Acid Reflux - GERD - Heartburn
Acid Reflux explained
(Mayo Clinic)
Bariatric surgery is being recognized as the most effective method of long term treatment for morbid obesity.
Procedures such as Gastric Bypass, Sleeve Gastrectomy or Duodenal Switch have helped improve or resolve co morbid conditions such as Type 2 Diabetes, hypercholesterolemia, hypertension, sleep apnea and cancer.
Studies have shown, that in approximately up to 25-30%, patients may experience acid reflux after weight loss surgery.
Acid Reflux (aka GERD) or heartburn results when acid and/or content of the stomach travels upwards to the esophagus causing a burning sensation.
In addition, patients may also experience that certain foods get “hung up” (dysphagia) followed by vomiting.
What causes reflux?
Gastroesophageal reflux (GERD) after bariatric surgery could be the result of a single variance after the procedure or due to combination of events including:
- Weight Regain
- Paraoesophageal Hernia – migration of the stomach
- Lack of proper contraction of the stomach (gastroparesis)
- Retained fundus
- Strictures or narrowing
- Kinking due to scar tissue
Complications of GERD:
Untreated reflux disease following bariatric surgery can lead to the development of the following conditions, including:
- Teeth decay
- Chocking at night when sleeping
- Chronic coughing
- Bitter aftertaste in the mouth (Halitosis)
- Erosive esophagitis
- Strictures
- Barrett’s esophagus, which can lead to a pre-cancerous condition
- Cancer of the esophagus
Workup and Diagnosis:
In order to proper understand the etiology of heartburn after weight loss surgery, several studies need to be ordered including:
- Upper endoscopy
- CT-scan of the abdomen
- Gastric Emptying study
- Ph/manometry
Treatment and Management:
if you are experience severe heartburn (GERD) after weight loss surgery, the first line of treatment is always conservative including:
- Lifestyle modifications
- Change your diet
- Add antiacids
- Avoid tobacco and alcohol
- Don’t go to sleep after a meal to avoid reflux during the night.
Provided this conservative management fails, then a surgical options should be considered.
Sleeve to Bypass: It is usually indicated when reflux (GERD) is associated with weight regain. The increase intra abdominal pressure “pushes” the sleeve upwards, thus migrating into the thorax. This phenomenon is known as a Hiatal Hernia or Paraesophageal Hernia.
This procedure also involves fixing the hernia
Fundectomy: Sometimes the upper stomach known as “fundus” is dilated following a Sleeve Gastrectomy. This anatomical variance can be responsible for weight regain and reflux. The technique that reduced the size of the fundus or pouch in a gastric bypass is known as fundectomy.
Revision of the Jejuno Jejunostomy: If GERD is experienced by patients who underwent a Gastric Bypass, it is possible that the connection with the small bowel is very closed to the pouch. By lengthening the amount of small bowel, intestinal juices wont reach the pouch
Stricturoplasty: This procedure aims to widening a narrow segment of the sleeve gastrectomy, responsible for acid reflux.
Revision of Gastro Jejunostomy: Strictures or narrowing at the joint between the stomach (pouch) and the small bowel in patients who underwent a gastric bypass are usually the results of ulcers at the anastomosis (stomach-bowel- joint). Inflammation in this area will result on scar tissue formation and narrowing of the outlet. Endoscopic dilatation is the first line of treatment, leaving a surgical correction as the last option.