It is possible to get rid of reflux !

What is Reflux?

The escape of stomach contents backwards upwards into the esophagus is called reflux . When discomfort occurs in the esophagus and higher pharynx due to reflux, it is called reflux disease . Even if the stomach contents are acidic or alkaline, when there is reflux, that is, back-escape, it will cause structural and sensory discomfort by causing chemical irritation to the esophagus and pharynx. It is possible to get rid of this disease with endoscopic reflux treatment.

reflü nedir

Endoscopic Reflux Treatment

There are two methods by which Reflux Disease can be treated with endoscopic methods;

  • ARMA (Anti Reflux Mucosal Ablation)
  • ARBL (Anti Reflux Band Ligation)

ARMA What?

ARMA (Anti Reflux Mukazal Ablation), which is an endoscopic reflux treatment, is performed between 20-30 minutes by putting it to sleep . There is no hospitalization after the procedure. We discharge our patients 1 hour after the procedure. With the ARMA procedure, our patients get rid of reflux disorders that have been going on for many years.

ARBL What?

The conditions in which reflux treatment ARBL should be performed are as follows;

  • People who continue to have reflux complaints despite lifestyle changes and medication
  • People who want to avoid the side effects of long-term drug treatment
  • People who cannot tolerate reflux surgical treatment due to comorbidities
  • People who have had sleeve gastrectomy or various stomach operations before

Normally, muscles are present at the lower end of the esophagus. These muscles relax during the entry of swallowed food into the stomach. After the swallowing process is over, they close and tighten. These circular muscles are called the Lower Esophageal sphincter (LES ). Everyone also relaxes from time to time during the day. However, these may not pose a permanent and noticeable problem. In cases of repetitive or continuous laxity, which is common in LES, and in cases where the esophagus cannot clean itself by washing itself with saliva with the peristalsis movement of the esophagus (snake-like forward wave-like movements), the regurgitated substances begin to irritate the surface of the esophagus. We call this condition reflux esophagitis . When the reflux material escapes higher, it can also cause laryngitis and pharyngitis.

What are the risk factors and causes of reflux disease?

Hiatal hernia

The opening through which the esophagus passes through the diaphragm is called the hiatus. This opening may sometimes be wider than it should be, in which case the upper parts of the stomach may slide a little upwards through this hole, we call it a hiatal hernia or gastric hernia. When the upper part of the stomach slides upwards, the physical tightness that should normally be at the hiatus passage site in the area where the esophagus and stomach meet disappears, and this leads to the facilitation of reflux.

Obesity obesity

In case of obesity, reflux becomes easier as intra-abdominal pressure increases.

Pregnancy

Increased intra-abdominal pressure during pregnancy or strain in hiatus hernia increases the tendency to reflux. In addition, the abundant secretion of the hormone progesterone, which has an inhibitory effect in the gastrointestinal tract, paves the way for reflux. Progesterone causes weak contraction of the muscles of the esophagus. Improper functioning of the muscles of the esophagus reduces the cleaning of the inner surface of the esophagus, washing it. Likewise, the use of progesterone as a drug for reasons other than pregnancy also increases the susceptibility to reflux.

Inappropriate behavior styles and certain foods

Acidic beverages such as raw tomatoes, raw onions, mint, chocolate, soda, cola and soda, excessively oily, excessively spicy foods, especially eaten at dinner, increase the complaint of reflux. Eating 3-4 hours before bedtime causes reflux when lying down. Smoking, alcohol and coffee consumption can also increase reflux disease.

Certain medications

Aspirin, ibuprofen, some muscle relaxants, some hypertension drugs (calcium channel blockers), some asthma drugs (bronchodilators), sedatives and tricyclic antidepressants, dopamine agonists used in Parkinson’s disease can be counted among these drugs.

Connective tissue diseases

Rheumatoid arthritis, lupus and scleroderma also predispose to reflux. Of these, scleroderma is a connective tissue disease that mainly affects the muscle layer of the esophagus. In these patients, in addition to difficulty in swallowing, there is also easy reflux.

