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Hyperacidity & role of surgery


Hyperacidity (GERD / gastritis / peptic ulcer / hiatus hernia) & Role of Surgery:


Hyperacidity is a term loosely used by people to express a group of symptoms like upper abdominal or chest (behind the sternum) discomfort / vague pain, nausea, bloating, occasional vomiting (sometimes self-induced in the hope of relief), tightness in the chest or abdomen, excessive burps etcetera. Often it is combined with back pain, neck pain, headache, flatulence, constipation, increased frequency of stools, foul smelling stools and many more. It is important for the doctor at such times to differentiate the exact organ involvement whether it is esophagus, stomach, pancreas, gall bladder, small intestine, large intestine; in short the entire GI system. This will be followed by making a clinical diagnosis like gastritis, acid reflux disease / GERD, pancreatitis, cholecystitis, colitis, renal colic, enteritis or anything else. When complaints are few and pertinent it is easier for the doctor to pinpoint the organ e.g. retrosternal / upper abdominal burning / pain, nausea, vomiting, bloating, regurgitation usually points towards esophagus and stomach. Rarely these could be complaints of a heart attack or biliary-pancreatic pain or even renal pain. However these are the most common complaints attributed to hyperacidity or excess acid in the stomach by patients. Often acid and bile are both labelled / mixed as पित्त by the patient.

These complaints are grouped under term dyspepsia and represent a variety of problems as mentioned above. However Only those diseases which arise from direct or indirect effect of gastric acid or diseases that lead to higher gastric acid secretion and therefore it’s ill effects can be considered under “hyperacidity” or acid peptic disease or ulcer dyspepsia. Those dyspeptic complaints that are due to biliary / pancreatic cause are termed pancreato-biliary dyspepsia. Those which are due to other organic causes are combined under non-ulcer dyspepsia. Finally those patients who are found to have no organ involvement after thorough and complete investigations; are considered for a possibility of functional dyspepsia. This includes stress / anxiety / depression related dyspepsia complaints. Patients often have overlapping problems like gall stones, gastritis and anxiety-depression.

What is true hyperacidity?

True hyperacidity or ulcer dyspepsia can include diseases like gastritis / inflammation of inner lining of stomach, peptic ulcer ( duodenal and gastric) and acid reflux disease / GERD. These problems directly arise from excessive acid secretion or reflux of normal or excessive acid from stomach into esophagus. Hiatal hernia and esophagitis / inflammation of inner lining of esophagus are often part of GERD.

What is gastritis?

Gastritis is inflammation / swelling of the innermost lining / mucosa of stomach

What is esophagitis?

Esophagitis is inflammation / swelling of the innermost lining / mucosa of esophagus

What is duodenitis?

Duodenitis is inflammation / swelling of the innermost lining / mucosa of duodenum

What is a peptic ulcer?

Peptic ulcer is an ulcer or wound in the lining of stomach / duodenum / esophagus resulting from the gastric acid.

What is GERD?

GERD or gastroesophageal reflux disease is reflux / reversed flow of normal or excessive secreted acid & gastric contents from stomach to esophagus.

What is the cause of high acid secretion?

High acid output by stomach could be due to drugs like painkillers especially strong painkillers (e.g. ibuprofen, diclophenac), steroids or even due to some antibiotics. Other causes are infections due organism like H. Pylori or smoking, alcohol, food products like citrus fruits (lemon), chocolates, spices like chilly ( red/green), pepper, rancid oil, food colouring agents, aerated drinks etcetera. Stress (anxiety / depression) perceived or at subconscious also provokes acid secretion. Rarely acid is excessively produced due to some tumors called gastrinoma.

What is the cause of GERD / acid reflux?

Acid can reflux into esophagus if the pressure in the stomach / abdomen becomes more than esophagus. There are many medical explanations for such scenario. Commonest being obesity. It can also happen after excessive eating and drinking especially fuzzy drinks. It can simply happen during bending forwards or lying flat immediately after meals when stomach is full.

Acid can also reflux when there is abnormal relaxation / decreased tone of the muscle at the lower end of esophagus. This can happen with or without a hiatus hernia. However hiatus hernia further decreases the tone and increases the reflux. The muscle tone can also reduce due to various medications and food products.

What is a hiatus hernia?

