Esophageal disorders

GASTRO-OESOPHAGEAL REFLUX DISEASE

Aetiology
Normal competence of the gastro-oesophageal junction is maintained by the LOS. This is influenced by both its physiological function and its anatomical location relative to the diaphragm. In normal circumstances, the LOS transiently relaxes as a coordinated part of swallowing, as a means of allowing vomiting to occur and in response to stretching of the gastric fundus, particularly after a meal to allow swallowed air to be vented. Most episodes of physiological reflux occur postprandially.
The absence of an intra-abdominal length of oesophagus results in a sliding hiatus hernia. The loss of the normal anatomical configuration exacerbates reflux, although sliding hiatus hernia alone should not be viewed as the cause of reflux. Many GORD sufferers do not have a hernia, and many of those with a hernia do not have GORD.
In western societies, GORD is the most common condition affecting the upper gastrointestinal tract. The cause of the increase is unclear, but may be due in part to increasing obesity.

Clinical features

The classical triad of symptoms is retrosternal burning sensation (heartburn), epigastric pain and reflux. Most patients do not experience all three.
Symptoms are often provoked by food, particularly those that delay gastric emptying (e.g. fats, spicy foods). As the condition becomes more severe, gastric juice may reflux to the mouth and produce an unpleasant taste. Patients with nocturnal reflux and those who reflux food to the mouth nearly always have severe GORD. Some patients present with less typical symptoms such as angina-like chest pain, pulmonary or laryngeal symptoms.
Dysphagia is usually a sign that a stricture has occurred, but may be caused by an associated motility disorder.

Diagnosis

In most cases, the diagnosis is assumed rather than proven, and treatment is empirical. Investigation is only required when the diagnosis is in doubt, when the patient does not respond to a proton pump inhibitor (PPI) or if dysphagia is present. The most appropriate examination is endoscopy with biopsy.
In patients with atypical or persistent symptoms despite therapy, oesophageal manometry and 24-hour oesophageal pH recording may be justified to establish diagnosis and guide management .
Manometry and pH recording are also essential in patients being considered for anti-reflux surgery.

Management of uncomplicated GORD

Medical management
Most sufferers from GORD do not consult a doctor and do not need to do so. They self-medicate with over-the-counter medicines such as simple antacids and H2-receptor antagonists. Consultation is more likely when symptoms are severe, prolonged and unresponsive to the above treatments.
Simple measures that are often neglected include advice about weight loss, smoking, excessive consumption of alcohol, tea or coffee, the avoidance of large meals late at night and a modest degree of head-up tilt of the bed.
PPIs are the most effective drug treatment for GORD. Given an adequate dose for 8 weeks, most patients have a rapid improvement in symptoms.
For the minority who do not respond adequately to a standard dose, a trial at an increased dose or the addition of an H2-receptor antagonist is recommended. If unsuccessful, these patients should be formally investigated.
PPI therapy is also important in patients with reflux-induced strictures, resulting in significant prolongation of the intervals between endoscopic dilatation.

Surgical treatments

The indication for surgery in uncomplicated GORD is essentially patient choice. The risks and possible benefits need to be discussed in detail. Risks include a small mortality rate (0.1–0.5%), failed operation (5–10%) and side-effects such as dysphagia, gas bloat or abdominal discomfort (10%).
With current operative techniques, 85–90% of patients should be satisfied with the result of an anti-reflux operation.
There are many operations for GORD, but they are virtually all based on the creation of an intra-abdominal segment of oesophagus, crural repair and some form of wrap of the upper stomach (fundoplication) around the intra-abdominal oesophagus.
Total fundoplication (Nissen) tends to be associated with slightly more short-term dysphagia but is the most durable repair in terms of long-term reflux control. Partial fundoplication, whether performed posteriorly (Toupet) or anteriorly (Dor, Watson), has fewer short-term side-effects at the expense of a slightly higher long-term failure rate. Most anti-reflux operations are now done with a laparoscopic approach.

Complications of gastro-oesophageal reflux disease

A)Stricture
Reflux-induced strictures occur mainly in the late middle-aged and the elderly, but they may present in children. It is important to distinguish a benign reflux-induced stricture from a carcinoma. Peptic strictures generally respond well to dilatation and long term

treatment with a PPI. As most patients are elderly, antireflux surgery is not usually considered. However, it is an alternative to long-term PPI treatment, just as in uncomplicated GORD in younger patients.

B)Oesophageal shortening

The extent to which severe inflammation in the wall of the oesophagus causes fibrosis and real shortening is less clear. If a good segment of intraabdominal oesophagus cannot be restored without tension, a Collis gastroplasty should be performed . This produces a neo-oesophagus around which a fundoplication can be done.


C)Barrett’s oesophagus (columnar-lined lower oesophagus)
Barrett’s oesophagus is a metaplastic change in the lining mucosa of the oesophagus in response to chronic gastro-oesophageal reflux. The hallmark of ‘specialized’ Barrett’s epithelium is the presence of mucus-secreting goblet cells (intestinal metaplasia). One of the great mysteries of GORD is why some people develop oesophagitis and others develop Barrett’s oesophagus, often without significant oesophagitis.
When intestinal metaplasia occurs, there is an increased risk of adenocarcinoma of the oesophagus, which is about 25 times that of the general population.
Patients who are found to have Barrett’s oesophagus may be submitted to regular surveillance endoscopy with multiple biopsies in the hope of finding dysplasia or in situ cancer rather than allowing invasive cancer to develop and cause symptoms.
When Barrett’s oesophagus is discovered, the treatment is that of the underlying GORD. There has been considerable interest in recent years in endoscopic methods of ablating Barrett’s mucosa in the hope of eliminating the risk of cancer development.

PARAOESOPHAGEAL (‘ROLLING’) HIATUS HERNIA

True paraoesophageal hernias in which the cardia remains in its normal anatomical position are rare. The vast majority of rolling hernias are mixed hernias in which the cardia is displaced into the chest and the greater curve of the stomach rolls into the mediastinum. Sometimes, the whole of the stomach lies in the chest. Colon or small intestine may sometimes lie in the hernia sac. The hernia is most common in the elderly, but may occur in young fit people. As the stomach rolls up into the chest, there is always an element of rotation (volvulus).
The symptoms of rolling hernia are mostly due to twisting and distortion of the oesophagus and stomach. Dysphagia is common. Chest pain may occur from distension of an obstructed stomach. Classically, the pain is relieved by a loud belch. Symptoms of GORD are variable. Strangulation, gastric perforation and gangrene can occur.
The hernia may be visible on a plain radiograph of the chest as a gas bubble, often with a fluid level behind the heart. A barium meal is the best method of diagnosis. Symptomatic rolling hernias nearly always require surgical repair as they are potentially dangerous.