The Reflux Center at JFK Medical Center offers a comprehensive approach for the diagnosis and treatment of acid reflux disease by combining highly skilled physicians and the latest technology to provide effective solutions. You can directly reach our reflux coordinator who will coordinate the individual plan of care throughout their diagnosis and treatment phases. This personalized and streamlined approach allows for accurate assessment and diagnosis to be made without being delayed by multiple doctor and procedure appointments.
GERD is the acronym for gastro-esophageal reflux disease. GERD is due to a weakened lower esophageal sphincter (LES). This sphincter is a “door” between the esophagus and the stomach that normally remains closed and only opens to allow food to pass into the stomach, allows a burp to escape or allows vomitting. In patients with GERD, the LES remains relaxed, allowing stomach acid to bathe the lower esophagus. This acid burns the lining of your esophagus presenting as what is often called “heartburn.” It feels like a burning sensation in the middle of the chest. Chronic irritation can permanently damage the delicate inner lining of the esophagus.
Symptoms of GERD
- Heartburn/chest pain
- Hoarseness (often in the morning)
- Asthma/wheezing/shortness of breath
- Dry cough
- Frequent burping
- Stomach fullness or bloating
- Sour or bitter taste in mouth
- Difficulty swallowing
- Sensation of food stuck in throat
- Bad breath
- Change in sense of taste
- Change in sense of smell
Complications of GERD
- Erosion of the esophagus (esophagitis)
- Narrowing of the esophagus (esophageal stricture)
- Regurgitation of acid into the lungs
- Barrett‘s Esophagus (increased risk of esophageal cancer)
- Esophageal cancer
- Adult onset asthma
- Pneumonia (infection of the lungs)
- Pulmonary fibrosis (scarring of the lungs)
Given how common gastro-esophageal reflux disease is, many patients are initially diagnosed and treated based solely on their history of symptoms. Many patients are already on an over-the-counter medication before they seek medical attention. If the reflux is mild enough that it completely resolves with over-the-counter medications, often no further work up is pursued. However, it is important to remember that although the symptoms are treated with medications, the actual reflux of stomach contents never stops, meaning that damage to the esophagus could be happening “silently.”
The Reflux Center at JFK Medical Center offers all diagnostic methods at one location, minimizing the number of appointments.
Esophago-gastro-duodenoscopy (EGD) is the most valuable initial method of diagnostic testing performed on patients with GERD because of the volume of information that can be obtained at one time. It is a procedure in which a tube-camera is placed through the mouth to visualize the esophagus, stomach and duodenum (small intestine). Our skilled gastroenterologists perform this procedure under sedation in order to keep patients comfortable through the procedure.
Often the esophagus of patients with reflux looks normal. However, in moderate to severe cases, the lining of the esophagus appears inflamed (esophagitis). Endoscopy can also rule out any tumors or strictures (narrowing) of the esophagus. The presence of esophagitis on medical therapy signifies poorly treated reflux, which should be further evaluated. If there is an abnormal transformation of the lining of the esophagus, the gastroenterologist will biopsy the area to rule out Barrett’s esophagus or esophageal cancer. An EGD also evaluates the stomach and first portion of the small intestine (duodenum) for tumors or ulcers.
The pH probe study is the most specific test for acid reflux. This study measures the frequency and duration of acidic fluid refluxing into the esophagus.
Standard procedure for this study is performed by placing a tube in a patient’s nose, resting in their esophagus. The patient goes home with a tube in the nose, to remain in place for 24 hours. Patients are unable to shower and are quite uncomfortable.
New Alternative: The BRAVO pH Probe
Here at The Reflux Center at JFK Medical Center, we have invested in the latest advance in pH testing – the Bravo pH probe, which is a wireless capsule that is implanted just above the LES (Lower Esophageal Sphincter). This allows our patients to go on with their normal daily activities without the cumbersome tube in their nose while we are able to obtain 24-48 hours worth of data measuring the acid exposure to the esophagus. This wireless capsule then transmits to a receiver that the patient clips on their clothing. During the day, the patient presses a button on the receiver when they are having symptoms. This enables us to correlate moments of acid reflux with symptoms. The capsule releases itself within one to two weeks and is excreted uneventfully.
Esophageal manometry is a study used to assess esophageal function; it is performed by our specially trained nurses here at The Reflux Center at JFK Medical Center.
A thin, pressure-sensitive tube is passed through your mouth or nose into your stomach. When the tube is in your esophagus, you are asked to swallows sips of water. The pressures of the muscle contractions are measured along the length of your esophagus. Upon completion of the test, the tube is removed. The study takes 30 to 60 minutes to perform.
