This chronic digestive disease occurs when stomach acid (produced for the breakdown of food) flows backwards from the stomach and up into the esophagus or food pipe (this reverse action is called reflux). Over time, the exposure to acid irritates the lining of the esophagus, causing the symptoms of gastroesophageal reflux disease, or GERD.
It’s important to distinguish GERD from occasional and normal heartburn. Many people experience the painful feeling of heartburn from time to time, usually after eating. However, if you experience acid reflux and heartburn twice a week or more, and these symptoms are interfering with your daily life, this maybe a sign of GERD.
GERD develops due to an abnormal relaxing or weakening of your sphincter valve, the band of muscle encircling the bottom part of your esophagus. Normally, your sphincter relaxes to allow food and liquid to flow into your stomach, then closes again. But if it doesn’t form a tight seal between your esophagus and stomach, stomach acid flows back up into the esophagus. Continuous exposure to strong acid can inflame the esophagus. Over time, this inflammation can wear away the esophagus, causing bleeding or even breathing problems.
When GERD becomes chronic, it can lead to additional and potentially serious complications such as Barrett’s esophagus or esophageal stricture. Additionally, an underlying condition such as hiatal hernia can also cause reflux and if left untreated may result in GERD.
Because these three conditions are linked to GERD, we group them here.
Barrett’s Esophagus About the esophagus
This muscular tube connects the throat and the stomach. Food and fluids are pushed through the esophagus partly by gravity and also by waves of rhythmic muscular contractions, called peristalsis. At the bottom end of the esophagus are ring-shaped muscles that open and close, preventing the contents of the stomach from flowing backwards into the esophagus and from there, into the throat.What is Barrett’s esophagus?
Chronic (over 10 years) gastroesophageal reflux disease (GERD) can damage the cells of the lower esophagus by repeatedly exposing them to irritating stomach acid splashing upwards from the stomach. Repeated exposure to reflux changes the normal tissue lining the esophagus, resulting in a condition known as Barrett’s esophagus. Though only a small percentage of those with GERD will develop Barrett’s esophagus, a diagnosis of Barrett’s esophagus slightly increases the risk of developing esophageal cancer. For this reason, proper monitoring involves periodic exams to check for precancerous and cancerous cells.What are the symptoms of Barrett’s esophagus?
Symptoms are usually those of acid reflux and can include:
- Frequent heartburn for more than 10 years
- Difficulty swallowing food
- Chest pain
- Upper abdominal pain
- Dry cough
Your doctor uses a procedure called upper endoscopy, which involves passing a lighted tube called an endoscope down your throat. The tube carries a tiny camera that lets the doctor examine your esophagus for signs that the tissue of its lining is changing in appearance. Rather than having pale, glossy tissue, a person with Barrett’s esophagus has red, velvety-looking tissue. In this case, your doctor may remove a few small tissue samples (biopsy). The tissue samples are tested to determine the extent of changes and how far along they are.What are my treatment options?
A majority of patients will require regular monitoring of the esophagus for cell changes, and biopsies may be performed to check for precancerous and cancerous cells.
Surgical intervention such as an esophagectomy may be recommended depending on the degree of tissue change or if cancer is present. Esophagectomy is the surgical removal of all or part of the esophagus. The surgeons at the Thoracic Surgery Division are generally able to utilize minimally invasive techniques to perform esophagectomy, avoiding large abdominal or chest incisions. Our outcomes for esophagectomy are one of the best in the country according to the Society of Thoracic Surgeons (STS) database.
Esophageal Stricture What is esophageal stricture?
Gastroesophageal reflux disease (GERD) can cause a gradual narrowing (or stricture) of the esophagus, which leads to swallowing problems. This happens in the following way:
If you have GERD, strong digestive acids are flowing backwards from your stomach up into your esophagus, causing inflammation in the lower part of the esophagus, where it connects to your stomach. This chronic inflammatory injury causes scarring as it heals. Eventually, this scarring produces damaged tissue that forms a ring that narrows the area where the esophagus opens into the stomach. When you swallow, food no longer passes smoothly down the full length of the esophagus.What are the symptoms of esophageal stricture?
- Difficulty swallowing; pain or discomfort with swallowing
- A feeling that food gets stuck in the esophagus
- Regurgitation of food (food comes back from the stomach into the mouth)
- Unintentional weight loss
- Barium swallow test (also called, barium X-ray): After you swallow a white fluid containing barium, which improves X-ray contrast, your doctor will administer a regular X-ray which will show whether your esophagus is narrowed.
- Endoscopy: The doctor passes a narrow, flexible tube with a light and tiny camera through your mouth and into your esophagus in order to view its inner lining.
