Gastroesophageal Reflux Working with you as a partner in...

Gastroesophageal Reflux and Hiatal HerniaWorking with you as a

partner in health care, your gastroenterologist

at GI Associates will determine the best diagnostic and treatment measures for your unique needs.

©2010 GI Associates & Endoscopy Center. All rights reserved.

Fax 601/352-4882 • 800/880-1231www.msgastrodocs.com

Jackson1421 N. State Street, Ste 203

Jackson, MS 39202601/355-1234

Vicksburg1815 Mission 66

Vicksburg, MS 39180601/638-8801

Madison106 Highland Way

Madison, MS 39110601/355-1234

Albert F. Chiemprabha, M.D.Pierce D. Dotherow, M.D.

Reed B. Hogan, M.D.James H. Johnston, III, M.D.

Ronald P. Kotfila, M.D.Billy W. Long, M.D.Paul B. Milner, M.D.

Michelle A. Petro, M.D.Vonda Reeves-Darby, M.D.

Matt Runnels, M.D.James Q. Sones, II, M.D.

April Ulmer, M.D., Pediatric GIJames A. Underwood, Jr., M.D.

Chad Wigington, D.O.Mark E. Wilson, M.D.

Cindy Haden Wright, M.D.Keith Brown, M.D., Pathologist

Samuel Hensley, M.D., Pathologist

Table of Contents

1 GastroesophagealRefluxCauses

3 UnderlyingCauses

3 Symptoms

4 ComplicationsofReflux

4 Diagnosis

5 Treatment

8 HiatalHerniaSymptomTreatment

The information contained in this brochure is intended as an educational tool, not as a substitute for medical care when needed.

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Treating Symptoms

If you have symptoms from a hiatal hernia, the goal is to help you feel better. These suggestions may help:

Lose excess weight.Excessweightputspressureonthestomachandesophagus.

Avoid LES relaxers.SomethingsmayrelaxtheLESandcausereflux.Avoidcigarettes,alcohol,fattyfoods,chocolate,andcoffee.

Avoid anything that causes symptoms.Stayawayfromanyfoodordrinkthatgivesyouproblems.Manymedicationscancausesymptoms.Discussyourmedicationswithyourdoctor.

Try acid-reducing medications.Over-the-counterantacidsmayrelieveheartburn.Talktoyourdoctoraboutotherover-the-counterandprescriptionmedicationthatcanalsohelp.

Surgery is rarely needed.Surgeryisusuallyneededonlyforsevere,uncontrolledsymptoms.Thediaphragmmaybetightened.Or,thestomachmaybeplacedbackbelowthediaphragm.

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Gastroesophageal reflux,commonlycalledreflux,isback-upofgastricjuiceintotheesophagus.Itmightbethoughtofasa“reverseflow”oftheusualdigestiveprocess.Patientswithrefluxexperiencefeelingsofburningand/orpressureinthestomachorupperabdominalareaasaresultofregurgitationor“burping-up”ofsourstomachcontents.Theuncomfortablesensationcausedbyrefluxisoftencalledheartburn,becauseoftheburningsensationintheesophagus,andit’slocation–fairlyclosetotheheart.

What causes reflux?Theentiregastrointestinalsystemfunctionswiththehelpofperistalsis,continualmuscularcontractions,thathelpmovefooddownwardandthroughthevariouspartsoftheGItract.Thatmovementishelpedbyanumberofmus-cular,valve-likestructures(sphincters)thatcontrolthemovementofdigestiveliquidsandpartiallydigestedfood.Suchvalvesnotonlyopentoletdigestivecontentsthrough,butalsoclosetokeepdigestivecontentsfromgoingbackward.Withinthedigestivetract,extremelystrong acid(suchashydro-chloric acid)anddigestive enzymes(suchasbileandpepsin)arenecessarytobreakdownthefoodweeatintoaformthatcanbeusedtonourishbodycells.Themusclecontractionsandvalve-likeclosuresofthedigestivetractprovideanaturallyprotectiveactionbykeepingstrongdigestiveliquidsfromhurtingthetissuesthatlinetheGItract.Whenirritatingliquidsdonotmovealongastheyshould,damagecanoccur.Avalve-likestructureknownasthelower esophageal sphincterorLESislocatedtowardthelowerendoftheesophagus(thetubethroughwhichfoodpassesfromthemouthtothestomach).TheLESopenstoletfoodintothestomachandclosestokeepfoodandstomachacidfromgoingbackup.Anothervalve,locatedatthebottomoutletofthestomach,knownasthepyloric sphincter,

Gastroesophageal Reflux

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CUT-AWAY VIEW OF STOMACH & SPHINCTER

ESOPHAGUS

HIATAL HERNIA WITH LOOSE LOWER ESOPHAGEAL SPHINCTER (LES)

PYLORIC SPHINCTER

operatesinasimilarman-ner,lettingfoodintothesmall

intestineandthenclosingtokeepfoodandgastricjuicesfrom

movingbackwardintothestomach.

