Gastro-oesophageal reflux occurs when gastric contents pass retrograde through the GOJ into the oesophagus.
Everybody experiences episodes of reflux, but in 10-40% of the population of the UK this occurs frequently enough to significantly impair their quality of life. The incidence of this problem seems to be increasing, though it is hard to accurately measure just how many people are affected. What is clear is that it is a highly significant problem accounting for a large number of attendances at both primary and secondary care, and requiring a large amount of money for therapeutic measures (mainly anti-secretory agent prescriptions). There are a number of mechanisms which help to prevent GORD, including a lower oesophageal 'sphincter', the diaphragmatic crura at the hiatus, and the presence of a short segment of distal oesophagus within the abdominal compartment. Some patients with GORD have a hiatus hernia, but it must be realised that the presence of a hiatus hernia does not imply reflux (most hernias are asymptomatic for GORD), and that having reflux does not imply the presence of a hiatus hernia (30-90% of reflux patients have a hernia).
Symptoms are variable; 'heartburn' is common with retrosternal burning and discomfort, regurgitation of food and acid into the mouth is unpleasant, and dysphagia to both solids and liquids can occur. Symptoms are worse when lying down, or bending over, and waking at night choking is described. Respiratory disease may be worsened by nocturnal aspiration, and teeth may be eroded by gastric acid. Clinical examination is unremarkable, and the diagnosis is most often obtained from history alone.
The majority of reflux responds to lifestyle adjustments and medical treatment. Losing weight, stopping smoking, avoiding spicy foods and alcohol help some people, but most require some form of acid reduction therapy with either H2 antagonists, or PPIs. Surgical intervention is only considered in cases that do not respond to medical therapy, and sometimes when patients request surgery as an alternative to life-long medication. Some patients have only a partial response to high doses of PPIs, and others have relief of the acid-related problems, but still have a large volume of gastric fluid regurgitating into their oro-pharynx.
Before considering surgery the oesophagus must be investigated to prove the diagnosis of GORD, and show motility disorders and anatomical variants. Endoscopy with distal oesophageal biopsies should be performed, as well as manom-etry and 24-h pH studies (see Oesophageal Function Tests).
There are many types of anti-reflux operations, but most include some form of fundoplication. The principles of a fundoplication procedure include reducing hiatus hernia if present, restoring a length of intra-abdominal oesophagus, and repairing the diaphragmatic hiatus. The commonest anti-reflux procedure is the Nissen fundoplication that involves a 360° wrap of the gastric fundus around the distal oesophagus. Various partial fundoplications exist with either anterior or posterior wrapping of the fundus over 180° or 270°. The development of laparoscopic surgery has renewed enthusiasm for anti-reflux surgery, as it can be performed without the need for a painful laparotomy or thoracotomy. The results from well-selected patients are good, with 85-95% reporting cure or significant improvement of reflux. Patients must know that certain complications occur with anti-reflux surgery: dysphagia affects at least 30% immediately post-operatively, but this resolves over the first 3 months; gas-bloat affects up to 30% where inability to belch air from the stomach causes gastric distension. Persistent dysphagia can be treated with endo-scopic balloon dilatation.
There is a well-described link between GORD and Barrett's oesophagus, and between Barrett's and oesophageal cancer (see Oesophageal Cancer). It would seem logical that a mechanical solution to reflux as provided by surgery would help prevent progression of Barrett's, but so far there is no evidence to support this theory. Anti-reflux surgery is not indicated as treatment for Barrett's oesophagus alone.
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Gastroesophageal reflux disease is the medical term for what we know as acid reflux. Acid reflux occurs when the stomach releases its liquid back into the esophagus, causing inflammation and damage to the esophageal lining. The regurgitated acid most often consists of a few compoundsbr acid, bile, and pepsin.