Reflux-GORDS

Reflux (GORDS)

Hiatal Hernia

 

Gastro oesophageal reflux is abnormal exposure of the lower oesophagus to gastric contents and that is caused by weakness of the sphincter at the junction between the gullet, the oesophagus and the stomach. That can be due to physiologic weakness of the sphincter or due to anatomic defects such as a hiatus hernia which is of two types, either a sliding or a rolling hiatus hernia. In this condition the mucus lining of the oesophagus gets exposed to the acid that gets secreted by the stomach and also by the bile that refluxes into the stomach which can be more dangerous than the acid itself. This condition is very common and the options of treatment are medical and surgical.

One of the complications that can arise from reflux disease in addition to the ongoing symptoms of heartburn is the fact that as a result of inflammation of the lower end of the oesophagus it can lead to changes in that part of the gastrointestinal tract into a situation which can be premalignant. This condition is called Barrett’s oesophagus in which the normal lining of the lower oesophagus gets changed from a normal, what is called squamous into a reactive new form which is called intestinal metaplasia. As a result of the chronic inflammation and irritation by the bile source and by the acidic material that can lead to development of cancer of the oesophagus which is increasing in incidence.

Medical treatment is very common but surgery has its indication.

Bile reflux into the stomach is relatively common and can make  GORD symptoms worse, it is associated with reduced ability of the stomach to drain properly and poor function of the pylorus . Often there are other factors involved in the pathogenesis of the disease and one of them is reflux of bile into the stomach due to incompetent pyloric sphincter and also inability of the stomach to empty properly. Another contributing factor that can often be found is the ability of the oesophagus to clear the contents due to abnormal motility. All these factors in addition to changes in the lower sphincter which is caused by weakness of the sphincter mechanism itself or the presence of a hiatus hernia which mean that there is a defect in the diaphragm where the oesophagus joins the stomach and due to increasing pressure in the abdomen a hiatus hernia can develop. A complicating problem with reflux disease is the fact that it can lead to adult onset asthma and lung fibrosis as a result of silent and ongoing aspiration. Symptoms of asthma get worse and patients tend to have a cough early in the morning as a result of micro aspiration of the contents of the oesophagus and the stomach into the lungs. Another form of reflux disease is what is called a volume reflux when the patient strains or bends forward, particularly to pick something up from the floor, the gastric contents can come back into the oesophagus in the form of regurgitation, usually associated with heartburn and nausea. Symptoms like that are usually difficult to treat and it is one of the important considerations to indicate surgery.

Condition, Treatment & Procedure

Treatment:

Reflux disease is very common and is a significant health burden. Most patients will be treated in a satisfactory manner with medications such as Nexium and Somac. These patients will have to stay on the medications long term. Other steps that can be helpful include weight loss, avoiding coffee, chocolate and smoking.

There are situations of either no improvement or partial improvement with medications, also patients who suffer from volume reflux and when the lower oesophagus is severely affected by the acid and bile exposure, surgery will be considered.

Reflux surgery aims at strengthening the sphincter by suturing the diaphragmatic crura closer and also reducing the hiatus hernia. Added to that the stomach gets wrapped around the lower oesophagus. Surgery is usually done laparoscopically and has a high success rate.

The operation:

The operation for reflux is in the form of laparoscopic repair of the diaphragmatic hiatus and 360′ fundoplication, which is wrapping the stomach around the oesophagus.

Patient usually get admitted on the morning of the operation and can expect to stay in the hospital for 2-3 days.

Oral intake is allowed in the form of liquids which is upgraded to a soft diet soon after. You will see a dietician to help you regarding the type of diet that you will need for three weeks

Illustration of Nissen fundoplication

Complications:

  1. Damage to the oesophagus is the most serious complication. It is uncommon but very serious and would likely need an open operation to deal with it.
  2. Bleeding: very small risk
  3. Difficulty swallowing: this usually respond to endoscopic dilatation
  4. Most patients will find it not possible to burp so they can get bloating and flatulence
  5.  A small percentage of patients will have recurrence of their symptoms

Diagnosis

Diagnosis of gastro oesophageal reflux relies on a few important tests in addition to a detailed history  and physical examination.

Investigations:

  1. Barium study: You will be given a white paste like material to drink and a videoscopic recording of the swallowing process and the clearing process of the oesophagus to the material is recorded to study the motility of the oesophagus.
  2. Endoscopy: Also, you will find that your Doctor will recommend an upper gastrointestinal endoscopy. The purpose of the endoscopy is to see any changes in the lower oesophagus in the form of inflammatory changes. It can also pick up a hiatus hernia. Though the diagnosis of hiatus hernia is more often made on the Barium study. Also, the other purpose of the endoscopy is to rule out other forms of disease such as ulcer or chronic gastritis or cancers of the stomach and the lower oesophagus that can be the source of the symptoms, particularly if it is associated with weight loss or difficulty in swallowing.
  3. pH monitoring: can sometimes be requested. In difficult cases you will be referred for a specialised laboratory to check the amount of the acid that refluxes back into the oesophagus over a 24 hour period of time and specific calculations will be made to find whether there is active reflux or not.
  4. Manometry of the oesophagus again sometimes can be requested, however, that will be more important if there is difficulty in swallowing more so than heartburn and acid regurgitation. The purpose of that study is to investigate the pressures, the motility and the reaction of the lower sphincter to the process of swallowing and its ability to relax in between the oesophageal peristalsis. The benefit of that is to ensure that there is no motility disorder because that will effect the decision as to whether surgical or medical treatment is indicated and also the type of the surgery that will be needed.
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