IftheLESfailstofunctionproperly,notonlyfood,butcausticacidfromthestomachmaycomebackupintotheesophagus,creatingaburningsensationandirritat-ingtheliningoftheesophagus.Similarly,ifthepyloricsphincteratthebottomofthestomachfailstooperateasitshould,potentdigestivejuices,suchasbileandpepsin,withpartiallydigestedfood,maymovebackward,upintothestomach.Itthenmayberegurgitatedupintotheesophagus,towardthethroat/mouth.

Refluxisafairlycommonoccurrence,withmanypeoplehavingexperienceditasaresultofover-eatingorotherirritationsoftheGItract.Others,however,mayexperiencerefluxasafrequentlyoccurringorchronicproblem.Chronicrefluxcancauseextremediscomfortandactualtissuedamagetotheesophagus,fromrepeatedexposuretoacidsecretions.

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Note: Some people need to completely avoid smoking, drinking and eating the foods/beverages mentioned. Others with a less severe prob-lem may be able to just cut down somewhat. Ask your doctor, if in doubt.

MedicationsYour GI doctor will prescribe antacids, pre-scription medications or both to help treat reflux.

AntacidsManyantacidmedicationsaresoldover-the-counter(canbeobtainedwithoutaprescription)atdrugstores,grocerystoresandnumerousotherlocations.Theseareveryeffectiveatneutralizingtheacidin

yourstomachandrelievingtheheartburnandindigestionthatoftenaccompanyreflux.Liquidsseemtoworkabitbetterthantablets.Theantacidshouldbetakenconsistently,atfrequentintervals,tobemosteffective.YourGIdoctorwillrecommendadosageschedule.Thefollowingareexamplesofantacidsthatyoumayuse:•Alternagel•Amphogel•Basojel•Digel•Gaviscon•Gelusil•Maalox•Mylanta•Riopan•Rolaids•TumsWarning: Some antacids can cause loose stools when used in great quantities, while others may cause constipation. Inaddition,someantacidsaresafeforseverely-restricteddiets,whileothersarenot.Eachantacidhasit’sownpros,cons,andsideeffects.ContactyourGIdoctorifyouexperienceproblemsorneedtodiscussyourchoiceofantacid.Other MedicationsInadditiontoantacids,yourphysicianmayprescribeanumberofothermedicationstorelieveyourrefluxproblem.Besuretotakethemasprescribedandreporttoyourphysicianorpharmacistanydifficultiesorsideeffects.Inseverecases,whereothermeasureshavefailed,asalastresort,surgerymayberecommended(iftheunderlyingcausecanbesurgicallycorrected).

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YourGIphysicianwillgiveyoudietaryguidelinesthatwillhelpyouloseweight.

6. Don’t bend or stoop forward after eating,sinceitmayhelpforcestomachcontentsupward.

7.Avoid tight, restrictive clothing.Donotwearanythingthatfitstightlyaroundyourwaistorstomach.Loosecomfortableclothingwillhelpminimizeyourrefluxproblem.

8. Avoid some foods.Somefoodswillaggravatereflux.Trytoavoidthefollowing:

Alcohol:Stoporcutbackasmuchaspossible Coffee:Onlyinmoderation(includingregularaswellas

decaffeinatedandSanka)

Also avoid these:•fatty,greasy,andfriedfoods•chocolate•citrusdrinks(orangeandgrapefruit)•tomatoproducts•spearmintorpeppermintAvoidanyotherfoodthatseemstoaggravateyourproblem.Avoid any substance or medica-tion that might irritate the esopha-gus, such as aspirin. If in doubt about any usual medications, ask for your GI doctor’s advice.

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What are the underlying causes of reflux?

Severalfactorsmayberesponsiblefortheunderlyingcausesofreflux:Failure of the valve-like sphincters to open or close effectivelymaybecausedbystructuralabnormalitiessuchashiatalherniaoranabnormalgrowth.Hiatal herniaisthepushingupofthestomachintothechestcavitythroughaholeinthediaphragm.ThepresenceofahiatalherniamayhindertheactionoftheLES.Almostallpersonswhohavehiatalherniaswillexperiencesomedegreeofgastroesophagealreflux,thusitistheleadingcauseofreflux.Iftheesophagealhiatusistoowide,partofthestomachmaybulgeabovethediaphragm.Thisbulgeiscalledahernia.IftheLESisnottight,stomachacidmaymoveupintotheesophagus(reflux).Irritation: IrritationofGItissuesfromanycause(suchasexcessacidsecretion)maybeanunderlyingcauseofreflux.Abnormalities of the GI tract:SomeabnormalitiesoftheGItractsuchasstrictures(narrowedpassages)cancausereflux,ascanabnormalgrowthsortumors.Another underlying cause of reflux is poor peristalsis (thewave-likemuscularcontractionsintheGItract).Poorperistalsismaybeduetoillness,certainmedicationsorothercauses.