Manometry is used to measure the effectiveness of the LES at preventing reflux. Also with the information obtained, we are able to diagnose and differentiate other conditions such as esophageal dysmotility syndromes, achalasia and presbyesophagus.
Manometry can identify when laparoscopic fundoplications or incisionless Transoral Incisionless Fundoplication (TIF) are viable treatment options for GERD and which type of procedure is the best option.
During an esophagram, a patient drinks either barium or a water based contrast that coats the upper digestive tract. This provides a clear silhouette of your esophagus, stomach and the upper part of your small intestine (duodenum) on an X-ray.
This study is the best study to evaluate the size and shape of a hiatal hernia and the position of the lower esophageal sphincter. This study is also helpful in seeing complications of reflux such as esophageal strictures and ulcers throughout the upper gastrointestinal tract.
Our skilled radiologists can also diagnose moderate to severe reflux and assess esophageal function based on observing the real-time video images during the exam.
Transoral Incisionless Fundoplication (TIF)
TIF aims to correct the root cause of GERD. TIF is completely incisionless as it is performed with the assistance of an endoscope and is performed from inside the stomach. The procedure reconstructs a durable anti-reflux valve and tightens the lower esophageal sphincter. This re-establishes the reflux barrier and restores the competency of the LES.
Is TIF Truly Incisionless?
TIF is a completely incisionless procedure, but it is real surgery. It falls into a category of procedures called natural orifice surgeries, because the device is introduced into the body through the mouth rather than by making incisions on the abdomen.
The advantages of incisionless surgery are a short hospital stay, reduced discomfort, no visible scars and high patient satisfaction.
How is TIF Performed?
While a patient is asleep under general anesthesia, the device is introduced into the body through the mouth and advanced into the esophagus under visualization of an endoscope (flexible camera). The device is then used to grab portions of the stomach and the esophagus. Utilizing specialized fasteners, several tissue folds (plications) are created encircling the LES. This creates a robust anti-reflux valve. Small hiatal hernias can be corrected at the same time.
Is TIF Effective?
Over 5000 patients have undergone a TIF worldwide. Clinical studies have measured symptoms, quality of life, use of PPI’s, impedance, pH-metry and manometry to assess the effectiveness.
- TIF improves typical symptoms such as heartburn and regurgitation in 75-89% of patients.
- TIF eliminates atypical symptoms such as cough and hoarseness in 72-90% of patients.
- TIF eliminates the need for daily medications in greater than 90% of patients.
TIF does not create a 360-degree wrap such as the laparoscopic fundoplication and cannot fix medium to large hiatal hernias, so it is best used for moderate refluxers with small hiatal hernias. It is not as effective when used on patients with severe reflux and large hiatal hernias. These patients are well treated with laparoscopic approaches, which are time tested, well tolerated and durable.
By correctly assessing patients and making the right decision as to which procedure is best for each individual person, The Reflux Center is able to maximize the number of satisfied, medication-free and symptom-free patients treated.
After undergoing the TIF procedure, patients are kept in the hospital overnight. Most patients can return to work within a few days following their TIF procedure. Patients should expect to experience some discomfort in their chest and throat for the first few days. Patients will be asked to restrict physical activity for the first month and will be given dietary guidelines to help maximize their success while their tissue heals.
Benefits of TIF
- Allows for an effective, long-term solution to GERD
- Similar effectiveness to laparoscopic procedures (with proper patient selection)
- No external incisions – no scarring
- Rapid Recovery
- With early intervention, eliminates heartburn and need for medications in most patients
- Does not limit future treatment options
- Can be revised endoscopically or laparoscopically, if required
TIF is Suitable for Those Who:
- Have heartburn or non-heartburn acid reflux symptoms two or more times a week
- Have symptoms on acid reflux medications
- Cannot tolerate the side effects of acid reflux medications
- Do not wish to use acid reflux medication in the long term
Patients report a high degree of satisfaction with the TIF procedure. The high success rate combined with shorter recovery time and reduced discomfort make this incisionless acid reflux treatment a valuable new option for acid reflux sufferers in the Tampa Bay Area.
Read more about Endoscopic Fundoplication.
Laproscopic Nissen Fundoplication
Read more about Laproscopic Fundoplication
Treating early-stage GERD usually centers on a combination of lifestyle and dietary changes, over-the-counter (OTC) medications and prescription drug regimens. If the disease continues to worsen, to correct the root cause, the lower esophageal sphincter (LES) needs to be fixed using incisionless or conventional laparoscopic techniques.
