Gastrointestinal esophageal reflux can remain troubling despite the best medical treatment. Symptoms can persist despite more conservative measures such as diet, weight loss and medication. If the persistent heartburn is severe and disabling, or if you have developed Barrett’s esophagus, you may be a candidate for surgery to increase the strength of the LES, also called a fundoplication. (Laparoscopy Repair)

Problems Associated With GE Reflux
GE Reflux (Severe Heartburn)
Heartburn, a burning sensation or feeling of fullness in the middle of the chest, usually occurs within an hour after eating, and is often brought on by certain types of food. About 36 percent of all Americans suffer heartburn at least once a month, and about 7 percent experience it daily. For some people heartburn is so severe that it becomes incapacitating. Most heartburn sufferers feel it right underneath the breastbone, but occasionally a "referred" burning is felt in the back between the shoulder blades or in the jaw and teeth. Why are some people bothered by heartburn while others are not? Chronic heartburn is a symptom of a disorder called gastroesophageal reflux.. The cause of the disorder is a small one-way valve, called the lower esophageal sphincter (LES), located between the esophagus and the stomach. When functioning properly, the LES allows food and water to pass into the stomach, but prevents backward flow. If the LES is loose or weak, ferocious stomach acids can back up into the esophagus, causing a powerful burning sensation as the acid comes in contact with the sensitive lining of the esophagus.

Hiatal Hernia
The esophagus passes through an opening in the diaphragm, or muscular wall dividing the chest cavity from the abdominal cavity, called the hiatus. When this opening becomes weakened and stretched, allowing a portion of the stomach to bulge through into the chest cavity, the condition is referred to as a hiatal hernia. This is actually a very common anomaly and often does not cause any discomfort or unusual symptoms. The mere presence of a hiatal hernia does not mean that surgery should be performed. In some people a hiatal hernia can contribute to a weak LES, which permits backflow of stomach acid into the esophagus, making symptoms of heartburn worse. For that reason, all of the treatments advised to relieve heartburn can also be applied when hiatal hernia produces symptoms. (Laparoscopy Repair)

Barrett's Esophagus
When heartburn is untreated over a long period of time, acid reflux from the stomach can cause the lining of the esophagus to change, from the usual skin-like (squamous) cells to cells reminiscent of those in the stomach or intestinal lining. This is called Barrett's esophagus and can also make heartburn worse. The changed lining can secrete acid directly into the esophagus, which will frequently develop an ulcer. The risk of cancer of the esophagus is increased in people who have Barrett's esophagus. For that reason, they require regular check-ups by their physicians, and some gastroenterologists recommend screening once a year by endoscopy. Treating Barrett's esophagus with medical or even surgical intervention will not usually reverse the changes in the lining of the esophagus, but surgery can delay or prevent worsening of the condition. Once Barrett’s is diagnosed, it is important to participate in a surveillance program designed to detect abnormal esophageal lining cells before cancer develops. The best treatment for Barrett's is to prevent its development by treating even mild heartburn.

Causes of Reflux
Certain foods are known to weaken or "relax" the valve, making reflux more likely. A weak LES over time is enough to cause chronic heartburn. Sometimes the condition is complicated by a hiatal hernia, an oversized opening in the diaphragm that allows the stomach to protrude into the chest cavity, making reflux of acid easier. There is only a loose connection between hiatal hernia and heartburn, however. Many people with hiatal hernia have no symptoms from it.

Excessive pressure on the abdomen can also make it easier for the stomach acids to flow back into the esophagus. As a rule, anything that increases the pressure on the abdomen-obesity, straining, or tight-fitting garments-can promote backflow of stomach contents to the esophagus. For this reason, heartburn is especially common during pregnancy. And some people experience heartburn only when their weight passes a particular limit.

Certain drugs may also contribute to heartburn by relaxing the LES or stimulating acid secretion by the stomach (TABLE 1). For most sufferers of heartburn the burning sensation is the only problem. For a few people, however, heartburn leads to serious complications. Repeated exposure to acid can inflame the lining of the esophagus, making it so sensitive that sometimes swallowing is painful. The irritated lining may start to bleed, or an ulcer may develop in the esophagus. Bleeding may cause the person to vomit fresh bright red blood or old "coffee-ground" blood. Sometimes the bleeding goes unnoticed until the individual passes black, tarry bowel movements, indicating the presence of blood. Or blood may show up when a physician tests the stool.

Or blood may show up when a physician tests the stool.

