The gastro-oesophageal reflux (GOR) is a disease characterized by the return of the acid produced inside the stomach to the esophagus. The majority of the people may present some of this physiologic reflux, mainly after ingestinga large amount of food, lying down right after the meals or ingesting chocolate/coffee/wine, etc. However, these episodes are sporadic. The patients with pathological reflux have intense and frequent symptoms caused by the return of the acid to the esophagus.
The main cause of GOR is the presence of a hiatal hernia. The hiatal hernia occurs when the transition from the esophagus and stomach, which should occur inside the abdomen, goes up through the esophagus hiatus and happens in the thorax. In the transition between the esophagus and the stomach, there is a valve/sphincter, known as the lower esophagus sphincter, which is responsible for stopping the stomach content from returning to the esophagus. The weakening of this sphincter lets the gastric content return to the esophagus, and is the main cause of GOR.
The main cause of GOR is the hiatal hernia. The hiatal hernia occurs when the transition from the esophagus and stomach, which should happen in the abdomen, goes up the esophagus hiatus and happens in the thorax. Besides this, obesity, caffeine, alcohol and chocolate mixtures may worsen the reflux. However, some patients have GOR without having a hiatal hernia.
About 5% of the people present daily symptoms of reflux, while 15% present frequent symptoms. The main symptoms are heartburn and difficulty to swallow food. It is also common for the patients to have a bitter taste in the mouth. These are known as typical symptoms of the reflux. Beside these, some patients may also present: irritation in the throat, chronic cough, hoarseness and a feeling of nocturnal choking – the so-called atypical symptoms.
The diagnosis is based on the patient’s symptoms, but it must be confirmed by complementary exams. The upper digestive endoscopy is the initial investigation exam. It is frequent that for us to find a hiatal hernia and reflux esophagitis (heartburn caused by the acid reflux). However, other exams are currently used for the precise diagnosis of reflux. The esophagus manometry measures the pressure inside the esophagus and normally detects the hypothomy or weakness of the lower sphincter of the esophagus.Another important exam is 24 hour pH measuring. Despite being an exam that is a little uncomfortable, for the patient remains with a small probe inside the esophagus for 24 hours, it is fundamental, for it allows the division of the physiological reflux (normal) and the excessive reflux (pathologic). The evolution depends on several factors. Generally, the reflux tends to worsen with time. However, patients who are treated adequately and change some feeding habits may have long periods without any symptoms. Those who are not treated/followed up adequately may have complications such as ulcers and esophagus stenosis. In a few cases, the chronical inflammation may cause the presence of the Barrett’s esophagus (alteration of the mucous or lining of the esophagus), which predisposes to the esophagus cancer.
Treatment The treatment may be divided into behavioral measures, drug treatment and surgical treatment.
O tratamento pode ser dividido em medidas comportamentais, tratamento medicamentoso e tratamento cirúrgico.
- Drug treatment
The utilization of drugs that block the production of acid inside the stomach, and consequently decreases the reflux of acid to the esophagus is the main pharmachological treatment. The treatment generally lasts for 4-8 weeks. The majority of the patients improves significantly from the symptoms.After the end of the medication, the patients must be observed. Many patients do not have any symptoms for a long period. Some patients start having symptoms soon after stopping the medication. In those cases, it is important to talk to a specialist to define the best treatment, which may be either a continuous drug treatment or a surgical treatment.
- Surgical treatment
Your doctor can help you decide if the surgery is the best option for your case. This decision must be taken after considering some information, such as: time the patient has had the reflux, the intensity and frequency of the symptoms. Besides, the perception of the client must always be taken into consideration: he must decide if wants to keep on taking the medicine or to be submitted to a surgery that will eliminate the symptoms definitively. The surgery is performed under general anesthesia and consists of the correction of the hiatal hernia (closing of the exaggerated opening of the diaphragm with some stitches) and preparation of a valve to stop the reflux. The valve is made with the stomach itself around the esophagus, without any foreign material.In the majority of the cases this procedure can be performed through video laparoscopy (“surgery of the little holes”), avoiding a large incision in the abdomen. The benefits of this minimally invasive approach are less post-operatory pain, fewer complications, earlier return to the activities and better aesthetic result. Initially carbonic gas is injected inside the abdomen of the patient to create space. Next a câmera is coupled to a monitor and small instruments are inserted through the incision allowing the visualization of the organs and the performance of the surgery.
Advantages and risks
When the surgery is performed through laparoscopy, the majority of the patients stay in the hospital only one day and can return to the daily activities in 1 to 2 weeks. The benefits of this procedure are: Little post-operatory pain, total and final elimination of the symptoms and small risk of infection and other complications. Even though the surgical results are excellent, some patients may have complications, as in any surgical procedure. The complications include conversion to a conventional surgery (“open”), lesion of the viscera, anesthesia, etc.
After the anti-reflux surgery it is important for the patient to take some care. Since the esophagus is handles, the patients tend to have difficulty to swallow. The duration of the difficulty is variable, generally of a few weeks.For this reason, the patients are instructed to follow a liquid diet at the beginning. This diet progresses from liquid to pureed, then soft and so on.
- Liquid diet initially, and increasing of the consistency of the food in a slow and progressive manner.
- Meet and dry and solid foods must be ingested only some weeks/months after the surgery
- Fizzy drinks must be avoided
- Avoid lifting weight
It is normal that for the patients to feel a little bloated after the surgery, caused by the decreasing of the gastric capacity. Generally, this is temporary. If you have reflux, it is important to talk to a skilled professional to have access to comprehensive and precise instructions. The objective must be to customize the treatment according to your case.