The best remedies against reflux.

If you suffer occasionally get a burning sensation in the esophagus, which is annoying, but not a disaster. This problem can become a disease, complete with complications. What can you do with reflux?
Who has never had that burning sensation in the esophagus known that sour taste in the throat ...? But where does this feeling come from? To understand that, it is sufficient to follow the path of the food we swallow: it passes through the esophagus to the stomach. At the transition between the esophagus and stomach, there is a barrier against regurgitation, in the form of a sphincter and a valve. The food, the stomach or inside, but can not go back into the esophagus. However, this barrier is never fully closed off, which is why it is called physiologically reflux. We can all have occasional reflux, usually after too greasy or spicy meal. But with 10 to 20% of the people it is a real disease, with troublesome symptoms and / or injuries.

The sour taste of the burp comes from the moisture which is naturally present in the stomach. "It contains hydrochloric acid, so positive hydrogen ions and negative chlorine ions," says Professor Guy-Bernard Cadiere, Head of the Digestive Surgery at the University Medical Center St. Peter's in Brussels. "The gastric mucosa tolerates the positive hydrogen ions without any problems. However, the mucosa of the esophagus is not resistant to attack by the acid, so that the positive hydrogen ions easily cause ulcers."

the symptoms

The symptoms vary from person to person. Some have even no symptoms they do have reflux, but experience is not affected. The less fortunate have two important and typical symptoms include heartburn (a sour stomach) and acid regurgitation.
But in the nose and throat oorzone or heart and lung area may also have other unusual symptoms occur. In these cases, the link with the reflux is not always evident. It involves symptoms such as sore throat, dysphonia (difficulty speaking, especially in the morning), chest pain without apparent cardiac causes, heart palpitations, a bad smelling breath, hiccups, nocturnal cough, asthma ...

Finally, there are the alarms (weight loss, anemia, bleeding, difficulty swallowing ...). Such phenomena have become rare, but when they do turn up they indeed serious complications suspect and require an immediate gastroscopy.

the complications

That the presence of gastric acid affects the esophagus, is no more than logical. The four most obvious complications are: esophageal inflammation, stenosis, Barrett's esophagus, and cancer.
esophagus Inflammation

As a result of the persistent irritation by the acid, can ignite the esophagus. According to the degree of severity, it can be a simple inflammation to ulceration.

stenosis

We speak of stenosis when the reflux narrows the esophagus, as a result of the scars of ulcers. "It can go very far," stresses Professor Erik De Koster, gastroenterologist at the Brugmann. "The food is stopped, they have difficulty swallowing solid foods and so on. Fortunately, less common and can easily be treated than before. Why? Because people today respond more quickly if they detect symptoms. They come to us look faster. And modern medicines work better. "

When one has to dilate stenosis of the esophagus, by means of a so-called endoscopic dilatation. "Twenty years ago we had patients who had to come back two or three weeks to be dilated. Today, patients respond well to the drugs, and it happens very rarely that a patient has to come back to broaden its stenosis."

Barrett's esophagus

This is a condition which can be a precursor to cancer. It occurs in approximately 10% of the patients who suffer from chronic reflux. What is happening? Under the influence of the acid changes the lining of the esophagus. "That change is dangerous," says Professor De Koster. "In the long term there esophageal come."

esophageal cancer

"It is rare, but the number is increasing," Professor De Koster says. "That probably has to do with the likely increase in the number of people with reflux." Men get to make more with it than women. The only possible cure is surgery.

The research

Gastroscopy (or endoscopy) is the main research gastro-oesophageal reflux. One can note detect lesions in the esophagus. The endoscope is a flexible tool that is inserted through the mouth and is equipped with a miniature camera. The research takes place under local anesthetic. One can also use the endoscope to perform biopsies (pieces of tissue removal), which is entirely painless. The patient must be sober for six hours and continue during the investigation, which lasts ten minutes, lying on the treatment table.

Gastroscopy is automatically recommended for people over 50 years. Younger patients receive the study if they do not respond to treatment or relapse after stopping treatment.

"There is no correlation between the severity of symptoms and the severity of the injury," Professor De Koster explains. "Some patients have no symptoms but severe injuries. Other people have severe symptoms while we find no injuries. With endoscopy, we can detect lesions and complications such as ulcers, stenosis and especially esophageal Barrett."

The treatment

To begin with, the patient can try a range of hygiene and nutrition measures that can help in mild reflux. Example, he can avoid as far as possible foods that are known they affect the tone of the sphincter of the esophagus: chocolate, coffee, fatty foods, mint, white wine, Pilipili ...

People suffering from reflux also wear better not tight clothes, they may lie not too soon after eating (in other words, have evening meal so early that they go only two or three hours later to bed), and put the headboard of their bed better fifteen centimeters above the foot. Do not smoke and avoid obesity, are also measures to help counteract the symptoms.

