Def: reflux of stomach contents (e.g. acid, food) causes troublesome symptoms and/or complications. Affects 20% of Australians.
Sx: heartburn (related to: meals, lying down, straining, stooping), waterbrash (increased saliva production), regurgitation, odynophagia (from ulcer, inflammation or acid), nocturnal asthma, laryngitis.
Causes: dysfunction of lower oesophageal sphincter (LOS), increased acid production, large sliding hiatus hernia (affecting the LOS as it ascends into the thoracic cavity), alcohol, drugs that reduce smooth muscle tone of LOS (Nitrates, Ca2+ Blockers, antimuscarinics).
Precipitants/triggers: fatty/acidic foods, lying down, straining, stooping, alcohol.
Ix: Endoscopy – first line, to check for oesophagitis, hernia, Barrett’s oesophagus or dysfunction of LOS.
24hr Oesophageal pH monitoring ± manometry (measure pressure on either side of LOS)
Mx: Lifestyle – smoking cessation, weight loss, raise the bed head, small regular meals, reduce fatty, spicy & acidic food consumption, avoid alcohol and carbonated beverages. Effective in 20% of patients in reducing reflux
- Medical treatment – first antacids or alginates to relieve symptoms. PPIs for life if lifestyle measures + antacids ineffective, increase dose as needed.
- Surgery – if very severe, refractory to medical treatment and there is severe reflux (according to pH monitoring).
Nissen fundoplication: the gastric fundus is wrapped around the lower oesophagus to reinforce the LOS closing function. Can be 360o or 270o (Belsey fundoplication – wrapped around anterior and lateral aspects, not posterior).
Cx: oesophagitis, ulceration, stricture (due to scarring after an ulcer), Barrett’s oesophagus (change from squamous epithelium to columnar (glandular) epithelium, therefore associated with oesophageal adenocarcinoma due to increased mitoses and change over – 0.7% rate).