Gastro Oesophageal reflux disease - OTFC
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Gastro Oesophageal reflux disease

When refluxed stomach acid touches the lining of the oesophagus, it causes a burning sensation in the chest or throat called heartburn. The fluid may even be tasted in the back of the mouth, and this is called volume reflux. Occasional heartburn is common but does not necessarily mean one has a serious problem. Heartburn that occurs more than twice a week may be worth investigating.

Anyone, including infants, children, and pregnant women, can have GORD.

 

Symptoms

The main symptoms are persistent heartburn and acid regurgitation. Some people have GORD without heartburn. Instead, they experience pain in the chest, hoarseness in the morning, or trouble swallowing. You may feel like you have food stuck in your throat or like you are choking or your throat is tight. GORD can also cause a dry cough and bad breath.

The most frequent symptoms of GORD are so common that they may not be associated with a disease. Self-diagnosis can lead to mistreatment. It is preferable to have the symptoms properly investigated rather commencing long term treatment on the assumption that you have reflux.

 

Causes

Hiatushernia- hiatushernia occurs when the upper part of the stomach is above the diaphragm, the muscle wall that separates the stomach from the chest.

Alcohol use – particularly white wine and spirits

Overweight – with increasing obesity most people will develop reflux

Pregnancy – this can be problematic , but generally resolves after the baby is born

Smoking – smoking has nothing to recommend it – reflux is just one of the many problems it causes

Posture – reflux is often worse when lying or bending. Activities such as gardening can make it worse. It may wake you from sleep with pain, coughing or choking. Occupations that require bending or lying flat eg. Car mechanics, can be very difficult if you have severe reflux.

 

Certain food and drinks are also associated with reflux> Spicy and fatty foods as well as coffee are all known to worsen reflux. Cola drinks, such as Coca Cola also make the problem worse

 

Diagnosis

  1. Medical history
  2. Response to acid suppressing medication A trial of medication such as omeprazole (Losec) is often prescribed by your GP. Most people with reflux will experience significant improvement in their symptoms when taking this. However, the problem is likely to recur when the medication is discontinued. You should have the problem further investigated with a gastroscopy prior to embarking on long term medication. This is done to ensure you do not have other problems that are more serious.
  3. Barium swallow radiograph A barium examination uses X rays to take a picture of the oesophagus and stomach. It can be useful to delineate hiatus hernias and some other abnormalities. It is often used first if the main symptom is difficulty swallowing.
  4. Endoscopy (Gastroscopy).

 

Treatment

Conservative treatment
Life style modification

  • Reduce weight if overweight
  • Restrict coffee to one or two cups per day
  • Reduce alcohol to one or two standard drinks per day
  • Avoid rich, spicy or fatty meals
  • Avoid going to bed immediately after a large meal
  • Sleep slightly propped up

 

Medications

  • Antacids, such as Mylanta or Mucaine are useful if the problem only occurs occasionally
  • H2 Antagonists, such as ranitidine (Zantac) can provide more long lasting relief
  • Proton pump inhibitors, such as Omeprazole (Losec) are the most powerful in terms of acid suppression. Some people will need to take them daily, others just need them every now and then – “on demand”
  • Alginates, such as Gaviscon, these can be soothing. They are not absorbed and there is no concern about use during pregnancy
  • Prokinetic agents. These drugs are used to try and speed emptying of the oesophagus and stomach. The main drug used for this today is Nizatidine (Tazac). This is often used in combination with a proton pump inhibitor

 

It is important to note that reflux is not a problem that is cured by a course of medication. If major lifestyle change can be implemented – eg substantial weight loss, then the need for medication may pass. However, for most people, long term medication is required, unless symptoms are sufficiently severe to warrant surgery.

 

Surgical treatment of reflux

Surgery is an option when medicine and lifestyle changes do not completely control the problem. Surgery may also be a reasonable alternative to a lifetime of drugs if you are young or planning pregnancy.

 

Laparoscopic Fundoplication

This surgery is performed under general anaesthesia.

If a combination of lifestyle changes and drug therapy does not remedy reflux symptoms, a Fundoplication can be a very effective surgical procedure to correct reflux. This procedure involves wrapping the upper portion of the stomach around the lower end of the oesophagus to reinforce the strength of the lower oesophageal sphincter. Until recently, the procedure required a large abdominal incision. A hospital stay of 5 or more days was usually required, and the time to full recovery and return to work was measured in weeks.

 

A laparoscopic Fundoplication is a minimally invasive approach that involves specialized video equipment and instruments that enable us to perform the procedure through five tiny incisions, most of which are less than a half-centimetre in size. One advantage of this method is a brief hospitalization. Most of the time it will require one or two nights’ stay. Other advantages include less pain (less of a need for pain medication), fewer and smaller scars, and a shorter recovery time.

Laparoscopic Fundoplication is generally a very effective treatment for GORD. However, in rare cases the laparoscopic approach is not possible because it becomes difficult to visualize or handle organs effectively. In such instances, the traditional incision may need to be made to safely complete the operation.

 

There are a variety of techniques available for performing fundoplication. My preference is to perform a “Toupet” fundoplication where the stomach is wrapped partially around the back of the oesophagus. Other techniques wrap more or less of the circumference of the oesophagus. I prefer a partial wrap as there is less risk of swallowing and bloating problems after surgery.