Continuous inflammation over a long period of time may cause scar tissue to build up in the esophagus, narrowing the opening. Such a stricture makes it difficult to swallow solid food, and the esophagus will have to be dilated by a special non-surgical procedure. Strictures are sometimes malignant, particularly for smokers and heavy alcohol users. So, even if you think you can live with the discomfort of daily heartburn, it's important for your future health to try to bring symptoms under control. Fortunately, reflux esophagitis is rarely associated with cancer of the esophagus. Smoking and alcohol can help cause cancer of the esophagus.

Diagnosis
There is no relationship between reflux esophagitis and heart disease, although sometimes the symptoms seem similar. Because part of the esophagus is located just behind the heart, heartburn can be confused with angina, chest pain caused by inadequate blood flow to the heart. There are certain distinct differences in symptoms, however. Heartburn is made worse by lying down and by eating fatty foods and chocolate; on the other hand, it is made better by antacids. None of these things is true for angina. Angina is usually brought on by exercise and is not helped by antacids. Even so, it is not always easy to distinguish between the two problems, and anyone experiencing chest pains should see a physician for correct diagnosis. These symptoms are usually enough to diagnose heartburn. However, many doctors will want the suspected diagnosis confirmed by an upper GI series (barium swallow). A hiatal hernia can also be seen on this type of x-ray. A barium swallow is always ordered when an individual has difficulty or pain in swallowing. To distinguish heartburn from angina, a Bernstein test is given. A pH probe and EKG may also be used.

Treatment
Heartburn responds well to dietary guidelines. Nutrition, along with some valuable changes in lifestyle, is the best treatment for heartburn. The program helps neutralize stomach acids. It is also naturally low in fat, a major culprit behind heartburn. High-fat foods are retained in the stomach longer and also tend to relax the LES valve between the esophagus and the stomach, which makes it easier for acid to backup. If you have a sudden attack of heartburn, sit up or stand up. Loosen restrictive clothing such as a belt or waistband. Take a dose of a liquid antacid such as Mylanta, Maalox, or Riopan. You can start with two tablespoons and go up to six tablespoons, if needed. Don't smoke or drink alcohol or coffee.

People who suffer from frequent heartburn can also make the following lifestyle changes to ease the discomfort.

• Meals. The idea is to avoid the foods that relax the LES valve and that increase stomach acid. The big culprits are fat, alcohol, and chocolate. Avoiding lying down for at least three hours after meals, and avoid eating for several hours before bedtime.
• Sleeping Habits. Many people who suffer from heartburn sleep with a pile of pillows under their head to keep stomach acid from backing up. Sleeping on pillows is not very effective because only your head and neck are elevated while your chest and torso remain flat. Sleeping on extra pillows can also cause your body to jackknife, actually increasing pressure on the abdomen and making reflux worse. Heartburn can be vastly relieved if you ca permanently elevate the head of your bed on 6-inch blocks. Elevating the head of the bed means that your body is in a comfortable position and your whole torso is raised; to back up into the esophagus, stomach acids would have to flow uphill.
• Clothing. Avoid wearing tight clothing.
• Weight. If you are overweight, especially if the excess weight is around your waist, lose some weight. You may first need to cut calories and increase exercise to establish your ideal
• Medication. A lot of heart medications such as calcium channel blockers, nitrates, and beta-blockers decrease LES pressure and aggravate heartburn. If you take OTC, or prescription medications for any medical problems, check with your, physician' to make sure they are not making your heartburn worse by inadvertently causing the LES valve to relax.
• Antacids. You can further neutralize the acid in your stomach by taking a dose of liquid antacid one hour after meals, the time that most acid is being released into the stomach. Add a bedtime dose because that is when acid is most likely to make its way backward into the esophagus. In addition, you can take a dose of antacid any time you experience heartburn

Medication
The measures mentioned above are all things you can do yourself to relieve the daily discomfort of heartburn. If you still experience heartburn after following the above recommendations, see your physician. Several prescription medications are available to relieve severe heartburn by blocking acid secretion from the stomach (Tagamet, Zantac, Pepcid, or Axid). These so-called H2-receptor antagonist drugs reduce heartburn by healing the esophagus. Many doctors use this class of drug as a first-line treatment for heartburn because of its overall safety and effectiveness. Occasionally the recommended dosage of these drugs-e.g., Zantac 150 milligrams twice a day-has to be doubled, or even tripled, in order to effectively relieve symptoms. Metoclopramide (trade name Reglan) is another class of drug that helps prevent acid reflux by strengthening the LES valve. It also encourages acid to empty downward into the duodenum. Reglan is often used in combination with antacids or one of the H,-receptor antagonists. However, many people who use this drug suffer side effects such as lethargy, depression, and abnormal muscle reactions, which limit its use. A new class of drugs called proton pump inhibitors such as omeprazole are approved by the FDA for reflux can be used when other measures fail to control symptoms.

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