GASTRO-OESOPHAGEAL REFLUX DISEASE

What is gastro-oesophageal reflux (GORD)?

This is a condition in which acid leaks from the stomach into your gullet (oesophagus).

What causes GORD?

The valve (sphincter) between the stomach and gullet (oeosphagus) which normally relaxes to allow food to pass into the stomach and stops acid leaking back into the gullet, can become weak or relax inappropriately. This results in leakage of acid from the stomach into the gullet (oeosphagus).

Risk factors for this include:-

• Being overweight or obese – places pressure on the stomach and weakens the valve (sphincter)
• Smoking, coffee or alcohol – cause relaxation of the valve
• Pregnancy – increased pressure on the stomach and hormone changes
• Hiatus hernia – part of stomach migrates upwards through the diaphragm
• Delayed stomach emptying
• Drugs – calcium channel blockers, nitrates, anti-inflammatories
• Stress

What symptoms does it cause?

 Common

• Heartburn – a burning sensation in the chest behind the breastbone
• Regurgitation – food or acidic fluid regurgitate into the mouth or nose

Less common

• Cough – particularly at night
• Hoarse voice
• Bad breath
• Tooth decay

How is it diagnosed?

The diagnosis is normally made on the basis of your symptoms. However where your doctor is uncertain, your symptoms are persistent or unusual (e.g. swallowing difficulty or weight loss), where medications do not work or where surgery is being considered, you may be referred for further tests. These could include:-

• Upper GI endoscopy or OGD – a thin telescope is passed via the mouth to examine the stomach and gullet (oesophagus)
• High resolution manometry – a thin tube is passed via the nose and a series of pressure measurements are made whilst the patient swallows small sips of water to assess the function of the gullet (oesophagus)
• 24 hour pH / impedance studies – a thin tube is passed via the nose into the gullet (oesophagus) where it stays for 24 hours whilst patients eat and drink normally. This measures levels of acid reflux within the oesophagus.
• Barium swallow – the patient drinks a a fluid containing dye that enables a live X-ray picture to be taken during swallowing
• Blood tests

What are the treatment options?

Lifestyle measures

• Eat small regular meals
• Stop smoking
• Reduce coffee and alcohol intake
• Raise the head of the bed
• Maintain a healthy weight

Medical treatment

• Over the counter antacids
• Proton pump inhibitors
• H2 receptor antagonists

Surgical treatment

This may be considered in the following circumstances:-

• Failed medical management – i.e. symptoms not controlled despite optimum medication
• Patient does not wish to take long term medication
• Patient cannot tolerate medication
• Complications relating to reflux (e.g. ulceration / inflammation / lung damage)
• Where anti-reflux surgery has been performed previously and the symptoms have recurred

All patients being considered for surgery are advised to undergo upper GI endoscopy, as well as oesophageal high resolution manometry and 24-hr pH studies in order to confirm the diagnosis and assess the anatomy of the stomach and gullet (oeosphagus).

The aim of surgery is restore the normal anatomy at the diaphragm (by ensuring that the stomach is lying within the abdomen and any hiatus hernia is corrected) and to reinforce the valve (sphincter) at the junction between the gullet and stomach.

What does surgery involve?

Before surgery

Once a decision is made to go ahead with surgery, you will need to attend the pre-assessment clinic, at which a number of routine checks and blood tests will be performed.

The operation

Surgery is performed with keyhole (laparoscopic) surgery. Five tiny incisions are made in the upper part of the tummy (abdomen). The operation involves closing any weakness in the diaphragm with stitches and then wrapping the top section of the stomach (fundus) around the lower end of the gullet (oesophagus) to reinforce the pressure valve (sphincter). This is known as a ‘fundoplication’ or ‘wrap’. The procedure normally takes less than 1 hour and takes effect immediately.

After surgery

All anti reflux medication can be stopped immediately following surgery. Some patients are discharged on the same day as the operation (daycase). Patients are normally ready to be discharged around 4-6 hours following surgery. You will be discharged with painkillers and written post-operative instructions. All stitches are dissolvable. The waterproof dressings are suitable for the shower and can be removed after 7 days.

You are advised to drink fluids only for the initial 24 hours after surgery before commencing a mashed diet for the following 2-3 weeks. More solid foods can then be gradually reintroduced as tolerated.

Recovery can take around two weeks however you are advised to avoid heavy lifting for up to 6 weeks after surgery.

What are the risks of surgery?

