Gastro-oesophageal reflux disease (GORD) occurs when stomach acid leaks back up into the oesophagus. This is known as acid reflux. The oesophagus is the tube that runs from your throat to your stomach.
GORD is often a chronic condition, which means that if you have it, you may experience recurring episodes for the rest of your life.
The symptoms of GORD may be improved by making lifestyle changes that affect acid reflux, such as eating smaller meals and, if you smoke, giving up.
There are also a number of medicines that can be used to relieve the symptoms of GORD. More severe cases of the condition may require surgical treatment.
Repeated episodes of GORD can make the lining of your oesophagus inflamed (known as oesophagitis).
GORD is a common condition, and it's one of the most frequent causes of indigestion and heartburn. It is estimated that 10 to 20% of people will have acid reflux at least once a week
Diagnosis
If you have the typical symptoms of GORD and acid reflux your GP will make a diagnosis based on your symptoms without any tests. If you have severe or unusual symptoms, or if they do not get better when treatment is started, you may need to have some tests.
These may include: endoscopy - a thin tube with a microscope on the end is passed down your oesophagus towards your stomach. It enables doctors to see whether the inside of your oesophagus is red and inflamed, acidity test on the inside of the oesophagus - the test is performed for a 24-hour period and involves a thin wire being passed through your nose and into your oesophagus.
The wire measures how acidic your oesophagus is and displays the results electronically, barium swallow - a substance called barium, which shows up white on an X-ray, is swallowed to enable doctors to identify any abnormalities in your oesophagus, or radiolabelled technetium - in some hospitals radioisotope imaging may be used to demonstrate gastro-oesophageal reflux. The technique uses very small doses of technetium-sulphur colloid to help confirm a diagnosis.
Surgical Treatment
Surgery to prevent reflux which is increasingly performed using the laparoscopic approach improves oesophagitis and can control symptoms in around 90% of people. The patho-physiology of reflux is centred on the lower oesophageal sphincter incompetence and recent evidence indicates that the diaphragmatic crural fibres surrounding the oesophageal hiatus act as an external sphincter in concert with the intrinsic lower oesophageal sphincter in avoiding reflux.
Surgical treatment would appear logical as it aims at re-enforcing this mechanism rather than decreasing acid production in the stomach.
Advantage of Surgery for Reflux disease : -
The potential advantages of Nissen fundoplication include removing the need for life long medication and an excellent success rate which does not decrease significantly with time.
DeMeester, reported 91% of patients had their symptoms controlled 10 years after surgery. Laparoscopic approach offers a better cosmetic result, quicker recovery, shorter hospital stay and a quicker return to work.
One has to however consider these benefits along side the small but measurable risk of complications from this procedure.
Indications for Surgery
Patients that should be considered for surgical treatment are : -
Those with a poor response to medical treatment where failure to suppress acid reflux is confirmed
Persisting Volume reflux
Regurgitation of gastric contents occurring especially at night with risks of aspiration
Difficult benign strictures
Patient choice especially those requiring long term maintenance treatment, including patients with Barrett's oesophagus
Keyhole surgery, also known as laparoscopic fundoplication surgery - for this procedure, small incisions are made and a small camera (telescope) is passed into the abdomen to let the surgeon view the affected area. Fine instruments are used to tighten up the sphincter muscle between the oesophagus and stomach.
The patients are discharged within 48 hours of the procedure which is carried out under a General Anaesthetic. Patients do have difficulty in swallowing soon after the operation which improves with time. Not all patients are suitable for surgery and it is important to discuss this with your consultant. Studies that have been carried out show that surgery can have many benefits for people who have GORD, particularly those who have chronic symptoms. Surgery can help reduce acid reflux, make heartburn less severe, and can also make the lining of the oesophagus less acidic.
Q. What is cancer of the oesophagus ?
Cancer of the oesophagus or gullet develops as a result of cell changes in the lining of the oesophagus.
There are two main types of cancer of the oesophagus: squamous carcinoma, which is more common at the upper end of the gullet, and adenocarcinoma, which is more common at the lower end, particularly around the junction between the gullet and the stomach.
There has been a recent increase in the proportion of tumours arising close to the junction of the stomach and gullet, but the reasons for this are not yet known.
In a condition called Barrett's oesophagus, the lining of the gullet becomes more like the lining of the stomach. Patients with Barrett's oesophagus are at an increased risk of developing cancer of the oesophagus and may benefit from regular follow-up and supervision by a doctor.
symptoms
The first symptom of the disease is almost always difficulty in swallowing. There is the feeling that food is getting stuck, often behind the lower end of the breastbone. At first the problem is only with solid food but later even semi-solids and liquids can cause problems.
Pain felt between the shoulder blades can also be troublesome. This discomfort is sometimes triggered by eating.
Another characteristic symptom is regurgitating unaltered food a few minutes after having difficulty swallowing the food. The patient often tries to handle these problems by eating less and avoiding solid food. This causes weight loss and fatigue.
Later on, heartburn, vomiting and vomiting of blood may become the dominant symptoms. The early symptoms are relatively minor and tend to creep up on patients. This means it is often several months before they consult their doctors.
Diagnosis
It can be diagnosed by using X-rays using special dye. Before the X-ray picture is taken, the patient will be asked to swallow a beaker of a whitish fluid called barium. X-ray pictures are taken as the barium travels down the gullet and into the stomach.
The procedure is completely painless and provides valuable information about the size of any abnormality present.
It does not provide a firm diagnosis though any irregular narrowing of the gullet would strongly suggest that there may be a cancer present.
The definitive diagnosis is made through direct vision using a camera attached to a flexible tube (an endoscope), which makes it possible to take a tissue sample (biopsy). The endoscopy (sometimes called a gastroscopy) is carried out while the patient is under sedation.
A long flexible tube, about the thickness of a fountain pen, is passed through the mouth, over the back of the tongue and down into the gullet and stomach. The tube is connected to a camera through which the doctor can inspect the lining of the gullet and assess whether or not it is normal.
A sample will be taken from any abnormal or suspicious areas. After processing, these samples will be examined by a pathologist who will decide whether or not there are any cancer cells present. It usually takes 7 to 10 days after the test before the pathologist's report is ready.
A CT scan is often performed to assess whether or not the disease has spread either locally or to the liver. This is a particularly important investigation if surgery is being considered.
Treatment of cancer of the oesophagus
Treatment may consist of surgery, radiotherapy, chemotherapy or a combination of these.
The best chance of cure is with surgery. Patients who are in good general condition and who have small tumours have more than a 25 per cent chance of cure with surgery.
In fit patients with more advanced disease, the combination of chemotherapy and radiotherapy may be used - this can produce cure rates of around 20 per cent. The combination is sometimes used to shrink tumours in order to make subsequent surgery easier and more effective.
Unfortunately the majority of patients are not fit for intensive treatment of this type. In their case treatment will be aimed simply at relieving symptoms.
This can sometimes be done most easily using a stent. A stent is simply a kind of tube that is inserted inside the gullet to help keep it open and allow the passage of fluid and food. There are various kinds available, ranging from a simple plastic tube to a device made of metal mesh that expands once it has been put in place.Stents can be put in place as a simple procedure at the same time as an endoscopy is carried out.
Radiotherapy can also be used to try and shrink the tumour and keep the gullet open for longer.
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