Gastro-oesophageal reflux disease Aetiology
Normal competence of the gastro-oesophageal
junction is maintained by the LOS. There has been considerable controversy
about the relative importance of the physiology
of the LOS and the anatomy of the
cardia. This controversy is not completely resolved, but it is currently
accepted that the most important factor in gastro-oesophageal competence is the
function of the LOS, which is augmented by a normally functioning diaphragmatic
hiatus.
Loss
of competence of the LOS leads to gastro-oesophageal reflux disease (GORD).
This rather clumsy name and inelegant acronym has come into common use because
the alternatives do not describe the condition. Sliding
hiatus hernia has a variable association with GORD. In general patients with
the more severe stages of GORD tend to have a hernia, but most GORD sufferers do
not have a hernia and many of those with a hernia do not have GORD. It should be
noted that rolling or paraoesophageal hiatus hernia is a quite different and
potentially dangerous condition (see below). Reflux oesophagitis is a complication of GORD that occurs in a
minority of sufferers. It occurs in 40—50 per cent of those
A
degree of gastro-oesophageal reflux is normal, particularly after meals when
there is a need to regurgitate swallowed air to maintain comfort. Physiological reflux mostly occurs during transient lower
oesophageal sphincter relaxations (TLOSRs) that are quite separate from
swallow-induced relaxation. In the early stages of GORD most of the pathological
reflux occurs as a result of an increased number of TLOSRs. In severe GORD a
greater proportion of reflux occurs across a LOS that has lost its basal tone
and has a shorter length exposed to intra-abdominal pressure. Understanding of
the function of the LOS has been largely elucidated by Dent, who discovered
the importance of TLOSRs. and by DeMeester, who clarified the importance of the
basic competence of the LOS which is governed by basal LOS pressure, the overall
length of the LOS and the length that is exposed to intra-abdominal pressure.
TLOSRs,
the most important factor in gastro-oesophageal reflux
Length
and pressure of the LOS is also important
In
westernised countries GORD is by far the commonest condition affecting the upper
G I tract. This is in part a relative change due to the declining incidence of
peptic ulcers as the incidence of infection with Helicobacter
pylori has reduced due to improved socioeconomic conditions. However, there
has almost certainly been an absolute increase in the incidence of GORD in the
last 20—30 years. The cause of the increase is unclear, but may be due in
part to increasing obesity. In a curious way it may also be an effect of the
reduced incidence of Helicobacter infection.
Since chronic infection of the gastric corpus
decreases acid secretion, and infection of the antrum increases acid secretion the overall effect of reduced
infection on gastric acid secretion in the community is a matter of conjecture.
Some suggest that the net effect is increased secretion that may increase the
incidence of GORD. The epidemiology of upper G I disease is a fascinating topic
of research that is evolving rapidly. It is a particularly important topic since
medication for GORD is now the largest single item on the healthcare budget of
many countries, and the incidence of cancer of the lower oesophagus and cardia
is also increasing, possibly as a result of the changed incidence of GORD (see
below).
Clinical
features
Dyspepsia
with fatty foods is more common in GORD than gallstone disease
Retrosternal burning pain (heartburn) and
epigastric pain are the commonest symptoms. These are usually provoked by food,
particularly fatty food. Indeed ‘fatty dyspepsia’ is a much more common
feature of GORD than of gallstones with which the association is rather
questionable. As the condition becomes more severe gastric acid may reflux to
the mouth and produce an unpleasant taste. In gross cases food may reflux to the
mouth and this can be a particularly trying symptom. It is in the more advanced
cases there is a history of pain and reflux when lying flat or on stooping. A
proportion of cases has odynophagia with hot beverages, citrus drinks or
alcohol. This symptom which occurs within a few seconds of ingestion is a very
useful confirmation that the patient is suffering from an oesophageal disorder
and not a peptic ulcer. 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.
Because
GORD is such a common disorder it should always be the first thought when a
patient presents with oesophageal symptoms that are unusual or that defy
diagnosis
after a series of investigations.