Delayed gastric emptying

If there is a delay in gastric emptying for various reasons, reflux becomes easier as the intragastric pressure will increase. Causes such as hypothyroidism and diabetes can be counted among the reasons for delay in gastric emptying.

What are the complaints and findings of reflux disease?

Common reflux disease symptoms are as follows.

  • Feeling of tightness or pressure under the breastbone
  • Bitter water in the mouth
  • Burning sensation in the chest
  • Nausea after meals

Rare complaints and findings are as follows.
• Food coming back into the mouth

  • Development of excessive salivation
  • Dry cough
  • Whistling sound when breathing
  • Difficulty swallowing
  • Hiccup
  • Thickening or bifurcation of the voice
  • Sore throat
  • decay on the inner surfaces of the teeth
  • halitosis
  • otitis media

These complaints may increase when we lean forward or lie on our backs, and they may be felt more especially after meals and at night.

  • Complication-related complaints and findings

There are complications in reflux disease that can develop over time. Additional findings may also occur due to these. For example, peptic strictures can be at any level, especially at the lower end of the esophagus. In case of stenosis, difficulty in swallowing will be seen.
Barrett’s esophagus is a complication of reflux disease. Although rare, adenocarcinoma secondary to Barrett’s esophagus may develop over the years, and findings such as difficulty swallowing, weight loss, and loss of appetite can be seen in these people.

What are the complications of reflux disease?

  • Deterioration of the existing patient
  • Gastric metaplasia of the mucosa of the lower end of the esophagus and the development of Barrett’s esophagus. Barrett’s esophagus is a precursor lesion for esophageal adenocarcinomas and requires treatment and follow-up.
  • The development of spasm in the bronchi due to irritation of the refluxed acid fluid (bronchospasm)
  • Chronic persistent cough and deepening of the voice
  • Easy tooth extractions
  • Ulcers in the esophagus
  • Development of stenosis in the esophagus

How is reflux diagnosed?

If the complaints are typical and there are no alarming complaints, treatment can be given without any test first. However, if the complaints have been present for a long time and are severe and suggestive of complications, diagnostic tests should be started.

Gastroscopy

It is the first test to be done. The lower esophageal sphincter and the lower end of the esophagus are visible, and in these areas, redness of the mucosa of the lower end of the esophagus, which we call esophagitis, and ulcerations in places are seen. In addition, complications such as peptic strictures and Barrett’s esophagus due to reflux disease will also be seen in endoscopy.

pH meter and impedance

This test allows us to understand whether the escapes into the esophagus for 24 hours or 48 hours are acid or alkaline or food. The absence of an acidic or alkaline pH measurement at the time of complaints may indicate that the complaints will be due to other reasons other than reflux. Click on this article for more detailed information on this subject.

Esophageal manometry

With esophageal manometry, we see whether the muscle functions of the esophagus are strong enough, and that it opens at the appropriate time and closes at the appropriate time, with pressure measurements. In diseases such as scleroderma, we understand that the peristalsis of the esophagus decreases significantly, so that there is no adequate esophageal cleansing. A persistently low lower pressure of the lower esophageal sphincter can also be detected with a pressure gauge. However, the LES pressure should be above a significant level at rest.
Esophageal manometry also has a place when surgery is considered for the treatment of reflux disease. When you want to surgically tighten and close the lower esophageal sphincter, you are expected to show that the esophageal muscles are working with sufficient strength with manometry beforehand. In a person with an esophagus that cannot contract sufficiently and perform proper peristalsis, fundoplication surgeries (reflux surgery) can sometimes lead to difficulty swallowing.

How Is Reflux Treated?

