What’s the story behind this GERD treatment continuum?
(aka rainbow infographic)
This infographic is designed to represent the GERD patient’s symptom and treatment journey.
Blue Zone: Early disease is typically experienced as mild symptoms on an infrequent basis, and is often characterized simply as reflux or heartburn.
Patients begin treating their occasional reflux symptoms by making changes to their lifestyle:
- Adjusting diet—by eliminating specific foods, eating smaller more frequent meals, carefully timing meals
- Sleeping with the head in a 30 degree elevation allowing gravity to help stomach contents stay down.
- Taking over the counter medications like antacids and H2 blockers
At some point, patients suffering from more frequent symptoms may ask a healthcare professional about how to better treat or manage GERD. They are likely to be given a prescription for proton pump inhibitors (PPIs) which will help with most symptoms for a period of time.
Yellow Zone: For many, symptoms will be managed with medical therapy, although that therapy may need to be taken indefinitely. The key divider for many patients occurs when their symptoms are not adequately controlled by continued PPIs or even high dose PPIs. Despite medication, symptom frequency and severity continue.
Ongoing symptoms may indicate that there is an anatomic issue causing a patient’s reflux. At this point, thorough examination by a GERD specialist will help confirm whether or not this is true.
Orange zone: Notice the gap between the medical therapy and conventional surgical approaches. After examination of the anatomy, the patient may be told that the structures are not normal and are likely contributing to their regularly occurring and intensifying GERD symptoms. Patients are usually presented with the option of surgical intervention.
Traditional surgery has a well-documented risk/reward profile. GERD symptoms are frequently resolved; however that resolution may also come with a new and different set of symptoms (difficulty swallowing, gas bloat, flatulence)—side-effects from traditional surgery.
When faced with this trade off, a patient and their physician may decide to delay anatomical correction with traditional surgical methods until anatomy has broken down to a point where symptoms are severe and mostly uncontrolled by any medications and lifestyle modifications.
Ideally, a better way to fill the gap would be a minimally invasive procedural intervention that:
- corrects anatomy, restoring the gastroesophageal junction to more normal function
- provides relief from GERD symptoms as well as or better than lifestyle and medications
- does not introduce a new set of side-effects.
Green, Yellow, Orange, and Red Zones: After seven years of clinical study and more than 40 published papers, the TIF procedure has emerged as a method to fill that treatment gap without making any cuts into the body. Because the TIF procedure is performed through the mouth, there are no incisions making it less invasive then traditional or laparoscopic surgery; this contributes to a low number of reported complications. Clinical data has demonstrated that the TIF procedure can control reflux symptoms better than PPI therapy(1) and avoids the long-term complications associated with traditional surgery(2).
There is a key overlap between medication and the TIF procedure. This is because patients that are showing early anatomical breakdown may experience any one or a combination of these situations:
- Require max dose prescription strength PPIs for months or years to control GERD symptoms
- Begin to experience reflux symptoms on max dose prescription strength PPIs
- Report an incomplete response to max dose prescription strength PPIs
- Suffer from atypical, non-erosive symptoms and/or have an insignificant response to max dose prescription strength PPIs
- Patient may become uncomfortable having to depend on max dose prescription strength PPIs due to a fear of long-term side effects associated with prolonged use of PPIs
Red Zone: The gastroesophageal reflux disease (GERD) is progressive and frequency and severity of symptoms often increase affecting daily quality of life regardless of lifestyle changes and medication. At this point in the disease patients’ quality of life is negatively affected.
Since the 1950’s, the most severe cases of GERD have been surgically treated with Nissen fundoplication to repair the anatomical structures—first open and now most typically laparoscopically. These surgeries, if performed in highly specialized centers, result in excellent symptomatic relief. However, in addition to well documented side effects associated with this surgery, results in community centers are less favorable. Therefore, fewer and fewer patients chose this option due to side-effects and concerns over surgical intervention.
The other key overlap between the TIF procedure and conventional surgery exists because once anatomy breaks down in the most severe cases; the only option remaining is traditional fundoplication techniques. Patients approaching severe GERD may have following conditions:
- Hiatal hernia (different in sizes and types)
- High Hill grade (III and IV) which indicates more severe anatomic changes
- Presence of esophagitis ( often graded by Los Angeles classification)
- Barrett’s esophagus ( needs endoscopic surveillance regardless of reflux treatment modality)
The above are indicators of GERD severity and factors that may disqualify a patient for the TIF procedure. Conventional surgery is still an option.
Any set of consistent symptoms that increase in frequency and severity should not be ignored. It’s important to speak with a medical professional to get a diagnosis which will determine an appropriate treatment plan.
To find a TIF-trained physician in your area enter your zip code into the search function on the right-side of this page.
Emir Deljkich leads medical affairs and is a clinical contributor to this blog. Emir has a front row seat to the clinical validation of the TIF procedure—he contributes to study designs, evaluates data from clinical studies and manages the largest TIF Registry conducted to date. Emir is an aficionado of competitive youth soccer and spends his weekends watching his child play.
Debbie Donovan is in the marketing department and is editor of this blog. She’s also managing the GERDHelp social media channels where we post hot stories on heartburn, acid reflux, GERD, Barrett’s esophagus and esophageal cancer. Deb ice skates and likes routines with fancy footwork and spins.