Dietary and Lifestyle Changes
By Michel Kafrouni, M.D.
Many patients succeed in relieving most if not all the symptoms of gastrointestinal reflux disease (GERD) by changing the way they eat, what they eat and when they eat. Several foods can decrease the pressure at the lower esophageal sphincter, which works as a gateway preventing the acid from getting to the esophagus. Spicy foods, fatty foods, alcohol, sodas, smoking cigarettes, chocolate, coffee and all caffeinated products, peppermints, tomato-based juices and products, and citrus products are examples of those foods. Avoiding those foods will help control GERD.
Some day-to-day lifestyle modification should be initiated and continued throughout the course of treatment for reflux disease. These include avoiding tight clothes, elevating the head of the bed, avoiding large meals, fasting for three hours before going to bed, and losing 5 percent of one’s body weight.
Medical treatment
By Michel Kafrouni, M.D.
Despite dietary and lifestyle changes, some patients still require medications to control their reflux symptoms. The medications can be given for a short period of time to help with the acute symptoms and to give time for the lifestyle and habits to change. However, some patients require lifetime treatment.
Many medications have been used to control gastroesophageal reflux disease (GERD). Proton pump inhibitors (PPIs) are the mainstay of treatment. They are potent acid reducers that block the pumps responsible for supplying the acid to the stomach. PPIs include omeprazole, lansoprazole, pantoprazole, esomeprazole and others. These medications are generally safe and can be taken once or twice per day (half an hour before breakfast or dinner).
Other medications have been used to treat GERD. Antacids neutralize the acidity of the stomach and provide short-term relief. Other medications, such as sucralfate, provide a barrier that lines the esophageal and stomach mucosa and protect it from the gastric juices, thus providing the time needed to heal. Some antihistamines, such as ranitidine and famotidine, also can be used to decrease the secretion of acid into the stomach lumen.
Dilation
The stricture can be dilated by using esophageal dilators, using bougies (plastic tubes that are passed from the mouth into the esophagus to dilate the esophagus) or balloon dilators during an upper endoscopy. The procedure may need to be repeated multiple times. The complete control of gastroesophageal reflux will help healing of the stricture. Aggressive acid suppression therapy with proton pump inhibitors has reduced the incidence of strictures. Despite this advance in therapy, 30 percent of patients with strictures require a repeat dilation within one year.
Below are two schematic presentations of balloon dilation for peptic stricture:
Esophageal Stenting
Esophageal stents are a relatively safe and effective method of palliation (improvement of symptoms) and treatment of peptic esophageal strictures.
Surgical Treatment
In patients who do not respond to medications and multiple esophageal dilation, surgery should be considered. The most efficient method of treating a reflux stricture has been dilation followed by an antireflux procedure to obtain complete control of gastroesophageal reflux. The aim of the surgical treatment is to restore the function of the lower esophageal sphincter (the valve between the esophagus and the stomach), to prevent the reflux of acid and bile (non-acidic juice) from the stomach into the esophagus and help healing of the stricture. The most common procedure to restore the function of the lower esophageal sphincter and prevent the gastroesophageal reflux is a minimally invasive procedure called laparoscopic Nissen fundoplication, which is routinely performed at the Memorial Hermann Southeast Esophageal Disease Center for the treatment of patients with gastroesophageal reflux disease.
Strictures associated with severe esophageal dysmotility (non functional esophagus) are extremely difficult to manage. In some extreme cases, esophagectomy (esophageal replacement) may be needed.