i. Gastro-oesophageal reflux disease
Gastro-oesophageal reflux disease (GORD) is a condition which develops when the reflux of stomach content causes troublesome symptoms or complications. This may include:
Common oesophageal symptoms:
- Regurgitation of stomach contents
- Acid taste in the mouth
- Difficulty or pain on swallowing
- Inflammation of the oesophagus
- Barrett’s oesophagus (see section on this)
- Oesophageal cancer
- Dental erosions
GORD may be caused by a hiatus hernia or dysfunction of the lower oesophageal sphincter. Symptoms of GORD may be worsened by certain foods e.g. spicy foods, caffeine, chocolate, high carbohydrate meals.
Sliding hiatus hernia
This occurs when the gastro-oesophageal junction is displaced above the diaphragm, resulting in disruption of the lower oesophageal sphincter function. This often, but not always, causes symptomatic gastro-oesophageal reflux. The cause is usually age-related degeneration, but other factors, such as congenital predisposition and trauma, may contribute.
- Symptoms: GORD is usually diagnosed based on a history of compatible symptoms. A positive response of these symptoms to treatment confirms the diagnosis.
- Gastroscopy can be used to look for complications of GORD (see Oesophageal injury above) or the presence of a hiatus hernia. (See Gastroscopy)
- 24 hour pH studies: If the diagnosis of GORD is in doubt, this test can be used to confirm or exclude the presence of GORD (See 24 hour pH studies)
Treatment of GORD depends on the severity of the symptoms and complications. This may vary from intermittent symptomatic treatment with antacid, to daily use of acid-suppressing drugs, and even surgery (See Surgery for gastro-oesophageal reflux disease)
ii. Barrett’s oesophagus
When cells lining the lower oesophagus change from their normal morphology into that similar to cells in the stomach, it is referred to as Barrett’s oesophagus (BO). This occurs in response to abnormal exposure to acid reflux from the stomach.
The diagnosis of BO may be difficult, and relies on certain endoscopic and histopathological findings. The clinical significance of diagnosing BO is that it is considered a “pre-malignant” condition and it increases the risk of oesophageal cancer developing.
The risk of developing oesophageal cancer from BO is classified according to the extent of the changes as well as the degree of pre-malignant change (dysplasia). Depending on these changes, recommended management varies from observation at set intervals (for no or low grade dysplasia) to endoscopic ablation and resection (for high grade dysplasia), and even surgical resection of part of the oesophagus if invasive cancer is found.
iii. Surgery for gastro-oesophageal reflux disease
In certain situations, surgery is an option in the management to gastro-oesophageal reflux disease (GORD). Indications for surgery are:
- Non-compliance to treatment
- Intolerance of medical therapy
- The desire not to take lifelong treatment in patients who are medication dependant
- High-volume reflux
- Failed optimal medical therapy
- Complications of GORD
- Benign stricture
- Severe oesophagitis
- Barrett’s oesophagus (but not when high-grade dysplasia or carcinoma is present)
Depending on a patient’s particular set of symptoms, it may be appropriate to perform certain investigations before proceeding to anti-reflux surgery. Such investigations may include:
- 24 hour pH studies
- Oesophageal maonetry
- Gastric emptying studies
Because of the risk of peri- and post-operative complications, the decision to have anti-reflux surgery should not be taken lightly and should be thoroughly discussed with your surgeon or gastroenterologist.