Gastro Oesophageal Reflux

What is Gastro-oesophageal reflux? 

Gastro-oesophageal reflux is a common condition, where acid from the stomach leaks up into the oesophagus. When its affecting the patients quality of life, its called gastro-oesophageal reflux disease (GORD).It usually happen when action of the anti-reflux mechanism at the bottom of the oesophagus becoming less functional. Not all who have the gastro-oesophageal reflux are symptomatic. However, many who has it can develop complications later.

Why does GORD occur?

There is a small length in the oesophagus inside the abdominal cavity creating a pressure valve mechanism and there is a angle at witch the oesophagus joins the stomach to create a flap valve mechanism both with contribute towards preventing acid leakage in to the oesophagus. There is a ring of muscle (sphincter) at the bottom of the oesophagus which opens to let food into your stomach and closes to stop stomach acid leaking back up into your oesophagus. This muscle is in the close proximity to the special sling of muscle from the diaphragm which the oesophagus pass through from the chest cavity in to the abdomen which further strengthens the ole oesophageal sphincter.

Some patients develop weakness in the above mentioned ring of muscle at the end of the oesophagus (weakness of the lower oesophageal sphincter). Some patients’ oesophagus become shortened (brachy-oesophagus) and the normal pressure-valve mechanism of the lower oesophagus is lost. Sometimes the stomach herniates in to the chest cavity through the diaphragm compromising anti-reflux mechanism (sliding hiatus hernia).

These results in stomach acid leaking back up into the oesophagus. This causes symptoms of GORD, which can include heartburn and acid reflux.

What are the symptoms of GORD?

When to see your doctor?

Visit your doctor if you're worried about your symptoms, or if:

Depending on the severity of your symptoms, your surgeon will decide on further tests. Tests can help to confirm the diagnosis of GORD, check for other possible causes of your symptoms and determine whether you may be suitable for surgery.

What are the tests for GORD?

Upper gastro-intestinal endoscopy

An UGI endoscopy is a procedure where the inside of your body is examined using an endoscope, which is a long, thin, flexible tube with a light and camera at one end.

The endoscope will be gently inserted into your mouth and down your throat. The procedure is usually carried out while you're awake, but you may be given a sedative to help you relax.

The camera can show if the surface of your oesophagus has been damaged by stomach acid, although this doesn't happen to everyone with GORD.

Barium swallow or barium meal

A barium swallow, or barium meal, is a test to assess your swallowing ability and look for any blockages or abnormalities in your oesophagus.

You are first given some barium solution, then some X-rays are taken. Barium is a harmless substance that shows up clearly on X-rays as it passes through your digestive system.

You'll be asked not to eat anything for a few hours before the procedure. Afterwards, you'll be able to eat and drink normally, although you may need to drink more water to help flush the barium out of your body.

Oesophageal Manometry

Manometry is used to assess how well the ring of muscle at the end of your oesophagus is working, by measuring the pressure in your oesophagus.

This can rule out other possible causes of your symptoms and can help determine whether surgery would be suitable.

During the procedure, a small tube will be passed up your nose and then down into your oesophagus. The tube contains pressure sensors that can detect the pressure in the oesophagus.

24-hour pH monitoring

It may be necessary to measure the acidity level (pH) in your oesophagus to confirm a diagnosis of GORD if nothing is found during an endoscopy.

The acidity level is measured over 24 hours, using a thin tube containing a sensor that's passed up your nose and down your oesophagus. This is usually connected to a recording device worn on your waist.

You'll be asked to press a button on the recorder every time you become aware of your symptoms and to record your symptoms in a diary. You should eat as you normally would during the test to ensure an accurate result.

Blood tests

Sometimes a blood test may be carried out to check for anaemia, which can be a sign of internal bleeding.

Complications of GORD

A number of possible complications can occur as a result of having gastro-oesophageal reflux disease (GORD) for a long time.

Oesophageal ulcers

The stomach acid that leaks into the oesophagus in people with GORD can damage the lining of the oesophagus (oesophagitis), which can cause ulcers to form.

These ulcers can bleed, causing pain and making it difficult to swallow.

Medications used to treat GORD, such as proton pump inhibitors (PPIs), can help ulcers heal by reducing the amount of acid that leaks into the oesophagus. Read more about treatments for GORD.

