Jamie from Houston sent us this question: “Hello, I have Gerd for 5 years now, I got the diagnosis after pH bravo testing. PPIs unfortunately don’t help that much with my symptoms, I don’t have a hiatal hernia, so I’m still not sure what causes my GERD. My manometry was normal, the only thing that was found in my endoscopy was a chronic gastritis type C, so I don’t have helicobacter. One doctor told me that the gastritis probably causes my reflux so he wouldn’t recommend surgery because it probably wouldn’t help, another doctor said chronic gastritis doesn’t cause reflux. So, I don’t know what to believe or to do now, I don’t even know if the gastritis or the GERD started first. I wonder if too much acid production or chronic gastritis causes acid reflux. Can a Nissen fundoplication still help to reduce reflux? Or is it even possible that gastritis can be the only cause for acid reflux?
Gastritis or stomach lining inflammation does not cause acid reflux disease or GERD. Gastritis may co-exist with GERD. H pylori is a common cause for gastritis and H pylori does not cause acid reflux disease. Smoking, stress, and daily use of non-steroidal anti-inflammatory drugs, NSAIDs, can also cause gastritis without having any effect on acid reflux.
A weak anti-reflux barrier results in stomach acid backwash into esophagus. Specialized stomach lining cells secretes acid to digest food. Stomach acid levels are tightly regulated, and stomach acid level is not elevated in GERD cases. Most acid reflux patients have a hiatal hernia. However, hiatal hernia is not necessarily a cause of acid reflux disease. There is a difference between cause and association. Indeed, many individuals have a hiatal hernia, but they don’t have acid reflux. Hence, you can have severe acid reflux in the setting of a small hiatal hernia not appreciated by you gastroenterologist on upper endoscopy. By the same token, you can have a normal manometry in the setting of GERD. Manometry is not a diagnostic test for GERD. Ambulatory pH testing, pH Bravo, measures the amount of acid in your esophagus over 4 days. A positive pH bravo study confirms GERD.
Nissen fundoplication restores the anti-reflux barrier. When properly performed, Nissen fundoplication reliably and safely stops acid reflux. Hiatal hernia repair is concomitantly performed with Nissen fundoplication. Hiatal hernia repair restores normal anatomy by repositioning the stomach and lower esophageal sphincter in the abdominal cavity below your diaphragm or breathing muscle. Hiatal hernia repair, however, does not restore normal anti-reflux physiology. Consequently, if you have severe acid reflux symptoms in the setting of positive pH bravo study and small or no hiatal hernia, you can greatly benefit from Nissen fundoplication surgery to stop acid reflux.