Extinguish the “fire” of serious heartburn
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Transcript of Extinguish the “fire” of serious heartburn
Extinguish the Fire of Serious HeartburnEric M High MD – General Surgery Department
2www.SpringfieldClinic.comwww.SpringfieldClinic.com
Overview• Define reflux
• Symptoms of reflux
• How do we diagnose reflux
• Treatment options
• What can I offer?
What is reflux?• backup of stomach contents
into esophagus
• normal component-occurs after meals and is typically short lived and doesn’t occur at night and causes minimal if any symptoms
What is reflux?• abnormal component-occurs
outside meals, during sleep, affects everyday life
What Would “Reflux” feel like
• Burning sensation beneath sternum and/or upper abdomen– “heartburn”
• regurgitation-gastric contents may come up into mouth during burping or hiccups or spontaneously
Other lesser known symptoms
•chest pains
•“lump in their throat”
•nausea
•persistent cough
•hoarse voice/raspy voice
A+B=C• Differential
– cardiac• heart attack
– esophageal dysfunction– gallbladder
• stones, sludge, low EF– stomach
• gastritis, ulcer, gastroparesis, tumors, infections– pancreas
• pancreatitis, tumor
What should I tell my doctor?
• pay attention if some/all of the above symptoms present
• if symptoms are worsening• discuss with your primary doctor
Diagnosis
• UGI– chalky material that patient drinks, then multiple
images are taken to see if contents “reflux”– can see hernias with this method sometimes
• Esophagram– similar to above except only looks at esophagus– can see masses, narrowing
Diagnosis
• Endoscopy– allows biospy– hernia– ulcers
Diagnosis
• other tests– manometry
• probe in esophagus to see pressures
– pH monitoring• probe inserted in esophagus to measure how
often reflux occurring• more often during evening, laying down, etc.• not used very often
Treatment
• Medical – lifestyle modifications
• weight loss• smoking cessation• avoid late night eating
– eating smaller meals
• avoid caffeine, chocolates, alcohol• sleeping positions
Treatment
• Medical– medications
• H2 blockers vs PPI– prilosec, protonix, etc.
– review meds to see if they could be causing any of the symptoms
Treatment
• Medical– Infection
• H. Pylori– 10-14 day course of antibiotics and medications to
eliminate the bacteria– need check after treatment to ensure bacteria gone
» urease test
Complications
• untreated reflux can lead to severe complications – strictures
• inability to swallow that may need repetitive dilatations
– cancer• leading cause for converting normal mucosa to
cancer
Treatment
• Surgical– hiatal hernia can lead to increased
incidence of reflux and need repaired surgically
– inability to adhere or tolerate medical therapies
– symptoms are not improving on medicine or needing increasing dosage
Treatment
• Complete picture from endoscopy, UGI, length of symptoms, and medical treatments
• May need surgery to fix/help with symptoms
Hiatal Hernia
Type I
Surgery: Nissen Fundoplication
Type II
Surgery: Paraesophageal Hernia Repair w/Nissen
Type III
Surgery: Paraesophageal Hernia Repair w/Nissen
Type IV
Surgery: Paraesophageal Hernia Repair w/Nissen
• Sliding hernia (Type I)• GE junction above diaphragm• Causes Acid Reflux Disease (GERD)• No true hernia sac• Nissen Fundoplication is performed
Normal Anatomy
Paraesophageal hernia (Type II)•Stomach fundus into chest•Fixed GE Junction
Paraesophageal hernia (Type III)•Stomach fundus into chest•GE Junction above diaphragm
Paraesophageal hernia (Type IV)•Stomach, GE Junction, and other organs above diaphragm
Primary Closure Straight suturingSmall herniasMost common
Mesh Closure Synthetic or Biologic MeshFor Large hernias (>5cm)Costly (biologic even more)Sutures or Tacks (cost)
Surgical Options
• “Wrap”– upper portion of stomach is wrapped
completely around end of esophagus– “Nissen”
Surgical options
• Partial wraps– Dor
• anterior wrap
– Toupet• posterior
• CT Surgery options– Belsey– used if multiple upper abdominal surgeries
or if very large hiatal hernia
Surgical Options
• Open– large midline incision, longer recovery
• now mainly used as choice if recurrent or multiple previous surgeries
• Laparoscopic – 4-6 incisions– carbon dioxide for inflating and giving room
to work– most often done now
Surgical options
• Robotically– similar to laparascopic surgery– 3-4 incisions– carbon dioxide for inflating
•3-Dimensional Anatomy•Protect Vagus Nerve, Aorta
Advanced Sealing / Dissection*•Wristed Vessel Sealer•Avoid gastric or esophageal perforation
Advanced Suturing Capability•Fundoplication can come undone•Assessment of wrap tightness
Learning Curve•In preparation for complex paraesophageal hernia or redo Nissens
Visualization
Primary Closure Straight suturingSmall herniasMost common
Mesh Closure Synthetic or Biologic MeshFor Large hernias (>5cm)Costly (biologic even more)Sutures or Tacks (cost)
Final thoughts
• reflux is very common • most patients are managed very well
with medications and lifestyle changes– obesity– smoking
• if symptoms are not improving– may need EGD to check anatomy– may need surgery to address problem
What can I offer?
• Board certified General Surgeon– advanced laparoscopic training – robotic trained
• Endoscopy trained
More Resources
Find videos, handouts and more resources at
www.SpringfieldClinic.com/DoctorIsIn