Gastro-Oesophageal Reflux Disease

[Myanmar Journal of Surgery]

Aetiology

Factors that predispose to reflux include:

* Increased intra-abdominal pressure
* Inadequate cardiac sphincter for anatomical reasons or factors
that reduce tone and also poor oesophageal peristalsis
* Smoking, alcohol, fat, coffee
* Pregnancy
* Obesity
* Tight clothes
* Big meals
* Surgery in achalasia of the cardia
* Hiatus hernia
* Drugs including tricyclics, anticholinergics, nitrates and
calcium channel blockers, systemic sclerosis

Gastro-oesophageal reflux disease (often just called reflux or reflux
disease) is a condition in which the acidic contents of your stomach,
called chyme (partially digested food and acid), regurgitate or reflux
(wash back) into the oesophagus (the gullet). It is the most common
cause of heartburn and indigestion in Western society.

The oesophagus, which is more commonly known as the gullet, is a long
cylindrical tube that leads from the throat to the stomach. The walls
of the oesophagus contract (squeeze) in rhythmic waves to move food
down into the stomach.

Where the throat joins the oesophagus there is a one-way valve which
doctors call a sphincter. Under normal circumstances this sphincter
lets food from the throat down into the oesophagus but doesn’t let it
back up.

At the other end of the oesophagus, where it joins onto the stomach,
there is another sphincter (the lower oesophageal sphincter). This
allows food to pass into the stomach and, under normal circumstances,
prevents it from coming back up the oesophagus again.

Differential diagnosis

* Oesophagitis from swallowed corrosives or drugs like NSAIDS
* Infection (especially in the immunocompromised); CMV, herpes,
candida
* Peptic ulcer
* GI cancers
* Non-ulcer dyspepsia
* Oesophageal spasm

Complications

Oesophagitis/ulcer, anaemia, oesophageal stricture, Barrett's
oesophagus (premalignant ectopic gastric mucosa).

Management

The UK National Institute for Health and Clinical Excellence has
published guidelines on the management of dyspepsia (including reflux
symptoms) that impact on clinical practice.

* Routine endoscopic investigation of dyspepsia is not necessary
for patients without alarm symptoms (of any age)
* However, referral for endoscopy is appropriate for patients aged
55 years and older with unexplained treatment resistant dyspepsia of
more than four weeks' duration. Refer any patient with dysphagia or
other alarm symptoms urgently - at any age!

In a prospective observational study the prevalence of gastric cancer
was 4% (and serious benign disease 13%) in a cohort of patients
referred urgently for alarm symptoms.7 Referral for dysphagia or major
weight loss at any age, together with those older than 55 years with
alarm symptoms, would have detected 92% of the cancers found in the
cohort.
In contrast, the presence of typical reflux symptoms was less likely
to indicate the presence of malignancy.

* Patients with reflux symptoms, but no alarm symptoms, should
receive initial treatment with full dose proton pump inhibitors for
one month.
* In cases of uninvestigated dyspepsia, eradication therapy for H
pylori can also be provided if infection is evident on serology or
urea breath test. Where there is known GORD (ie post gastroscopy) H
pylori eradication is not recommended.
* If symptoms return after treatment, and long term acid
suppression is required, a step-down strategy to the lowest dose of
proton pump inhibitor that provides effective relief of symptoms is
more cost effective than the step-up approach.6 Start acid suppression
at a healing dose for 1 to 2 months. Then either step up a level if
still symptomatic, or step down once symptoms have improved to the
lowest level that provides effect symptom control. All patients should
have a treatment plan and should be told if they can stop if symptom
free
* If endoscopy is carried out and oesophagitis is present, a
healing dose of proton pump inhibitor should be prescribed for two
months.
In such patients symptoms usually relapse when treatment is
withdrawn, and maintenance proton pump inhibitor therapy is usually
required.