Gastroesophageal Reflux (GERD)

Gastroesophageal reflux disease (GERD) is defined as the reflux of acid-rich stomach contents into the esophagus, burning the inner layer of the esophagus and causing symptoms that are sufficient to interfere with quality of life. GERD is one of the most common causes for primary care physician visits and a leading cause of noncardiac chest pain. Symptoms of GERD include heartburn, a burning sensation felt in the chest, foul-smelling breath, and cough. Other symptoms include wheezing, hoarseness, and recurrent respiratory infections. Complicated GERD may cause esophagitis, permanent scarring of the esophagus, and even precancerous transformation of the esophageal lining.

A competent lower esophageal sphincter (LES) is needed to prevent GERD. The length of intra-abdominal esophagus, the strength of the circular muscle fibers at the LES, and the normal emptying function of the stomach dictate LES strength. Acid production is also an important factor in the symptoms of GERD.

Obesity is a strong independent risk factor for GERD, as 25 to 50 percent of the morbidly obese population will have GERD. Obesity is associated with GERD through several mechanisms. The increased intraabdominal pressure exerted by the abdomen promotes reflux. Fatty foods are also known to relax the LES, which, in combination with an increase in food volume, promotes reflux.

There are several effective treatment options for GERD, which range from lifestyle modification, medications, and surgical approaches. Lifestyle modifications include weight loss, decreasing nighttime eating, decreasing meal size, and avoiding foods that relax the LES. Medications include those that decrease acid production (H2-blockers and protein pump inhibitors) and those that increase the strength of the LES and improve the emptying of the stomach (prokinetics).

Surgical procedures are reserved for those whose symptoms are still severe despite other treatments. The standard surgical procedure in normal-weight and overweight individuals is called a Nissen fundoplication. However, in the morbidly obese, a gastric bypass or lap band may be more effective treatment. Both of these treat the underlying problem of elevated intra-abdominal pressure from too much intra-abdominal fat by allowing the patient to lose weight. If the morbidly obese patient has an incompetent LES or a hiatal hernia that are causing the reflux, then only a surgical approach will be effective. In these instances, a medical approach is contraindicated. Both procedures can be performed using minimally invasive surgical techniques.