Acid Reflux

Most surgeons skip the diagnostic workup and go straight to an operation. I do not. Acid reflux looks the same from the outside no matter what is causing it. The only way to know what is happening is to measure it.

The workup answers three questions in order. What does your anatomy look like. How well does your esophagus move. Is acid actually coming up, and how much.

Anatomy first. An upper endoscopy lets me look directly at the lining of your esophagus and stomach. I can see irritation from acid, a narrowing, a hiatal hernia, or changes in the lining that need to be watched. Imaging of the anatomy is added when it will change the plan.

Then motion. Your esophagus is a muscle. It has to squeeze in a coordinated way to move food down. If it does not, some treatments become the wrong choice. Manometry measures that motion.

Then acid. A pH study records how often acid reaches your esophagus and for how long, while you go about a normal few days. Symptoms alone do not tell us this. Some people feel very little and have heavy acid exposure. Others feel a great deal and have almost none. Both of those results change the treatment.

Not everyone needs every test. I will tell you which ones I am recommending for you and what each one is going to answer.

Then we sit down with the results. I will show you what they say in plain language, and we choose the treatment from there. If the testing says an operation will not fix your problem, you will hear that from me.

Read the full upper endoscopy page

This study measures acid. A small wireless capsule is attached to the wall of your esophagus during an endoscopy. It reads how acidic that spot is, over and over, while you go about your normal days.

There is no tube in your nose and no wire taped to your face. The capsule sends its readings to a small recorder you carry with you. You eat normally, sleep in your own bed, and go to work. That matters, because a study done while you are lying still in a lab does not reflect your real life.

You keep a simple log of when you eat, when you lie down, and when you feel symptoms. That log is how we match what you feel to what the capsule measured. It is often the most useful part of the study.

The capsule detaches on its own and passes through your body. Nothing has to be taken out.

When the recording is done, I have a real number for how much acid your esophagus is exposed to and whether your symptoms line up with it. That is what tells us whether acid is the problem, and whether treating it harder is going to help.

Manometry measures muscle. A thin flexible catheter is passed through your nose into your esophagus, and you take small sips of water. Sensors along the catheter record the pressure of each squeeze as it travels down.

That tells me two things. Whether your esophagus moves food along with a normal, coordinated wave, and whether the valve at the bottom relaxes and closes the way it should.

This is why the study matters before any repair is considered. A repair tightens the area where the esophagus meets the stomach. If the esophagus is not squeezing well, tightening that area can leave you with trouble swallowing instead of relief. I want to know that before we make a decision, not after.

The study takes a short time in the office. You are awake for it. It is not comfortable, and I will not pretend otherwise, but it is brief and it changes what we do.

There is no single reflux treatment. The paths run from medical, to endoscopic, to surgical, and the testing decides which one fits you.

Medical. Medication and targeted changes to how and when you eat. For some people this is the whole answer, especially when the testing does not show a structural problem to repair.

Endoscopic. Treatment delivered through a scope passed through the mouth, with no incisions. This is an option for some patterns of reflux and not for others.

Surgical. Repair of the mechanical problem itself, such as a hiatal hernia or a valve that no longer closes. When the anatomy is the cause, medication can only cover the symptom.

I am not going to list a procedure here and let you assume it is the one you need. Two people with the same symptoms can need two different treatments, and I will not know which is yours until the workup is done. [CLINICAL REVIEW: which reflux procedures does Dr. Good perform herself?]

What I will commit to is this. You will get the reason behind the recommendation, in language you can repeat to your family, and you will get the option to say no.

Read the full diagnostic and therapeutic endoscopy page

Reflux means stomach contents move back up into the esophagus, the tube that carries food from your throat to your stomach. Stomach acid belongs in the stomach. The esophagus is not built for it.

Heartburn is the symptom people expect. Many people never get it. Reflux also shows up as a cough that will not quit, a hoarse voice, a lump in the throat, chest pain, trouble swallowing, dental problems, disrupted sleep, or asthma that keeps flaring. That is part of why it gets missed for years.

Underneath the symptoms there is usually a mechanical reason. The valve between the esophagus and the stomach may not close properly. Part of the stomach may have moved up through the diaphragm, which is called a hiatal hernia. The esophagus may not be moving food along the way it should. These are different problems. They need different treatments. You cannot tell them apart by how the symptoms feel.

Here is where I differ from a lot of surgeons. Many go straight from symptoms to an operation, skipping the diagnostic workup entirely. That is how people end up with an operation that was never going to fix their problem. I do not operate on a guess. I test first, I read the results, and the results decide the treatment.

There is one more thing worth saying plainly. The link between reflux and metabolic health runs both directions. Metabolic disease can drive reflux. But an anatomic problem or untreated reflux can also drive metabolic change. When eating hurts, when swallowing is hard, when sleep is broken night after night, your eating, your energy, and your metabolism all shift. Treating the reflux can change the metabolic picture. That is why these two sides of the practice belong together.

People who have been on acid-reducing medication for a long time and still have symptoms, or who do not want to stay on it indefinitely.

People whose symptoms come back the moment they stop medication. That is information, not failure.

People with symptoms that were never connected to reflux. Chronic cough, hoarseness, throat clearing, chest pain that has been cleared by cardiology, trouble swallowing, or sleep that is wrecked by lying flat.

People with a known hiatal hernia, and people who have had reflux surgery before and are still having symptoms.

People being evaluated for metabolic surgery. Reflux changes which procedure is the right one, so it has to be understood first.

Reflux affects more men than women. I mention that because men are less likely to be evaluated for it and more likely to live with it for years, and because a lot of people assume this is not a problem that applies to them.

The conversation. We start with your history. What the symptoms are, when they started, what makes them worse, what you have taken and what it did. This part matters more than people expect.

The workup. Testing looks at three questions. What does the anatomy look like, how well does the esophagus move, and is acid actually coming up. Depending on your case that can include an endoscopy to look directly at the esophagus and stomach, a study of how the esophagus contracts, a study that measures acid over time, and imaging of the anatomy. I will explain which tests I am recommending for you and why. [CLINICAL REVIEW: confirm the exact reflux testing Dr. Good orders and offers in office, including naming conventions she prefers for manometry and pH testing.]

The plan. We sit down with the results and I tell you what they show in plain language. Treatment may be medical management, changes matched to what the testing found, an endoscopic treatment, or a surgical repair of the anatomy. If an operation is the right answer, I will explain exactly why the testing points there. [CLINICAL REVIEW: which reflux treatments and repairs does Dr. Good perform herself, and which does she refer out?]

After. We follow up to see whether the treatment did what it was supposed to do, and adjust if it did not.