• Shoulder tip pain – This is common after keyhole surgery and normally resolves within 24 hours. It is due to gas used to inflate the abdomen during surgery
• Bleeding – This can occur with any operation and on occasions may require a blood transfusion (unless the patient expresses a wish not to). It is more common in patients taking blood thinning medications (e.g. warfarin, clopidogrel, dipyridamole)
• Infection – This may affect the wounds, lungs or site of intravenous lines.
• Blood clots in the legs or lungs (deep vein thrombosis or pulmonary embolism) – Patients wear antiembolism stockings and may receive heparin injections to reduce this risk
• Damage to nearby structures – this is uncommon
• Bloating – this can affect upto 1 in 3 patients and patients may find it diffciult to belch
• Flatulence – due to bloating and inability to belch in some patiens this can lead to increase flatulence
• Diarrhoea – some patients develop diarrhoea following surgery, the cause for which is not always clear. This may require management with medication to control.
• Dysphagia – difficulty swallowing is relatively common in the initial post-operative period but normally improves by 6 weeks. In rare circumstances it may persist longer than 6 months and may require further intervention.

Recurrence – 10-15% of patients may develop recurrent symptoms such as heartburn or acid regurgitation in the future

HIATUS HERNIA

What is a hiatus hernia?

This is a condition in which part of the stomach slips through the opening in the diaphragm (hiatus) into the chest. There are two main types:-

• Sliding (80%)– the stomach slips upwards through the diaphragm
• Paraoesophageal – the stomach and/or other organs slip through the diaphragm alongside the gullet (oesophagus)

What causes a hiatus hernia?

It is thought to arise as a result of weakening of the muscle of the diaphragm and/or increased pressure in the abdomen.

Risk factors include:-

• Increasing age (1 in 3 people over the age of 50 have a hiatus hernia)
• Being overweight or obese
• Pregnancy
• Rarely present from birth – congenital

What symptoms does it cause?

This is dependent on the size and type of hiatus hernia. Symptoms include:-

• Heartburn
• Acid regurgitation
• Chest pain
• Difficulty swallowing
• Breathing difficulty
• Anaemia

What are the treatment options?

Sliding hiatus hernia

No specific treatment is required in those with no symptoms. Where acid reflux is present this should initially be managed by lifestyle measures such as maintaining a healthy weight, eating small regular meals and stopping smoking. Where these measure are ineffective, medical treatment using antacid medication and/or proton pump inhibitor drugs is used. Surgery may be considered in the following circumstances:-

• Failed medical management – i.e. symptoms not controlled despite optimum medication
• Patient does not wish to take long term medication
• Patient cannot tolerate medication
• Complications relating to reflux (e.g. ulceration / inflammation / lung damage)
• Where anti-reflux surgery has been performed previously and the symptoms have recurred

Paraoesophageal hiatus hernia

Surgery is considered in those patients with symptoms or where there is a risk of complications relating to the hiatus hernia.

What does surgery involve?

Before surgery

Once a decision is made to go ahead with surgery, you will need to attend the pre-assessment clinic, at which a number of routine checks and blood tests will be performed.

The operation

Surgery is performed with keyhole (laparoscopic) surgery. Five tiny incisions are made in the upper part of the tummy (abdomen). The operation involves restoring the normal anatomy at the opening in the diaphragm (hiatus) by reducing the stomach back into the abdomen, closing any weakness in the diaphragm with stitches. In some cases the top section of the stomach (fundus) is wrapped around the lower end of the gullet (oesophagus) to minimise reflux and fix the stomach within the abdomen.  This is known as a ‘fundoplication’ or ‘wrap’. The procedure normally takes upto 2 hours.

After surgery

All anti-reflux medication can be stopped immediately following surgery. Most patients are discharged the following day after surgery. You will be discharged with painkillers and written post-operative instructions. All stitches are dissolvable. The waterproof dressings are suitable for the shower and can be removed after 7 days.

You are advised to drink fluids only for the initial 24 hours after surgery before commencing a mashed diet for the following 2-3 weeks. More solid foods can then be gradually reintroduced as tolerated although in some cases you may be advised to maintain the mashed diet for a longer period.

Recovery can take around two weeks however you are advised to avoid heavy lifting for up to 6 weeks after surgery.

What are the risks of surgery?

• Shoulder tip pain – This is common after keyhole surgery and normally resolves within 24 hours. It is due to gas used to inflate the abdomen during surgery
• Bleeding – This can occur with any operation and on occasions may require a blood transfusion (unless the patient expresses a wish not to). It is more common in patients taking blood thinning medications (e.g. warfarin, clopidogrel, dipyridamole)
• Infection – This may affect the wounds, lungs or site of intravenous lines.
• Blood clots in the legs or lungs (deep vein thrombosis or pulmonary embolism) – Patients wear antiembolism stockings and may receive heparin injections to reduce this risk
• Damage to nearby structures – this is uncommon
• Bloating – this can affect upto 1 in 3 patients and patients may find it diffciult to belch
• Flatulence – due to bloating and inability to belch in some patiens this can lead to increase flatulence
• Diarrhoea – some patients develop diarrhoea following surgery, the cause for which is not always clear. This may require management with medication to control.
• Dysphagia – difficulty swallowing is relatively common in the initial post-operative period but normally improves by 6 weeks. In rare circumstances it may persist longer than 6 months and may require further intervention.
• Recurrence – 10-15% of patients may develop recurrent symptoms such as heartburn or acid regurgitation in the future