Download - Extinguish the “fire” of serious heartburn
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Extinguish the Fire of Serious HeartburnEric M High MD – General Surgery Department
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2www.SpringfieldClinic.comwww.SpringfieldClinic.com
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Overview• Define reflux
• Symptoms of reflux
• How do we diagnose reflux
• Treatment options
• What can I offer?
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What is reflux?• backup of stomach contents
into esophagus
• normal component-occurs after meals and is typically short lived and doesn’t occur at night and causes minimal if any symptoms
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What is reflux?• abnormal component-occurs
outside meals, during sleep, affects everyday life
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What Would “Reflux” feel like
• Burning sensation beneath sternum and/or upper abdomen– “heartburn”
• regurgitation-gastric contents may come up into mouth during burping or hiccups or spontaneously
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Other lesser known symptoms
•chest pains
•“lump in their throat”
•nausea
•persistent cough
•hoarse voice/raspy voice
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A+B=C• Differential
– cardiac• heart attack
– esophageal dysfunction– gallbladder
• stones, sludge, low EF– stomach
• gastritis, ulcer, gastroparesis, tumors, infections– pancreas
• pancreatitis, tumor
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What should I tell my doctor?
• pay attention if some/all of the above symptoms present
• if symptoms are worsening• discuss with your primary doctor
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Diagnosis
• UGI– chalky material that patient drinks, then multiple
images are taken to see if contents “reflux”– can see hernias with this method sometimes
• Esophagram– similar to above except only looks at esophagus– can see masses, narrowing
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Diagnosis
• Endoscopy– allows biospy– hernia– ulcers
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Diagnosis
• other tests– manometry
• probe in esophagus to see pressures
– pH monitoring• probe inserted in esophagus to measure how
often reflux occurring• more often during evening, laying down, etc.• not used very often
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Treatment
• Medical – lifestyle modifications
• weight loss• smoking cessation• avoid late night eating
– eating smaller meals
• avoid caffeine, chocolates, alcohol• sleeping positions
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Treatment
• Medical– medications
• H2 blockers vs PPI– prilosec, protonix, etc.
– review meds to see if they could be causing any of the symptoms
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Treatment
• Medical– Infection
• H. Pylori– 10-14 day course of antibiotics and medications to
eliminate the bacteria– need check after treatment to ensure bacteria gone
» urease test
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Complications
• untreated reflux can lead to severe complications – strictures
• inability to swallow that may need repetitive dilatations
– cancer• leading cause for converting normal mucosa to
cancer
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Treatment
• Surgical– hiatal hernia can lead to increased
incidence of reflux and need repaired surgically
– inability to adhere or tolerate medical therapies
– symptoms are not improving on medicine or needing increasing dosage
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Treatment
• Complete picture from endoscopy, UGI, length of symptoms, and medical treatments
• May need surgery to fix/help with symptoms
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Hiatal Hernia
Type I
Surgery: Nissen Fundoplication
Type II
Surgery: Paraesophageal Hernia Repair w/Nissen
Type III
Surgery: Paraesophageal Hernia Repair w/Nissen
Type IV
Surgery: Paraesophageal Hernia Repair w/Nissen
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• Sliding hernia (Type I)• GE junction above diaphragm• Causes Acid Reflux Disease (GERD)• No true hernia sac• Nissen Fundoplication is performed
Normal Anatomy
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Paraesophageal hernia (Type II)•Stomach fundus into chest•Fixed GE Junction
Paraesophageal hernia (Type III)•Stomach fundus into chest•GE Junction above diaphragm
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Paraesophageal hernia (Type IV)•Stomach, GE Junction, and other organs above diaphragm
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Primary Closure Straight suturingSmall herniasMost common
Mesh Closure Synthetic or Biologic MeshFor Large hernias (>5cm)Costly (biologic even more)Sutures or Tacks (cost)
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Surgical Options
• “Wrap”– upper portion of stomach is wrapped
completely around end of esophagus– “Nissen”
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Surgical options
• Partial wraps– Dor
• anterior wrap
– Toupet• posterior
• CT Surgery options– Belsey– used if multiple upper abdominal surgeries
or if very large hiatal hernia
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Surgical Options
• Open– large midline incision, longer recovery
• now mainly used as choice if recurrent or multiple previous surgeries
• Laparoscopic – 4-6 incisions– carbon dioxide for inflating and giving room
to work– most often done now
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Surgical options
• Robotically– similar to laparascopic surgery– 3-4 incisions– carbon dioxide for inflating
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•3-Dimensional Anatomy•Protect Vagus Nerve, Aorta
Advanced Sealing / Dissection*•Wristed Vessel Sealer•Avoid gastric or esophageal perforation
Advanced Suturing Capability•Fundoplication can come undone•Assessment of wrap tightness
Learning Curve•In preparation for complex paraesophageal hernia or redo Nissens
Visualization
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Primary Closure Straight suturingSmall herniasMost common
Mesh Closure Synthetic or Biologic MeshFor Large hernias (>5cm)Costly (biologic even more)Sutures or Tacks (cost)
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Final thoughts
• reflux is very common • most patients are managed very well
with medications and lifestyle changes– obesity– smoking
• if symptoms are not improving– may need EGD to check anatomy– may need surgery to address problem
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What can I offer?
• Board certified General Surgeon– advanced laparoscopic training – robotic trained
• Endoscopy trained
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More Resources
Find videos, handouts and more resources at
www.SpringfieldClinic.com/DoctorIsIn