In the normal scenario the esophagus enters the abdomen through an opening in the thoracic diaphragm like many other important structures. The normal junction of esophagus and stomach is in the abdomen. Various attachments / supports and protective body mechanisms (diaphragmatic crura) maintain this normal anatomy. However when the supports and protective mechanisms fail due to excessive intraabdominal pressure / natural defects then the entire gastroesophageal junction complex starts moving upwards or it gets pushed inside the lower thorax. In short it gets herniated through the diaphragmatic hiatus into thorax. This is called hiatus hernia that we are discussing. There are other types of hiatus hernia too; but they are irrelevant to the topic under discussion.

What is the cause of symptoms?

Symptoms occur due to inflammation/ swelling of the lining of esophagus / stomach / duodenum or ulceration.

What are the symptoms?

Most of the common symptoms have been mentioned in the beginning of the article. Apart from them patients sometimes have respiratory complaints if the acid reflux reaches the vocal cords (causing inflammation and hoarseness of voice), bronchi / lungs (causing inflammation / bronchitis and recurrent cough), throat (pharyngitis & difficulty in swallowing or pain during swallowing). It can also give rise to dental problems like gingivitis.

Some patients can develop complications like bleeding from acute or chronic ulcers (blood vomitus when large quantity / black stools when small quantity), chronic deep ulcers, stomach / duodenal ulcer perforations from acute or chronic ulcers, narrowing of esophageal / stomach / duodenal lumen ( especially following healing of chronic ulcers) causing vomiting and some patients can develop esophageal or stomach cancer.

Will the patient need investigations?

Young patient with very classical symptoms can be given a trial of medication without any investigations especially if there is associated supportive history to point out cause like medications or alcohol.

However many patients especially middle aged to elderly or those with vague complaints or those who have previously received some treatment will certainly need investigations. These include basic investigations like CBC, stool test (to rule out occult blood, worms and infection like giardiasis/ amoebiasis), liver function tests and abdominal sonography. An endoscopy of esophagus & stomach may be asked straightaway or after the initial investigations are checked.

An endoscopy can reveal esophagitis, hiatus hernia, gastritis, duodenitis, ulcers / erosions, polyps, tumor etcetera. Biopsy/multiple biopsies may be taken based on findings. Biopsy sample will be tested for H Pylori status (Rapid Urease Test — RUT). H Pylori is often tested in the clinic on a breath urea test. Patients with H Pylori gastritis may require repeat endoscopy to see treatment response especially if symptoms persist. At such times biopsy sample maybe sent for antibiotic culture sensitivity test. Similarly patients with complicated GERD may require repeat endoscopy at frequent intervals to assess treatment response.

Patients with severe GERD, hiatal hernia and complications like precancerous changes or early narrowing may be asked to do 24 hour Ph study and esophageal manometry (study of inta-esophageal pressures). This helps in deciding whether patient will benefit with a surgery. These tests will also be done if there is no response to initial medical line of treatment.

If a cancer is suspected then biopsy sample is sent for histopathology. When a gastrinoma is suspected serum gastrin levels will be checked after stopping all medications for at least 2 weeks.

What is the treatment for gastritis / peptic ulcer / GERD / hiatus hernia ?

Medications that reduce acid secretion are the pillars of treatment. There are various drugs from baseline to 2nd & 3rd line used depending on severity and treatment response to initial medication. The treatment duration may vary from few days to many weeks followed by a gradual tapering of dosage. Apart from the drugs that reduce acid secretion, drugs increasing esophageal & gastric motility are also sometimes prescribed to clear the contents and prevent reflux. Simple antacids in multiple combinations are used to prevent further damage to the lining.

Patients with H Pylori need specific set of antibiotics for 10-15 days. If there is no response to 1st line therapy due to resistant organism or patient compliance problems, 2nd and 3rd line treatments are necessary.

Apart from medications patients are instructed about dietary restrictions like avoiding spicy oily citrus foods, fuzzy beverages, chocolates, smoking, tobacco in any form, alcohol, coffee etcetera. Also lifestyle modifications like multiple small meals, exercise, meditation, elevating head end of the bed, not lying down for 2-3 hours after meals, weight reduction if obese, stress relief techniques are recommended.

Who needs a surgery? What is the nature of surgery?

In today’s era surgery is rarely required for acid related issues due to excellent medications. Still an occasional patient with complications of benign peptic ulcer needs an acid reducing surgery along with a bypass for food if stomach is obstructed.