"We have good reason to think that there is a link between body mass index (BMI) and reflux," says Professor De Koster. "Especially male obesity, so a big belly, the contents of the stomach into the esophagus down to Losing weight can help:. One must then less or no medication take more other hygienic and diet measures are not allowed the life of the patient. too difficult, we must up our minds:. if someone is not helped by a strict diet, it's time to take medication, and then people can again eat and drink what they want. ".

Medicines

In addition to hygiene and nutrition measures, treatment with medication. The symptoms of a light reflux can be overcome temporarily with antacids, which neutralize the acidity of the stomach. This is also possible with H2-receptors, which partially block the acid secretion.

But the strongest and most common approach is based on proton pump inhibitors (PPI). The principle? The secretion of positive hydrogen ions block in the stomach: the stomach is then no longer acidic. The reflux itself does not disappear, but it contains no acid. And the suppression of gastric acid is no objection for digestion.

"We see it in the Asian example (see box p. 49): Someone produces little acid, does not suffer from reflux, even if the anatomical causes are present," explains Professor De Koster out. "The treatment with PPI is based on this principle: it reduces the secretion of gastric acid."

But we do not walk away as the Asians, more risk of stomach cancer? "No, because there is an essential difference: the drugs have a limited duration, they are less than 24 hours operating result, the acid gets several hours time to do its job in the stomach, which is sufficient for the harmful bacteria to.. switch that have developed during the day. "

For some patients, it is sufficient a brief treatment of 4 to 6 weeks. But relapses are not uncommon, and require a long-term treatment of one or two years. In worse cases, one should continue to use long-term medications, sometimes for life.

Surgery

"Many people are satisfied with their treatment with PPI," notes Professor Cadiere on. "But not all of them. Some patients tolerate the medication bad, others do not want them to use all their lives, yet others suffer Burp itself and not just the acidity. Those people do not symptomatic but require a causal treatment. In other words, , a mechanical operation that restores the barrier against reflux. This is possible with surgery. "

The Nissen procedure

This is the most classical surgery. "We are trying to reconstruct the sphincter and a valve," explains Professor Cadiere out. "We spend a portion of the stomach behind the esophagus, so that tissue excised should be. This is done using laparoscopy, so through small incisions without opening the abdomen. Between 90% and 95% of patients are satisfied with the operation. After ten years, only 10% relapse. the patient can then use drugs again, but at a lower dose than before the operation. "

"The surgery can have side effects such as dysphagia (difficulty swallowing), diarrhea, bloating (farmers can not), and the inability to vomit. These side effects are difficult to treat, which is one reason why some gastroenterologists hesitate to send their patients to us. another possible complication is the relaxation of the valve. That is rare but when it happens, we have to operate again. "

According to Professor Cadiere continues this surgery worth recommending, inter alia, for patients who relapse after a properly conducted treatment for one year with PPI, or for young patients who do not want to swallow lifelong medication (see operating under part Wanneeer, p. 52 ). "I am more convinced than ever that we generally no longer than five or six years to wait if the patient shows not satisfied with the treatment he has undergone with PPI."

The EsophyX procedure

For two years there is a new procedure was first used in humans in the St. Peter's Hospital and the Leopold Park Clinic in Brussels. The operation is done with a developed in the United States articulated instrument, the EsophyX.

"The instrument is inserted through the mouth," says Professor Cadiere. "With the help of a little screw, we take esophageal tissue, and we bring it downwards, in order to make a cover. We then make it solid with staples. We can use this technique, which requires no incision, offering for sale without that the patients have to wait five years . the operation, however, replace the Nissen procedure is not. the latter remains effective because the EsophyX not reconstructs the sphincter. "

Of the 400 operations with the EsophyX performed worldwide, 250 have occurred in Belgium. The EsophyX is not refundable and is still expensive (only all-in instrument costs nearly 3,000 euros). The Nissen procedure will be fully reimbursed by health insurance.

Choose between drugs and surgery

"It's a difficult choice," says Professor De Koster. "Comparative studies are scarce You should especially understand that surgery is not always a permanent solution. Studies show that 70% of patients re-used drugs after thirty years, even though the dose reduced A large US study recently showed. that long-term effect of surgery is hardly different from this drug. "

"Over the drugs should take the patient's life, I always say that we will sustain the treatment ten years. Why ten years? That's long enough and a fundamental discovery in order to develop its first clinical application. Some changes can be impossible predict. the surgeons would of course like to operate more people than gastroenterologists send them. But it's obviously a personal, subjective choice that depends on the patient and the doctor. it is not a question of right or wrong!

When operate?

if the patient relapses after a well-executed treatment for one year with PPI if a young patient chooses surgery over a lifetime treatment if the patient is not satisfied with the PPI if the patient does not follow a regular treatment to socio-economic or other reasons if the patient suffers from a Barrett's esophagus, which is not stabilized by the treatment, or relapse after cessation of treatment if the patient suffers from a stenosis of the esophagus which does not respond to PPI and endoscopic dilatation.