Gastro-oesophageal reflux Disease

Gastro-oesophageal reflux Disease


What is Gastro-oesophageal reflux Disease (GORD)?

This is often mistakenly referred to as heartburn. Heartburn is one of the many symptoms that one can get from GORD. This condition arises when there is a failure of the anatomical lower oesophageal sphincter to stop the stomach contents ‘refluxate’ from getting into the oesophagus. The failure of the body’s natural antireflux mechanism can be due to:

  • Transient Lower Oesophageal Sphincter Relaxations
  • Vagal mediated reflex
  • Not associated with swallow induce relaxation
  • Persists for longer than 10 seconds
  • Frequency is increased by distension of the stomach by gas
  • Hypotensive Lower Oesophageal Sphincter
  • Associated with:
  • Obesity
  • Smokers
  • Caffeine/ chocolate
  • Disruption of GOJ, often associated with a hiatal hernia

How is Gastro-oesophageal reflux Disease (GORD) diagnosed?

This would require a visit to a specialist who will take a thorough history and perform a complete physical examination. Most patients will require a gastroscopy as an initial investigation. Additional investigations can include oesophageal manometry and Ph studies as well as radiological imaging which might be a barium swallow or CT scan with oral contrast depending on the patients history and findings.

What is oesophageal pH and manometry studies?

Oesophageal manometry is used to assess the contractions of the oesophagus to check if there is any underlying motility problem with the oesophagus. This involves passing a small tube through one of your nostrils (once it has been numbed), and placing this tube at varying lengths starting at the gastro-oesophageal junction (site where the oesophagus joins the stomach). It can take between 30-45 mins. Oesophageal pH studies involves measuring how acidic the fluid is within the oesophagus. This is done over 24 hours with a small tube passed through the nostril and once placed at the determined location it is connected to a 24 hour recording device.

If you are on medication to treat reflux, this should be stopped prior to performing an oesophageal pH study.

What are the symptoms of Gastro-oesophageal reflux Disease (GORD)?

Oesophageal symptoms:

  • Symptomatic syndromes
  • Typical reflux syndrome (heartburn & regurgitation)
  • Reflux chest pain syndrome (epigastric pain)
  • Symptoms with oesophageal injury
  • Reflux oesophagitis
  • Reflux stricture
  • Barretts Oesophagus

Extraoesophageal Syndromes

  • Reflux cough syndrome
  • Reflux laryngitis syndrome
  • Reflux Asthma syndrome
  • Reflux Dental erosion syndrome (gastric acid in mouth)

What can I do to reduce my Gastro-oesophageal reflux symptoms?

  • Avoid alcohol, spicy foods and fatty or acidic foods
  • Eat smaller meals
  • Avoid late meals
  • Lose weight
  • Elevation of the head of the bed or sleeping with 2 or more pillows
  • Avoid tight fitting garments

Can my Gastro-oesophageal reflux Disease (GORD) be managed entirely by medication?

The principle behind medical management of reflux disease is that is treats the symptoms and not the underlying cause of it. Hence medical management will be lifelong. There are a wide variety of medical treatments available and this is mostly (but not limited to) H2 antagonists e.g cimetidine or ranitidine, proton pump inhibitors e.g esomeprazole or omeprazole. The effectiveness of this can diminish over time, and in time the total cost for this life long medication increases.

How is Gastro-oesophageal reflux Disease (GORD) diagnosed?

This would require a visit to a specialist who will take a thorough history and perform a complete physical examination. Most patients will require a gastroscopy as an initial investigation. Additional investigations can include oesophageal manometry and Ph studies as well as radiological imaging which might be a barium swallow or CT scan with oral contrast depending on the patients history and findings.

What is an oesophageal pH and manometry study?

Oesophageal manometry is used to assess the contractions of the oesophagus to check if there is any underlying motility problem with the oesophagus. This involves passing a small tube through one of your nostrils (once it has been numbed) and placing this tube at varying lengths starting at the gastro-oesophageal junction (site where the oesophagus joins the stomach). It can take between 30-45 mins. Oesophageal pH studies involves measuring how acidic the fluid is within the oesophagus. This is done over 24 hours with a small tube passed through the nostril and once placed at the determined location it is connected to a 24 hour recording device.

If you are on medication to treat reflux, this should be stopped prior to performing an oesophageal pH study.

When should I consider surgery for my Gastro-oesophageal reflux Disease (GORD)?

The patients that undergo surgery broadly fall into 2 groups:

  • Patients who have failed medical therapy
  • Increasing dose of medication
  • Non compliant with medication
  • Developments of complications of reflux despite being on medication
  • Patients who’s symptoms are well controlled but do not want to be on lifelong medication
  • Patients with proven correlation of reflux and respiratory symptoms

What types of surgery are there for this?

Laparoscopic Fundoplication.

What is laparoscopic fundoplication?

This is a ‘key hole’ operation or laparoscopic surgery. Often there is is a hiatus hernia present at the same time – this is repaired first. The fundoplication is an attempt to recreate the anti reflux valve is by ‘wrapping’ the stomach around the oesophagus. This can be done in a posterior fashion (toupe or laparoscopic posterior 270 degree fundoplication), an anterior fashion (dor or laparoscopic anterior 180 degree fundoplication) or a complete wrap (laparoscopic nissen fundoplication or a 360 degree wrap of the stomach around the oesophagus ). Your specialist will discuss the advantages and disadvantages of each of these with you.

In summary the aims are:

  • Restoration of the intrabadominal oesophagus
  • Restoration of the extrinsic sphincter (approximation of the crura of the diaphragm)
  • Reinforcement of intrinsic sphnicter

How long is my recovery time from this surgery?

Typically most patients would go home on day 2 after the surgery. This may vary depending on the patients co-morbidities and the intraoperative findings.

What can I eat after the surgery?

This can vary with individual circumstances, but broadly most patients will be on free fluids for up to 2 weeks post surgery. A complete avoidance of bread and steak during this time is advised.

Why can’t I eat solid food after my surgery?

The aim of the operation is to close the defect around the oesophagus. This can make it difficult for solid food bolus to pass through resulting in difficulty swallowing and regurgitation and vomiting. The increase in abdominal pressure with this regurgitation and vomiting can result in damaging the repair and closure of the hiatus.

Will I lose weight after my surgery?

It is not uncommon to lose some weight after the operation but generally most people have regained any lost weight at 3 -6 months.