Most people with reflux find that their symptoms are more serious at night. Gravity is not opposing the reflux when lying down, as it does in the upright position. Refluxed liquid travels farther up the esophagus and remains there longer.
It is recommended to elevate the upper body when lying in bed in order to decrease the amount and extent of reflux. Most people find that elevation with multiple pillows initially helps with their symptoms. However, as the reflux becomes more severe, they find that they must sleep upright in a chair to counteract the forces of their reflux.
Smoking is a significant contributor to reflux. Smoking reduces the pressure of the lower esophageal sphincter, thereby promoting reflux. Smoking also increases the chance of developing gastric and duodenal ulcers.
Several changes in eating habits can be beneficial in treating GERD. Reflux is worse following meals because the stomach is distended with food and transient relaxations of the lower esophageal sphincter are more frequent. Therefore, smaller, frequent meals and earlier evening meals may reduce the amount of reflux. Smaller meals result in decreased distention of the stomach and earlier meals allow the stomach to be empty by the time one is lying down to sleep.
Certain foods are known to reduce the pressure of the lower esophageal sphincter. These include:
- Caffeinated beverages
In addition, people find that the list of foods they cannot tolerate expands to include spicy, fatty, and acidic foods.
The First Steps
- Control alcohol and tobacco use
- Reduce trigger foods
- Adjust medications
- Become active (lose weight)
- Stay upright
- Adjust sleeping position (elevate upper body)
- Loosen clothing
For more information, see the Gerd Diet topic in our Health Library.
Antacids such as Tums, Mylanta or Rolaids neutralize the acid in the stomach so that when the reflux occurs, there is less acid in the refluxate. Antacids work quickly but the problem is that their action is brief. They are emptied from the stomach in less than an hour and the acid then re-accumulates.
The best way to take antacids is to take them about one hour after eating a meal in order to stop symptoms before they begin.
H2 Blockers (Histamine Antagonists)
H2 blockers are medications such as Pepcid and Zantac. Histamine is a chemical that stimulates acid production by the stomach. When histamine attaches to receptors on the stomach’s acid producing cells, it signals the stomach to produce acid. H2 blockers work by binding and blocking these receptors on the stomach, thereby preventing histamine from stimulating the acid-producing cells. H2 blockers work best when taken 30 minutes before meals so that they will peak in the body after the meal when the stomach is actively producing acid.
Proton Pump Inhibitors
Proton pump inhibitors block the secretion of acid into the stomach by the acid-secreting cells. They shut off acid producers (proton pumps) more completely and for a longer period of time than H2 blockers. PPI’s are not only good for treating symptoms, but are sometimes effective in protecting the esophagus from acid in order that esophageal inflammation (esophagitis) may heal.
Most Proton pump inhibitors (PPI‘s) are prescription medications, but there are some over-the-counter formulations such as Prilosec OTC. Examples of Proton pump inhibitors include: Nexium, Prevacid, Prilosec, Protonix, Aciphex, Zegerid, Kapidex, Dexilant and Vimovo. PPI’s should be taken 30 to 60 minutes before a meal as they only bind to actively secreting proton pumps.
Pro-motility drugs are intended to empty the stomach earlier, which should reduce reflux. Multiple studies have been performed on pro-motility drugs. These studies have shown that this class of drugs is not very effective in treating either the symptoms or complications of GERD. The most common drugs in this class are Reglan (metoclopramide) and Urecholine (bethanecol).
Read more about medications for GERD.
Why Pharmaceuticals Are Not a Long-Term Solution
Medications are quite effective in treating mild to moderate GERD. The problem is that these medications lose their effectiveness over time. They also do not treat the underlying cause of reflux – the deteriorated anatomy of the anti-reflux barrier. Therefore, life-long medication therapy is required. In addition, recent studies are showing adverse effects with the long-term use of PPI’s. The FDA issued a warning regarding the increased incidence of hip, wrist and spine fractures in those taking PPI’s for longer than one year. Other associations have been found in various studies, such as increased risk of pneumonia, decreased Vitamin B12 absorption, increased gastric polyps, interference with anti-platelet medications such as Plavix and increased incidence of clostridium difficile colitis.
Here at The Reflux Center, we keep up to date on the latest information and can help you make an informed decision.
For more information on GERD, visit the Heartburn and GERD Center in our Health Library.