MINIMALLY INVASIVE TECHNIQUES
Once sedated, the surgeon passes several tubes of different diameters through the esophagus to stretch the narrowed part (stricture). Another approach is to pass a lighted flexible tube (endoscope), which contains deflated balloon through the mouth into the esophagus. The balloon is inflated to stretch and enlarge the narrowed area.
Extendable polyester silicone-covered stent
A tiny tube called a stent is permanently placed at the site of the narrowing, propping it open.
Nissen total or Belsey partial fundoplication
Fundoplication involves wrapping the top of the stomach (the fundus) around the lower end of the esophagus where the two meet, then stitching the stomach in place. This helps the “gateway” muscle between your esophagus and stomach close tightly and fully, keeping stomach acids out of the esophagus. Nissen and Belsey surgical approaches differ in how much–and where–the lower esophagus is wrapped by the stomach.
Esophageal lengthening with antireflux surgery
Esophageal resection (esophagectomy) and reconstruction
The narrowed section of your esophagus is removed and replaced with a section of intestine.
Hiatal Hernias What is a hiatal hernia?
A hernia occurs when layers of the abdominal muscle become weak or torn. The pressure from the inside the abdomen pushes the lining of the abdominal wall out through this area of weakness, creating a bulge. A hiatal hernia occurs when the upper part of the stomach bulges into the chest cavity through an opening or weakness in the diaphragm, the muscular wall that normally separates the chest from the stomach.
Under normal circumstances, the esophagus (food pipe) leads to the stomach through a small opening (a hiatus) in the diaphragm. The groundwork is laid for a hiatal hernia when this opening is too large or the muscles around the opening grow weak. This muscular weakness or enlarged opening lets a piece of the stomach squeeze through.
Whether because of a too-large opening or weak sphincter muscles where the stomach and esophagus meet, the main symptom of a hiatal hernia is reflux of the contents of the stomach into the esophagus. This can lead to chronic heartburn, which in turn, is a common cause of gastroesophageal reflux disease (GERD). That is why treating hiatal hernia can reduce and often eliminate the symptoms of GERD.
There are two main types of hiatal hernia:
Diaphragmatic hernia, also called sliding hernia
This most common type occurs when part of the stomach bulges above the diaphragm, the wall of muscle that normally keeps the stomach in place. As a result, the connection between the esophagus and stomach is now located above the diaphragm, together with a piece of the stomach. Both the connection and part of the stomach have now slid up into the chest.
In this case, part of the stomach protrudes through the hole that allows the esophagus to pass through the diaphragm. As a result, the hernia lies next to the esophagus. This type of hernia tends to get larger over time and can pull up other abdominal organs into the chest.
The main symptom of either type of hiatal hernia is reflux. Besides the burning sensation of heartburn and possibly difficulty swallowing, larger hiatal hernias—particularly the paraesophageal type–can result in a medical emergency in which the stomach's blood supply is cut off.What are the risk factors for hiatal hernia?
Hiatal hernia is most common in people who are obese and/or over 50. In addition, pressure on the stomach from excess weight may contribute to the formation of a hiatal hernia.How is hiatal hernia diagnosed?
Because the hernia is protruding into the chest rather than the abdominal wall, there is no telltale bulge. Therefore, a diagnosis requires one of the following tests:
Upper body GI endoscopy: Inserting a long thin tube equipped with a light and tiny camera (an endoscope) through the mouth into the chest, the doctor is able to examine the structures inside the chest cavity.
Barium swallow study (also referred to as a barium X-ray): Patients drink a solution that coats the walls of the esophagus and stomach to provide contrast during an X-ray.
CT scan: Special X-ray equipment produces multiple images of the chest and abdomen, which are joined together by a sophisticated computer into multidimensional views of these areas.
MRI: This imaging technique lets doctors see the interior of the abdomen and chest in detail.
MINIMALLY INVASIVE TECHNIQUE
Laparoscopic paraesophageal hernia repair
Surgery is aimed at reducing the hernial sac, with closure of the abnormally wide esophageal hiatus. Through small incisions in the abdomen, the surgeon inserts special tools and a long metal tube tipped with a tiny video camera (called a laparoscope). Guided by video images taken by the camera, the surgeon pulls the stomach back down to its proper place, stitching it to the abdomen, while also making the hole in the diaphragm smaller.
Laparoscopic Nissen fundoplication may also be performed at the same time to treat gastroesophageal reflux disease (GERD), which often accompanies a hiatal hernia.
To make an appointment with a thoracic surgeon at Mount Sinai Beth Israel contact them individually. You can also click here to fill out an appointment scheduling form. A staff member will get back to you within 48 hours to schedule an appointment. You can also email your questions to BIThoracicSurgery@chpnet.org