nasal catheter 24-hour pH test. This is uncomfortable and irritating to the throat and nasal passage and patients tended to avoid testing. With the Bravo pH test, a tiny pH transmitter, about the size of a vitamin capsule, is endoscopically attached to the wall of the esophagus. The capsule sends esophagus pH level data to a pager sized recording device worn around the waist. Patients are able to continue their regular daily routine and consume a normal diet. After 24 – 48 hours the tiny transmitter capsule is naturally sloughed off and eliminated through a normal bowel movement. After two days, the patient simply returns the recording device to the motility office and our motility expert later analyzes the data for diagnostic evaluation.

Additional diagnostic tools include endoscopy and esophageal manometry. Using an endoscope, physicians are able see the inside of the esophagus and stomach to biopsy and diagnose conditions like Barrett's esophagus. Esophageal manometry measures the pressure and contractions of the lower esophageal sphincter (LES) muscle, identifying or ruling out LES muscle weakness as the cause of GERD.
Back to top

Laparoscopic and Endoscopic Interventions

Endoscopic Interventions

Laparoscopic and endoscopic treatments for GERD have emerged as alternatives to chronic medication treatment. Since the primary physiological cause of GERD is the physical barrier loss at the gastroesophageal junction (GEJ), the goal is to “tighten” the LES valve, thereby reducing reflux.

Candidates for interventional procedures are patients with severe and chronic GERD, GERD accompanied by paraesophageal or hiatal hernias suffering from uncontrollable symptoms, or patients failing to respond to H2 blocker and PPI medication therapy.

Endoscopic gastroplication or endoscopic sewing attempts to restore functionality of the stomach sphincter surrounding the esophagogastric (cardia) by using an esophageal sewing technique. The endoscopist places a series of stitches in the folds of the cardia to create a pleat in the sphincter at the GEJ. The endoscopic sewing machine, a product distributed by Bard Technologies called EndoCinch, received FDA approval in early 2000. We are currently investigating three additional endoscopic techniques for GERD through our research clinical trials and will have these available for use in the near future.

Usually patients require only conscious sedation for this procedure, greatly reducing risk. However, procedures carry some risk of bleeding and infection.

The procedure does not require and incision, therefore, is usually done in the outpatient GI lab. Most patients return home the same day as treatment and resume normal daily activities one day following the procedure. Patients usually experience a sore throat and may experience some nausea for the first few days postoperatively. Most pain can be controlled with over the counter analgesics such as Motrin or Tylenol.
Back to top

Laparoscopic Intervention

Laparoscopic Fundoplication constructs a new esophageal valve by wrapping the upper portion of the stomach (fundus) around the lower end of the esophagus. The wrap is sutured into place and supports the sphincter muscle controlling this valve so that stomach acid is not allowed to push its way up into the esophagus.
Many patients with GERD also have a paraesophageal or hiatal hernia caused by an opening in the diaphragm allowing the stomach to bulge into the chest cavity. These conditions can cause increased heartburn and difficulty swallowing. The hiatal hernia is believed to be caused by a variety of factors including obesity, trauma, stress, heavy lifting and in some cases, people are born with a hernia.

Using a laparoscope, the surgeon makes only four or five quarter-inch incisions at various points on the abdomen to provide access for laparoscopic instruments. One incision is used for the laparoscope and the others are used to manipulate structures and perform surgery. The procedure lasts approximately 90 minutes to two hours and reduces the hospital stay to one or two days, with a one to two week recovery period.

The risks unique to laparoscopic fundoplication for GERD include bleeding, infection, and conversion to an open operation. These complications occur in less than 1% of patients treated laparoscopically. More serious, yet extremely obscure, complications include gastric or esophageal perforations, vagal nerve injury, tissue ulceration or ischemia, or splenopancreatic injury. Other risks associated with surgery in general include pneumonia and blood clots also occurring in less than 1% of patients. The long-term recurrence rate is 10-15%.

Most patients feel well enough to go home within one or two days and return to their normal activities within two weeks. Generally, patients can walk a few hours after surgery. A soft diet is started the day after surgery and patients usually advance to a regular diet within six weeks after surgery. Pain is controlled with oral narcotic medications.
Back to top

Patient referral and insurance coverage

Patients need a referral from their primary care provider or physician specialist prior to scheduling their diagnostic options, or interventional endoscopic or laparoscopic surgical evaluation. Many pre-evaluation laboratory and radiological results can be forwarded to the physician’s office prior to consultation.

Treatment for GERD is a surgical option covered by Medicare, Medi-Cal and most private insurance companies. In order to avoid unexpected medical expenses, it is always best to contact your insurance company prior to treatment to confirm coverage for this service and obtain prior authorization.

For more information or patient referral please contact our specialty referral coordinators at 1 (888) 637-2762.


Back to top