One in five people experience reflux at least once a week, triggering 2.2 million visits to ambulatory care centers per year. Primary care physicians often hear the typical symptoms of reflux, such as heartburn and regurgitation. What physicians may not be aware of, according to Anish A. Sheth, MD, is that many patients with GERD have atypical symptoms.
“A number of treatments are available for GERD, but first we have to recognize the disease. Although heartburn is the most familiar complaint, patients with GERD can have less obvious symptoms such as sore throat, chronic cough, voice changes, globus or cardiac-like symptoms,” Dr. Sheth explains.“Certain ‘red-flag’ symptoms warrant immediate referral to a gastroenterologist, including trouble swallowing, weight loss, loss of appetite or anemia. I also recommend that physicians refer patients with longstanding GERD for a screening endoscopy to test for Barrett’s esophagus, as well as to refer patients for whom proton pump inhibitors (PPIs) are not effective and any patients who have required long-term use of PPIs. Gastroenterologists can help these patients – usually without surgery.”
Issues With Long-term PPIs
Patients are moving away from long-term use of PPIs for two reasons, according to Dr. Sheth: clinical disadvantages identified by physicians and patients’ own desire to make a change.
“In the last 5 years, patients have heard a variety of claims about the long-term risks of PPIs. The worrying negative impact of PPIs on bone health and osteoporosis risk have been clinically verified, but other concerns have not.”
Dr. Sheth further explains that although PPIs are largely safe and effective where osteoporosis is not a concern, they are not a panacea for GERD. However, physicians often prescribe PPIs for many esophageal symptoms. Patients who have required long-term use of PPIs need to see a gastroenterologist to be screened for esophageal problems, including Barrett’s esophagus, which can lead to esophageal cancer if it is not identified. A gastroenterologist can offer other treatments to move patients away from chronic PPI use.
Advanced Testing for GERD
Gastroenterologists have several tests at their disposal to help them characterize reflux. Dr. Sheth is a proponent of early testing in patients who are not helped by medication. He begins with endoscopy to evaluate any esophageal damage and moves on to esophageal pH monitoring, an objective way to learn about acid in the esophagus: how much enters, when it enters, and how long it remains.
“pH monitoring enables us to correlate the patient’s symptoms with an actual reflux event in the outpatient setting. Patients push a button when they have heartburn, and we learn what is happening in their esophagus during the episode,” says Dr. Sheth.“This detailed information informs treatment choices. If pH monitoring confirms that the patient’s symptoms correlate with reflux, then the problem is a malfunction of the lower esophageal sphincter, not simply excess acid. Therapy needs to focus on that malfunction. Basically, PPIs only reduce the amount of acid in the reflux – but they don’t prevent the reflux events,” he added.
In the past, treatment for GERD was either PPIs or surgery. Now physicians have more options. Referral to a gastroenterologist usually does not mean surgery; GERD may instead be treated with a minimally invasive, low-risk outpatient procedure.
Dr. Sheth recommends laparoscopic Nissen fundoplication for patients with severe reflux and a large hiatal hernia for whom less invasive procedures are not an option. “Surgery helps some patients but can have long-term effects like gas, bloat and dysphagia. Research shows that 10 years after surgery, two thirds of patients are using reflux medications again. At that point, the patient may need additional surgery. For most patients, including those whose hernia is less than 2 cm, a less invasive option is preferable.”
Dr. Sheth performs a low-risk, non-surgical procedure called Stretta Therapy to relieve reflux and reduce long-term PPI use without surgery. Administered endoscopically under conscious sedation, Stretta Therapy uses a transoral catheter device to treat with low-heat radiofrequency energy at multiple levels above and below the lower esophageal sphincter muscle. The treatment strengthens and thickens the muscle to improve the barrier between the stomach and esophagus to prevent reflux. The outpatient procedure takes about 40 minutes for Dr. Sheth, and patients can resume normal eating in a few days. The full effect takes three to six months. Patients continue PPIs for this period, and then are weaned off the medications as their symptoms improve.
“Stretta is a non-invasive option that is appropriate for many patients. The shared characteristic is that all Stretta candidates show objective reflux on pH monitoring,” Dr. Sheth explains. “We don’t have as many years of data as we do for surgery, but Stretta’s effect has been shown to last 4 to 10 years, and has a much lower complication rate than surgery. It significantly reduces acid exposure in the esophagus and allows healing of erosive esophagitis. Patients experience long-term relief without medications because Stretta addresses the mechanical cause of GERD – something that was not possible without surgery in the past.”