Recurrent GERD Symptoms

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When recurrent or new symptoms of gastroe-sophageal reflux develop in the late postoperative period (>3 months), the symptoms should be investigated. For individuals who develop symptoms identical to those in which they underwent surgery, a trial of PPIs is appropriate. In addition, a barium swallow will demonstrate any new anatomic abnormalities in 90% of patients with anatomic failure.6 If the barium swallow does not demonstrate any anatomic problems, it is unlikely that the PPIs will be of much benefit. In this case, it is likely that the recurrent symptom is the result of a problem distinct from GERD. Because so-called extrae-sophageal reflux symptoms (cough, asthma, hoarseness, chest pain, etc.) are so common, it may be difficult to determine which of these symptoms, if any, are related to reflux and which are related to other conditions such as extrinsic asthma, or postnasal drip. It may take the performance of a fundoplication to determine, once and for all, which extraesophageal symptoms are related to reflux and which are not. It seems that extraesophageal symptoms that correlate with reflux events on a 24-hour pH study are more likely to respond to surgery than symptoms that occur with no correlation to reflux events. Frequently we have found that the typical symptoms of reflux (heartburn, dysphagia, regurgitation) will be eliminated by fundo-plication but the extraesophageal symptoms in the same patient (sore throat, cough, hoarseness, wheezing) will not be eliminated by surgery. The best preoperative predictors of symptom relief after fundoplication are the presence of typical symptoms, an abnormal preoperative 24-hour pH study with a positive symptom index, and responsiveness to PPIs.

If the barium swallow does not reveal any anatomic abnormalities, and trial of medical therapy fails, further investigation is unlikely to detect problems but should be done anyway. In 10% of patients referred for postoperative reflux symptoms, esophagogastroduodenoscopy (EGD)

PERSISTENT SYMPTOMS AFTER ANTI-REFLUX SURGERY AND THEIR MANAGEMENT

A. Early Dysphagia (First 3 Months)

Diet Modification, Dilation

Dilation

Feeding Tube Placement or TPN

B. Late Dysphagia (> 3 Months) -►Barium Swallow

(with 12.5 mm Barium Pill)

B. Late Dysphagia (> 3 Months) -►Barium Swallow

(with 12.5 mm Barium Pill)

Total Parenteral Nutrition

Figure 7.1. Evaluation of the patient with new dysphagia after laparoscopic Nissen fundoplication.TPN, total parenteral nutrition; EGD, esophagogastroduodenoscopy; EMS, esophageal motility study. (Reprinted from Hunter JG. Approach and management of patients with recurrent gastroesophageal reflux disease. J Gastrointest Surg 2001;5(5):451-457, Copyright 2001, with permission from Elsevier.)

Figure 7.1. Evaluation of the patient with new dysphagia after laparoscopic Nissen fundoplication.TPN, total parenteral nutrition; EGD, esophagogastroduodenoscopy; EMS, esophageal motility study. (Reprinted from Hunter JG. Approach and management of patients with recurrent gastroesophageal reflux disease. J Gastrointest Surg 2001;5(5):451-457, Copyright 2001, with permission from Elsevier.)

revealed an additional anatomic problem that was not detected on barium swallow.6 The most common anatomic problem discovered by EGD when the barium swallow was normal is a slipped or misplaced fundoplication. Because the gastroesophageal junction may be difficult to define on barium swallow, the EGD is necessary to demonstrate the presence of gastric folds extending through and above the fundoplication narrowing. In addition, the gastric folds may be seen coursing up into the valve, instead of remaining circumferential around the retroflexed scope (Figure 7.2). Also, a partially disrupted fundoplication may only be visible on EGD in a retroflexed position and missed with a barium swallow. This may be best demon-

MANAGING FAILED ANTI-REFLUX THERAPY

A. Early (first 3 months)-► Reasurance

± Barium Swallow

Reassurance ± PPI

Continued Symptoms

More Reassurance ± PPI

Continued Symptoms

Yet More Reassurance

Reassurance ± PPI

Continued Symptoms

More Reassurance ± PPI

Heller Myotomy Wrap

Continued Symptoms

(occasionally with Heller myotomy)

Figure 7.2. Evaluation of the patient with recurrent reflux symptoms after laparoscopic Nissen fundoplication. EGD, esophagogas-troduodenoscopy; EMS, esophageal motility study; PPI, proton pump inhibitor. (Reprinted from Hunter JG. Approach and management of patients with recurrent gastroesophageal reflux disease. J Gastrointest Surg 2001 ;5(5):451 —457, Copyright 2001, with permission from Elsevier.)

strated by a patulous gastroesophageal junction (does not hug the retroflexed endoscope), or a portion of the valve that has fallen away from the circumferential wrap. When the results of the EGD are normal and the barium swallow is normal, it is most unusual to find a patient that has a positive 24-hour pH study confirming GERD (Figure 7.3).

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Herbal Remedies For Acid Reflux

Herbal Remedies For Acid Reflux

Gastroesophageal reflux disease is the medical term for what we know as acid reflux. Acid reflux occurs when the stomach releases its liquid back into the esophagus, causing inflammation and damage to the esophageal lining. The regurgitated acid most often consists of a few compoundsbr acid, bile, and pepsin.

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