REFLUX.

The gastroesophageal reflux (GOR), which is known among the public as reflux, is the process that happens when the stomach content (stomach acid, pepsin, pancreas enzymes and gall) leaks back to the esophagus. This happens together with the burning feeling at the chest that is the typical indicator of reflux and various levels of damage at the esophagus (erosion and ulcers). In such situations “gastroesophageal reflux disease” (GORH), in other words “reflux” as called by the people, is in question. The existence of a damage that can be determined in scope of the esophagus based on endoscopic and/or histopathologic methods is called “the reflux esophagitis”.

The symptoms of GORH can be categorized into two groups as typical and atypical symptoms.
The typical symptoms of reflux is the burning feeling (heartburn) which is felt behind the breastbone that rises upwards from the below, towards the throat and when the eaten foods return to the mouth or the esophagus (regurgitation). These complaints generally increase during the periods after meals, when leaning forward or when you lie on your back, and generally passes or decreases when the medications called antacid are used. It can make you wake up after late dinners. The food and secretion coming from the stomach can stain the patient’s pillow.

Some atypical symptoms can be observed in scope of GORH, in addition to such classical symptoms. Some patients visit the physicians based on only the atypical symptoms, without experiencing the classical ones. Chronical laryngitis, hoarseness, chronic coughing and breathing problems similar to asthma are the most frequent problems among the atypical symptoms. Another atypical symptom of GORH is the chest pain (chest pain based on non-cardiac reasons). No reason is found to explain the breast pain as the result of the examination of 25-30% of patients with that kind of pain which, at first, is thought to be based on cardiac reasons. Then it is understood the reflux or esophagus’ functional disorders are the causes of breast pain for half of such patients.

Our stomach secretes acid all the time. The amount of this secretion is increased after the meals so that the stomach contributes to the digestion of the foods. In other words there is always an acidic content within the stomach. Although this acid is very strong, it normally does not harm the stomach thanks to the protection mechanisms of the stomach. But the esophagus does not have protective mechanisms against acid. The only thing that protects the esophagus is the system that acts as a functional valve at the connection point of esophagus and stomach, which prevents the stomach contents from leaking to the esophagus (inferior esophageal sphincter) . Under normal conditions the leakage is minimum and does not cause damage. But if this functional valve system does not function suitably, the stomach’s acidic content leaks a lot to the defenseless esophagus and damage caused by acid occurs. This occurring damage causes complaints.

Diagnosis of reflux can easily be made by an experienced physician by carefully listening to the patients who state typical complaints. It is another method of diagnosis to observe that the patient’s complaints end after a short-term reflux treatment. Some additional tests are required for patients with atypical symptoms who do not respond to the treatment or for which a diagnosis cannot be made.

Gastroscopy (examining the esophagus and stomach with gastroscope, a telescopic instrument with light, endoscopy) is the most frequently preferred method to diagnose the reflux as it allows us to see the esophagus directly and take tissue samples for histopathologic examination when required.

Measuring the amount of acid (pH) within esophagus for 24 or 48 hours (pH monitorization) is another method that can be used to make a diagnose in scope of the patients whose complaints refer to reflux but nothing is observed during the endoscopic examination about reflux. During this test the patient continues daily activities and the acidity within the esophagus is recorded by using a special device via the detectors on a thin catheter placed inside the esophagus, and later it is evaluated with the help of a computer software and a gastroesophageal reflux diagnosis can be made.

“Esophageal manometry”, which is a method in which the pressure within the esophagus is recorded is not a routinely applied method to make reflux diagnosis, but it can be helpful to make a diagnosis in scope of the patients with atypical symptoms or who do not respond to the treatment, who state swallowing difficulties although the endoscopic examination result is normal.

Although the studies show that gastroesophageal reflux existence slightly increases the esophagus cancer rate, this increase is not very visible in cases of reflux at medium and slight severity levels. (Those with reflux complaints: 0,002%; those with slight and medium level reflux: 0,003-0,018%; those with severe reflux: 0,035%).

The changes made in the life styles of the patients with GORH diagnosis constitute the first stage of treatment. A diet that is especially poor in terms of fries, spicy foods, very salty and sour foods is important. The patients must stay away from tea, coffee, cola etc. drinks with caffeine and acid as much as possible. Smoking less and reducing the alcohol consumption, and even if you are not smoking, staying away from places where people smoke are recommended.

30-40 minutes of light exercises each day, lifting the bed top 15-20 cm upwards and eating at least 3 hours before going to bed and sleeping with an empty stomach are other changes that can be counted, in addition to dietary changes.

Acid suppressing medications (proton pump inhibitors and h2 receptor blockers) and antiacids can be added for the patients who cannot get results despite of the changes in their lifestyles and dietary applications.

The symptoms are reduced with such precautions and treatments in majority of these patients up to 80% but it must be remembered that when the GORH precautions and treatments are not tightly followed these symptoms frequently reappear and the patients visit the hospital with the same complaints.

Operation is recommended for the patients who cannot obtain results from the medical treatment and who have structural pathologies such as stomach hernia found as the result of the examinations. The method commonly used today is the laparoscopic (closed method) Nissen Fundoplication surgery. In this surgery, with the help of 4 or 5 holes opened from the abdomen, the loose valve structure at the connection point of esophagus and stomach, is supported with the stomach. The biggest advantage of the surgery is, as the laparoscopic method is used, patient returns to normal life quickly when compared to open surgeries. Although the reflux complaints after the surgery are reduced almost completely, some swallowing difficulties can be experienced. Laparoscopic reflux surgery is a technique that is being safely used throughout the world.