Lifestyle changes

  • Losing excess weight can regress complaints in many patients.
  • Raising the bed by placing a rising object, such as a brick or wedge, at the bottom of someone else. This method is physically effective, especially in people who have complaints while lying down at night. It is wrong to understand this method as putting plenty of pillows under the head. Raising the pillow does not provide an adequate solution and can lead to extra neck and lower back pain.
  • Relationship with food should be discontinued 2-3 hours before bedtime
  • Not wearing clothes that tighten the abdomen excessively
  • Drinking all kinds of medicines with plenty of water and not lying down for a few hours
  • Avoiding alcohol and cigarettes
  • Drinks such as raw onions, raw tomatoes, mint, chocolate, soda, cola soda, excessively fatty and excessively spicy foods should not be consumed at dinner.
  • Instead of NSAID drugs such as ibuprofen, if possible, taking paracetamol group drugs

Medical treatments

Antacids

Antacids are fast-acting and quickly stop the substernal burning sensation. They can be taken after meals and at bedtime, but their effects are short-lived.

Proton pump inhibitors

Proton pump inhibitors permanently block the acid-producing pumps in the stomach. Therefore, they have a long and strong effect. The effects can last for 24 hours. After 24 hours, when the gastric mucosa makes new acid pumps, it is necessary to take medication again. With the use of Proton pump inhibitor in the morning and evening for 10 days, it is expected that the reflux complaints will end during this period. Sometimes this treatment can replace you for reflux disease. Otherwise, advanced tests such as endoscopy and pH meter are needed.

H2 receptor blockers

H2 receptor blockers are not as potent in reducing site as proton pump inhibitors. If alkaline reflux is shown to be more prominent with a pH meter, they are preferred instead of proton pump inhibitors. H2 receptor blockers are used at night when you go to bed and serve to control the usual increase in acid at midnight.

Prokinetics

H2 M…. and d…. Medications such as esophagus increase the further peristalsis movement of the esophagus, which improves the clearance of the esophagus. In this way, they reduce the effects of reflux. (We can’t publish drug names on the site for policy reasons.)

Sucrlaurate

It adheres to small ulcers on the surface of the esophagus and stomach, forming a layer on it and protecting the area from irritating external factors and allowing it to heal. It can be preferred especially in alkaline reflux damage.

Alginic acid

Its general feature is to create a layer on the stomach contents and to cut off the acid or alkaline effect of the stomach contents. It is a syrup that is frequently used in reflux.

Interventional endoscopic reflux treatment

Endoscopic fuplication procedures are becoming increasingly popular in patients with reflux, including hiatal hernia cases not exceeding 3 centimeters or less. Surgical fundoplication may be an alternative in the next few years.

Who needs surgical or endoscopic reflux surgery?

  • If proton pump inhibitors do not provide sufficient control in reflux patients with complaints.
  • Even if they are under control with medication, those who do not want to use medication for a long time and want to be treated at once
  • Those with Barrett’s esophagus
  • Those with extra esophageal findings
  • Young patients
  • Those who have problems with compliance with the drug, those who disrupt their medication
  • Postmenopausal ladies with osteoporosis
  • Those who have conduction defects in the heart and may have rhythm problems
  • Those who keep the cost of drug treatment high, those who do not have social security, who will have to buy their medicine with money all the time

GERDX, Transoral Incisionless Fundoplication (TIF) procedure

For the last 10 years, lower esophageal laxity that causes reflux can be treated with increasingly endoscopic methods. The lower end is tightened with small wires placed from the inside to the lower end like a wire stapler with the additional apparatus accompanying the endoscopy device.

ARMS (anti reflux mucosectomy) and ARMA (anti reflux mucosal ablation)

In the cardia area, the area is first damaged by performing a mucosectomy close to 270 degrees or by burning it with argon or cautery. Then, while it heals within a few months, the LES tightens because this area will shrink. ARMA is a safe procedure performed with an argon plasma coagulator that takes about 15 minutes and does not require hospitalization. ARMA process can be performed in our unit. Click here for more information about the ARMA process.

Surgical reflux treatment

Several types of surgeries called fundoplication can be performed by laparoscopic methods. The upper dome part of the stomach, called the fundus, is passed behind the esophagus and sutured after wrapping 270 degrees or 360 degrees around the lower end of the esophagus. Thus, the lower end of the esophagus is tightened.

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