The symptoms of refluxPatientswithrefluxexperiencefeelingsofburningand/orpressureinthestomachorupperabdominalareaandalsomaynoticeregurgitation(orburping-up)ofsourstomachcontents.Burningpainmayoccurbetween20and30minutesaftereating,especiallyafteraheavyorparticularlyspicymeal.Sometimesnauseaandregurgitationofstomachcontentsintothethroatandmouthwilloccur(withoutvomiting).Thatmayoftenbefollowedbyfoul-smellingbreath.Painfromrefluxmaybeaggravatedbybendingoverorlyingdown.Inextremecases,refluxmayinterferewithswallowing.Thatconditionisknownasdysphagia.

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Complications of reflux

Refluxcaninterferewithone’senjoymentofeatingandcancauseconsiderablefrustrationandanxietyamongthosewhoexperiencetheproblem.Inadditiontothoselife-stylethreats,moreseriouscomplicationscanalsooccur.Esophagitis,aninflamed,irritatedesophagus,mayoccurwithreflux.Itissometimessevereenoughtocauseulcerationandbleedingoftheesophagus.Esophagitisisanactualinjurytothetissueoftheesophagusresultingfromrepeatedexposuretopotentdigestivesecretions,suchas hydrochloric acid,pepsin andbile.Withchronicreflux,scarringmayoccurintheesophagus.Whenthisoccurs,astricturemayformwhichinterfereswiththepassageoffood.Theresultingproblemwithswallowingisreferredtoasdysphagia.ProfessionalsfeelthattheremaybealinkbetweenrefluxandthedevelopmentofaconditionknownasBarrett’s esophagus(especiallyamongthosepatientswhohaverefluxnotcausedbyhiatalhernia).Barrett’sesophagusisaconditionthatisoftenaprecursor(beginningstage)ofaformofesophagealcancer.Barrett’sesophagusisthoughttooccurasaresultofthechronicirritationofreflux,althoughmuchisstillnotknownabouttheconnectionbetweenthetwoproblems.Toavoidboththeevery-daydiscomfortsofrefluxandthemore

seriouscomplications,itisessentialthatyourGIphysiciandiagnose

andtreattheunderlyingcause ofreflux.DiagnosisAdetailedhistorycanhelpyourGIphysiciandiagnosethecauseofreflux.Yourthoroughexplanationofyoursymptomsisanimportantpartofthatprocess.YourGIphysicianmayrecommendthatyouhaveanendoscopic examinationtodeterminetheunderlyingcauseofreflux.

Thatinvolvestheinsertionofalightedtubeintotheesophagus,soyourphysiciancanactuallyseetheinsideoftheesophagus,lookforthecauseoftheproblemanddeterminetheextentofdamage,ifany.YourGIphysicianmayalsoorderanupperGIX-raytohelpdis-coverthesourceoftheproblem.

What is the usual treatment for reflux?Oncerefluxisdiagnosed,ananti-reflux programcanbestarted.Somepatientshavetomaintainastrictprogramtorelievesymptoms,whileotherswithlessseveresymptoms,maynothavetoaltertheirusualroutineverymuch.Treatmentofesophagealrefluxconsistsoftwomajorcomponents,lifestyle changesandmedication.

Lifestyle Changes:1. Don’t smoke!Ifyoucan’tstopcompletely,cutdown.

Cigarettes(andothertypesoftobaccoproducts)causeincreasedacidsecretionthatcanaggravaterefluxandcontributetoulcerformation.Inaddition,ithasbeenproventhatpatientswhousetobaccoproductshaveamoredifficulttimehealingfromaGIproblemsuchasesophagitisoranulcer.Also,thosepatientswhosmokearemorelikelytohavesuchproblemsrecur.

2. Avoid large meals.Trytoeatsmaller,morefrequentmeals.Also,avoideatingfast.

3. Don’t lie down immediately after eating.Waitatleast3hoursaftermealsbeforegoingtobed.

4.Elevate the head of your bed.Elevatingtheheadofyourbedfourinchesormore(dependingonyourdoctor’srecom–mendation)willhelpkeepacidandstomachcontentsinyourstomachinsteadofbackingupintoyouresophagus.Woodenblocksorbooksareoftenusedforthispurpose.Ifthatisnotpossible,askyourdoctorforsuggestions.

5. Avoid excess weight.Ifyouareoverweight,trytoshedpounds.Beingoverweightcontributestotheproblem.

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