Reflux Treatment – Medication
Proton Pump Inhibitors
These work by reducing the amount of acid produced by the stomach so that any reflux fluid is no longer acidic. In this way, symptoms are reduced and any inflammation is allowed to heal. It is important to understand that these medications do not stop mechanical reflux as such, just reduce the amount of acid made and therefore the amount of acid that can reflux. In most cases, this is sufficient but certain symptoms may not respond to acid reduction – e.g. regurgitation, cough / choking at night.
Some patients find they experience infrequent episodes of reflux that need treatment for a few weeks then settle. Others find that they have chronic persistent symptoms that require ongoing medication. If they stop the medication, the symptoms return very soon. They are thus “medication dependent”. In this case, it is likely that the patient will require medication for life. Long-term use of acid suppressing medications are generally thought to be safe. However these have been associated with osteoporosis and an increased risk of gut and lung infections. It is also possible that over time, increasing doses will be required to maintain control of symptoms.
At times, other medications that create a “barrier” – such as Mylanta or Gaviscon may be used to treat symptoms intermittently. Agents that improve the emptying of the stomach are also employed in specific circumstances and can act in concert with acid suppression to good effect.
Reflux Treatment – Reflux Surgery
When medications and lifestyle measures do not control the symptoms adequately, surgery to reinforce the valve at the lower end of the oesophagus may be appropriate.
Surgery may also be reasonable if you have chronic reflux and prefer not to use medication long term. Surgery is generally very effective in controlling the symptoms of reflux and medication can usually be stopped. Surgery to stop reflux is called a “fundoplication”.
It is usually a “keyhole” (laparoscopic) procedure. This is generally well tolerated and recovery is fairly rapid. A general anaesthetic is required. The surgery is performed through 4-5 small keyhole incisions (5mm-1cm) in size. Hospital stay may vary from 2-3 days and time off work 2-3 weeks.
The aim of surgery is to use the upper part of the stomach to create a “wrap” around the lower oesophagus (gullet) to create a “pressure zone” and replace and augment the defective valve (Lower oesophageal sphincter, LOS) to stop stomach content refluxing up into the oesophagus. The “wrap” can be “complete” or “partial” For detailed discussion please speak to your surgeon. Briefly there are complete & partial fundoplication (wraps)…
- Complete wrap (strengths)
- Oldest and a durable operation
- Used in many studies (even those with Barretts)
- Good satisfaction rate
- Complete wrap (weakness)
- Food tolerance not as good as partial wrap (dysphagia)
- Bloating and inability to burp
- Passage of flatus
- Partial wrap (strengths)
- Great satisfaction rate
- Less issues with bloating
- Better food tolerance (in the short term)
- Partial wrap (weakness)
- Established but not as long as the complete wrap
- No uniform technique in partial wrap.
- Passage of flatus
Surgery is generally safe with a low complication rate. Some risks include perforation of the oesophagus or stomach, bleeding or infection. The operation may sometimes create side effects including some difficulty with swallowing and wind trapping in the bowels which may cause bloat and extra passing of wind but most often these symptoms are mild and improve with time.
Post Reflux Surgery
In the appropriate patient, surgery is very successful (>90%) and satisfying. However, there are minor and sensible adjustments to lifestyle post surgery. The aim of surgery needs to be balanced with your symptoms and your expectation from surgery.
Almost all patients with “problematic” reflux are prepared to trade-off “reflux” for “lifestyle adjustment” as long as they are aware and prepared. The adjustments essentially involve having to chew and enjoy food thoroughly and minimization of carbonated drinks as they lead to bloatiness and flatulence.
Most patients will experience some degree of weight loss in the early phase. They will often regain this weight in approximately 2 years. Most patients will be off acid suppressing tablets approximately a month afterwards, however some patients may still elect to stay on it.
A common reason includes taking another medication that may erode the stomach (eg. Aspirin) and the acid suppressants can protect the stomach.
Eating well after fundoplication
Soon after the operation, there is some swelling that will over time settle. In the short term, the swelling makes the esophagus less pliable where it enters the stomach. This is a completely normal phenomenon.
Eat and drink slowly. Avoid gulping, chew and enjoy your food thoroughly.
- To help minimise burping and belching, avoid fizzy or carbonated drinks.
- When on a liquid diet, ensure that you receive sufficient protein content for wound healing. This should be in the form of milk or mild derived products, fruit smoothins, eggflips or commercially available supplements such as Resource, Ensure, 2-Cal
- Chew food thoroughly and carefully. Avoid foods that are lumpy and cannot be broken up easily. In the early phases, these include soft white bread, doughy pasta, dry hard meats or those with sinews.
Following Reflux Surgery
Please discuss with your surgeon. There are 3 phases of dietary upgrade. Pending the type of your surgery, the duration of phases will be discussed with you before discharge.
- Fluid phase- Whilst in hospital, you will start on a fluid diet which needs to be maintained until instructed. If anything else besides fluids arrives on your meal tray, do not eat it.
- Puree/ mashed phase- If you feel that you have no issues at the end of the instructed fluid phase, start on the pureed/ mashed phase. Essentially this requires putting all food through a blender. This should start off as thin as drinking up a straw. Over time, the consistency can be thickened to be picked up by a fork.
- Soft diet phase- If you feel that you have no issues at the end of the pureed phase, start on the soft diet. This avoids any large lumps and pieces that are potentially doughy or dry. Gradually increase on the consistency. If at any stage, pain or discomfort happens, then take a step back to your “comfortable” texture for a couple of days then “retry”.
- Normal diet- This involves sensible eating, chewing food well and minimizing carbonated beverages. Progress to a normal diet can vary between individuals.
Foods to generally avoid in this early phase include- Fresh bread, cake, cereals with dry fruits and nuts, lumpy meats, fruits with skin or pith, vegetables with high indigestible fibre, large pieces of cheese, crispy fried food and carbonated beverages.
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