Introduction
- The problem lies in a faulty valve (like a door) at the lower end of the food pipe (esophagus) where it opens into the stomach. This door like mechanism called the lower oesophageal sphincter (LES) allows the food to move from the food pipe into the stomach and prevents it from moving back into the food pipe from the stomach
- A faulty LES allows food to move in either direction. As a result the stomach contents reflux into the food pipe anytime when the pressure in the stomach rises or due to gravity as happens when we bend down.
- There are certain conditions which increase the risk of GERD, these are hiatus hernia, obesity, pregnancy and certain
- Smoking, coffee, alcohol, eating late, heavy fried foods can aggravate GERD
- This reflux of acidic contents of stomach into the food pipe, damages it’s lining and causes symptoms as described below
Signs and symptoms
- Retrosternal burning pain – The patient complains of burning sensation in the chest (heartburn)
- Regurgitation of stomach contents in the mouth – bitter fluid coming into in the mouth on lying down (Water brash)
- Sore throat – The refluxing fluid can enter the windpipe especially when the patient is asleep and cause bouts of coughing and pneumonia.
- Dysphagia – feeling of obstruction on swallowing
- Bad breath
- Tooth decay
- Nausea and vomiting
Complications
- Wheezing, asthma and pneumonia due to refluxed contents entering the air passages
- Damage to oesophageal lining resulting in ulcers, strictures and Barrett’s oesophagus (a premalignant condition due constant irritation of oesophageal lining by stomach acid
Diagnosis
- Endoscopy – A long narrow tube is passed through the mouth into the food pipe and stomach and their lining visualised. The endoscopy can reveal presence of a hiatal hernia, swelling and redness of lining of the food pipe, ulcerations (wounds) and strictures. Simultaneously any suspicious area can be biopsied and studied
- 24 hour pH monitoring – A probe is placed in the food pipe which measures the local pH. This test confirms the presence of significant reflux
- Manometry – The pressure inside the food pipe is measured in response to a swallow and helps in the decision of optimal surgical procedure for the patient.
- Ba Swallow studies – Can demonstrate the presence of reflux
Treatment
- Lifestyle modifications
- Bedtime should be minimum 3 hours after dinner
- Elevation of head end of the bed
- Sleep turned to the left side
- Turn lights off and minimise sound disturbances
- Medications
- Antacids
- Proton pump inhibitors – decrease stomach acid secretion
- Prokinetics – medications which stimulate forward propulsive action of intestines
- Sucralfate – forms protective layer on stomach wall and stops acid from attacking it
- H2RA antagonists – Decrease stomach acid secretion
- Endoscopic treatment
- Stretta procedure – uses radio frequency ablation, long term results unavailable
- TIF – Transoral incisionless fundoplication – long term results unavailable
- Laparoscopic Treatment
- Laparoscopic fundoplication –
- Reconstruction of valve at lower end of food pipe to stop stomach acid reflux
- Performed by laparoscopy
- Is Gold standard treatment for GERD
- Recommended when performing surgery for hiatus hernia
- Laparoscopic fundoplication –
Post operative recovery
- The patient is started on a liquid diet the next day of surgery
- Soft diet is introduced on the second or third day of surgery and continued for a week before progressing to a normal diet
- Patient may experience dysphagia (food getting suck in the food pipe) for about 2 weeks. This is a sign of a successful surgical procedure and is transient in nature