Scarred and narrow oesophagus

Repeated damage to the oesophagus by stomach acid can also cause it to become scarred and narrowed.

This is known as oesophageal stricture and it can make swallowing difficult and painful.

If this happens, a procedure to widen the oesophagus (Endoscopic stricture dilatation) using a small balloon or other widening device may be recommended.

Barrett's oesophagus

Repeated episodes of GORD can sometimes lead to changes in the cells in the lining of your lower oesophagus. This is known as Barrett's oesophagus.

It's estimated that about 1 in every 10 people with GORD will develop Barrett's oesophagus, usually after many years.

Barrett's oesophagus doesn't usually cause noticeable symptoms other than those caused by GORD.

However, there's a risk that the changed cells could become cancerous in the future. Your doctor may suggest having an therapeutic endoscopy (such as Endoscopic Argon Plasma Coagulation of the Barret's epithelium) to treat it or diagnostic endoscopy every one or two years or less to check for this.

Oesophageal cancer

It's estimated that 1 in every 10-20 people (or 1 in every 200 every year) with Barrett's oesophagus will develop oesophageal cancer within 10-20 years.

What are the treatment options?

The main treatments for GORD are:

Lifestyle modifications:

Eat smaller and more frequent meals, rather than 3 large meals a day – don't eat or drink alcohol within 3 or 4 hours before going to bed, and avoid having your largest meal of the day in the evening.

Avoid anything you think triggers your symptoms – common triggers include coffee, chocolate, tomatoes, alcohol, and fatty or spicy food.

Don't wear tight clothing – clothes that are tight around your tummy may make your symptoms worse.

Raise the head of your bed by up to 20cm (8 inches) – placing a piece of wood or blocks underneath one end of your bed may reduce symptoms at night; don't just use extra pillows, as this can put a strain on your tummy.

Try to relax – stress can make heartburn and GORD worse, so learning relaxation techniques may help if you're often feeling stressed.

Maintain a healthy weight – if you're overweight, losing weight may help reduce your symptoms.

Stop smoking – smoke can irritate your digestive system and may make your symptoms worse.

If you're taking medication for other health conditions, check with your doctor to find out whether they could be contributing to your symptoms (such as NSAIDS: Asprin, Brufen, Voltaren/Diclofenac).

Medication

Antacids – these neutralise the effects of stomach acid temporarily

Alginates – these produce a coating that protects the stomach and oesophagus from stomach acid

Proton-pump inhibitors (PPIs)

H2-receptor antagonists (H2RAs)

You may only need to take medication when you experience symptoms, although long-term treatment may be needed if the problem continues

Surgery for GORD

Surgery may be an option if the above treatments don't help, aren't suitable for you, or cause troublesome side effects or you don't want to take medication on a long-term basis

The main procedure used is called a laparoscopic Nissen fundoplication (LNF). Alternative modified techniques have been developed more recently.

Laparoscopic Nissen's fundoplication (LNF)

LNF is a type of laparoscopic or "keyhole" surgery. This means it's carried out using special surgical instruments inserted through small cuts (incisions) in the skin.

The procedure is used to tighten the ring of muscle at the bottom of the oesophagus, which helps to stop acid leaking up from the stomach. It's carried out in hospital under general anaesthetic.

Most people need to stay in hospital for 2 or 3 days after the procedure. Depending on your job, you may be able to return to work within 3 to 6 weeks.

For the first 6 weeks after surgery, you should only eat soft food, such as mince, mashed potatoes or soup. Some people experience problems with swallowing, belching and bloating after LNF, but these should get better with time.

Newer operations and procedures

Endoscopic injection of bulking agents – where special filler is injected into the area between the stomach and oesophagus to make it narrower.

Endoluminal gastroplication – where folds are sown into the ring of muscles at the bottom of the oesophagus to restrict how far it can open.

Endoscopic augmentation with hydrogel implants – where implants containing special gel are placed into the area between the stomach and oesophagus to make it narrower.

Endoscopic radiofrequency ablation – where a tiny balloon is passed down to the bottom of the oesophagus and electrodes attached to it are used to heat it and make it narrower.

Laparoscopic insertion of a magnetic bead band (LINX) – where a ring of magnetic beads are implanted around the lower part of the oesophagus to strengthen it and help keep it closed when not swallowing.