Patients with GERD & hiatus hernia sometimes need a surgery called fundoplication in which upper portion of stomach (fundus) is wrapped around lower end of esophagus thus preventing acid reflux. Fundoplication is required in patients who do not respond well to medical management or develop complications of acid reflux like precancerous changes called Barrett’s esophagus or narrowing or worsening esophagitis. Patients with GERD and a large hiatus hernia often need surgery however surgery is usually not required for small hiatus hernia.

Both the surgeries are usually done laparoscopically. Occasionally there are limitations to laparoscopy due to disease factors or patient factors. In such situations an open surgery is required.

What benefit is expected from the surgery?

Acid reducing Surgery / vagotomy for complicated peptic ulcer disease will reduce acid production. The gastric drainage procedure or partial stomach removal is often combined with this to help stomach drainage.

Fundoplication prevents the acid reflux into esophagus by keeping lower end of esophagus closed except during swallowing.

Are there any postoperative problems after fundoplication?

Most patients may have little tightness during swallowing in 1st few weeks after surgery. This discomfort usually disappears over time.

Problems occur when the fundoplication/wrap is too loose or too tight. In the 1st situation the reflux complaints will not be relieved. In the later situation patients find it difficult to swallow food.

Apart from this uncommon complications like recurrent hiatus hernia, migration of the wrap can occur.

Are there any problems after acid reducing surgery?

Dumping syndrome is the most important and troublesome problem that can occur after a gastrectomy for benign ulcer. The primary function of the stomach is to act as a reservoir, initiate the digestive process, and release its contents gradually into the duodenum so that digestion in the small bowel is optimally performed. The anatomical changes that result after gastrectomy affect the emptying time of the stomach. If the pyloric valve located between the stomach and first part of the small intestine (duodenum) is removed, the stomach is unable to retain food long enough for partial digestion to occur. Food then travels too rapidly into the small intestine producing a condition known as Dumping syndrome.

This syndrome is characterized by a lowered tolerance for large meals, rapid emptying of food into the small intestine or “dumping,” abdominal cramping pain, diarrhoea, lightheadedness after eating as well as increased heart rate and sharp drops in blood sugar levels. Symptoms may occur approximately one-half hour after eating ("early" dumping syndrome) or they appear two to four hours after eating (“late” dumping syndrome). The carbohydrate component draws water into the intestinal lumen causing sudden fluid shifts in the early dumping whereas late dumping is caused by a reactive hypoglycemia. The incidence and severity of symptoms are related directly to the extent of gastric surgery.

Treatment of Dumping syndrome includes small frequent meals which are high protein & low carbohydrate (especially low in concentrated sweets) diet. Fluids should be taken at the end of the meals and in limited quantity.. On occasion, medications may be required to help control these symptoms.

Apart from “Dumping”, recurrence of ulcer is another important complication after acid reducing surgery (vagotomy with drainage or gastrectomy). This may happen if the stomach denervation (vagotomy) is inadequately done. It may be managed with medicines but can require a second surgery.

The rapid gastric emptying can affect calcium absorption in the small intestines leading to calcium deficiency over a period of many years. This can cause osteoporosis many years later.

Iron deficiency anemia can develop because removal of the stomach often leads to a marked decrease in the production of gastric acid. This acid is necessary to convert dietary iron to a form that is more readily absorbed in the duodenum. Anemia usually does not occur for a few years after gastric surgery because iron is stored in moderately large amounts in the bone marrow, where red blood cells are produced.

Oral iron and calcium supplements are often needed to prevent the development of deficiencies in these minerals.

Life after surgery / survivorship:

Patients will require regular follow up after surgery whichever it may be. This will help to pick up nutritional deficiency, early symptoms of surgical failure / side effects / complications / disease progression and treat them on time. Some patients will require intermittent endoscopic assessment or imaging in the form of CT scan.

Surveillance after fundoplication:

Patients who have developed premalignant changes in the esophagus will certainly require regular surveillance endoscopy at frequent intervals.

Is there any alternative treatment to fundoplication for precancerous change (Barrett’s esophagus)?

Barrett’s changes are often reversible after fundoplication. However high grade / dangerous changes may require an endoscopic resection prior to fundoplication. Rarely an esophagectomy (removal of part or complete esophagus) is required.

For more information on Liver, Gall bladder and Pancreatic surgery work done by Dr.D.R.Kulkarni,


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