Gastro-Oesophageal Reflux Disease
What is gastro-oesophageal reflux disease?
Gastro-oesophageal reflux disease occurs when the contents of the stomach flows backwards (reflux) into the oesophagus and causes symptoms or complications. A certain degree of reflux is considered normal and usually well tolerated, but if troublesome symptoms occur, then further action is required. Reflux can consist of acid, but also other elements such as bile and food.
What are the symptoms of reflux disease?
Typical symptoms include a burning sensation behind the chest bone (heartburn), cough, acid reflux and regurgitation which can lead to a sour or bitter taste in the mouth. Other symptoms include a sore throat (particularly, in the morning), shortness of breath or asthma like symptoms, tightness of the chest, problems with swallowing (dysphagia) and the feeling of a lump in the throat.
What are the reasons for reflux disease?
There are two main reasons for reflux. While there can be sometimes an overproduction of stomach acid, the main problem is usually impaired function of the valve meant to prevent back flow from the stomach to the oesophagus. Reflux is exacerbated when this valve mechanism is impaired (e.g. in the presence of a hiatus hernia), due to increased abdominal pressure and with positional change.
What is a hiatus hernia and what can I do about it?
The diaphragm is a flat muscle separating the chest and abdomen which assists breathing. There are natural gaps to allow anatomical structures such as the oesophagus to pass from the chest into the abdominal cavity. When these natural gaps are stretched and become too wide, then a “hiatus hernia” may occur. Hiatus hernias are made worse by increased intraabdominal pressure as can happen, for example, in pregnancy or rapid weight gain. Symptoms may therefore be improved with lifestyle changes and medical treatment, but a keyhole surgical approach called “laparoscopic fundoplication” can also be considered.
What tests do I need to diagnose reflux disease?
The diagnosis is usually made based on the clinical history, including the character and severity of symptoms and the response to medical treatment (see below). In some cases an endoscopic assessment by a gastroscopy or OGD (oesophago-gastro-duodenoscopy) is required.
Additional tests to further characterise the reflux condition and to get the best information in order to make an informed suggestion for further treatment can also be considered. This might include a barium swallow (an X-ray film of swallowing some contrast liquid) and objective reflux assessment by a pressure test of the oesophageal muscles (manometry) and 24 h acid (pH-metry) or comprehensive reflux monitoring (pH-impedance).
How is reflux disease treated?
The most healthy way to treat reflux disease are life-style and diet changes. If the symptoms have been preceded by a period of weight gain, then physical activity and weight loss is encouraged. If these measures fail, then medical treatment with a stomach acid blocker (proton pump inhibitor, PPI) for 4 weeks is the next step. After the 4 weeks, the symptom response needs to be assessed to be able to discuss the next steps. There are other medical options available which could either be used as an alternative or in addition to a PPI. In case of non-acidic reflux, a visceral pain modifier such as Amitriptyline is often also helpful. If these options fail, then interventional anti-reflux treatment should be considered and the respective options will be discussed.
What are the complications of reflux disease?
The most common complication is erosive oesophagitis that means more severe inflammation in the lower oesophagus with erosion of the lining of the oesophagus and sore spots that can sometimes be confluent and cause difficulties swallowing or even bleed.
Long-term reflux increases the risk of cellular changes in the lower oesophagus in about 10% of the patients. Barrett’s oesophagus is defined as a condition in which the normal lining of the oesophagus transforms into a lining consistent of cell types usually present in the stomach or the small bowel. Patients with Barrett’s oesophagus (named after Norman Barrett who described this condition first in 1953) have a slightly increased risk to develop cancer in this area (0.1-0.3% per year). Current guidelines recommend endoscopic assessment of Barrett’s oesophagus in regular intervals to detect any progressive changes at an early stage when minimal invasive treatment is possible.
A further complication caused by chronic reflux is called a Schatzki ring. This is a scarred ring formation just above the entry to the stomach which can also cause difficulties swallowing.
The different types of oesophageal cancer.
There are two main types of oesophageal cancer. The “classical” type is called oesophageal squamous cell carcinoma and affects more the upper and the middle part of the oesophagus, originating directly from the lining of the gullet. It is more frequent in patients with a considerable smoking history and those who drink large amounts of alcohol, in particular spirits. There are further conditions that can affect the muscles of this part of the oesophagus or the connective tissue in this are that can further predispose to this type of cancer.
Of increasing importance is the second type, called oesophageal adenocarcinoma. This usually arises from the glandular lining of Barrett’s oesophagus (see above) and is most often located in the lower part of the oesophagus, directly above the entry to the stomach. This cancer is related to chronic reflux disease and high BMI.
What tests are needed to diagnose oesophageal cancer?
The gold standard for diagnosis of oesophageal cancer is endoscopic assessment by gastroscopy. This does not only allow direct assessment of suspicious areas within the oesophageal lining, but also sampling of tissue for confirmation of the actual diagnosis. Imaging by CT or barium contrast swallow does not allow any confirmation of diagnosis and delivers only indirect signs that can often be misinterpreted.
How is oesophageal cancer treated?
The best treatment pathway depends on the stage at which the condition is diagnosed. If confined to the upper layers of the oesophageal lining, then endoscopic, local treatment is often still feasible and allows curation without major surgery. If changes are more advanced, then radical surgery is often the best option. This can be combined or replaced by either radiotherapy or chemotherapy. The decision which modality is the best in each individual case depends on a variety of factors and is usually discussed at the Oxford Cancer Centre in a multidisciplinary Team Meeting (MDT).
How do I prevent oesophageal cancer?
Factors causing and aggravating reflux should be avoided. This includes consumption of alcohol above the recommended limit as well as cessation of smoking.