Diagnosis
In the majority of cases the diagnosis is
assumed rather than proven and treatment is empirical. Endoscopy is done mainly
to exclude more serious pathology such as cancer. If the typical appearance of
reflux oesophagitis, peptic stricture or Barrett’s oesophagus is seen the
diagnosis is clinched, but oesophagitis is not present in most cases. The
endoscopic appearances of the normal oesophagus, hiatus hernia, oesophagitis and
stricture are shown in Figs 50.24—3 0. In patients with severe or persistent
symptoms in whom it is judged that an objective diagnosis is essential,
oesophageal manometry and 24-hour oesophageal pH recording should
However, the author has seen cases of
achalasia with a pH recording identical to that of GORD and in whom the symptoms
of achalasia have been completely relieved by Heller’s myotomy without a
concurrent antireflux procedure and without the onset of GORD on prolonged
follow-up.
Barium
swallow and meal examinations give the best appreciation of gastro-oesophageal
anatomy (Fig. 50.31). This may be important to the surgeon planning an operation
that may be complicated by oesophageal shortening or a
For
the most part making a diagnosis of GORD is not difficult, but because it is so
common there is a large number of people in whom the diagnosis is obscure. It
should be borne in mind that proton pump inhibitors (PPIs), which are now quite
properly in widespread use by family doctors, heal reflux oesophagitis rapidly
so that there may be nothing abnormal to see at endoscopy. The effect of PPIs on
acid secretion may be surprisingly prolonged, in some cases leading to
false-negative oesophageal pH studies. As a matter of routine, PPIs are stopped
a week before oesophageal pH recording, but acid secretion is sometimes reduced
for 2 weeks or more. In cases of doubt 24-hour pH recording should be repeated
and it is sometimes useful to stop PPIs 4 weeks before pH recording.
Achalasia
and GORD are easily confused
A
further perversity in the diagnosis of GORD is the ease with which its symptoms
may be confused with those of achalasia. With the more widespread use of
oesophageal manometry achalasia is often diagnosed at a much earlier stage than
previously, long before the classic symptom pattern is established and long
before the classic X-ray appearances are seen. It is perhaps surprising that
the early symptoms of achalasia may be indistinguishable from those of GORD even
with hindsight. This is especially important when patients are being considered
for antireflux 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, antacid-alginate preparations and H2 receptor
antagonists. Consultation is more likely when symptoms are severe or
prolonged. By the time a patient comes to consultation, and particularly
hospital consultation, it is highly likely that simple treatment will have
been tried and found wanting. Nevertheless it is always worth checking. Simple
measures that may have been neglected include advice about weight loss,
smoking, excessive consumption of alcohol, tea or coffee and a modest degree of
head up tilt of the bed. Tilting the bed has been shown to have an effect that
is similar to taking an H2 antagonist. However, the common practice
of using additional pillows has no significant effect apart from causing
discomfort.
PPIs
are the most effective medication for severe GORD
PPIs,
such as omeprazole, lansoprazole and pantoprazole are by far the most effective
drug treatment for GORD. Indeed they are so effective that, once started,
patients are very reluctant to stop taking them. The PPIs have been a major
advance in the treatment of CORD. Given an adequate dose oesophagitis heals in
the majority of cases and even most strictures respond well to one or two
dilatations and long-term PPI treatment. The only reservation is whether there
will be serious side effects with long-term consumption. Thus far the PPIs have
an excellent safety record, but doubts have been expressed as to whether the
increased incidence of adenocarcinoma of the lower oesophagus and cardia in many
countries may be due in part to the long-term treatment of GORD with powerful
acid suppression.
Surgery
Strictly speaking the need for surgery should
have been reduced since medication has improved so much. Paradoxically, the
number of antireflux operations has remained relatively constant and may even
be increasing. This is probably partly due to increased patient expectations and
partly to the advent of minimal access surgery that has improved the
acceptability of surgical procedures.
The
results of antireflux surgery are generally good
The
indication for surgery in uncomplicated GORD is essentially patient choice. The
risks and possible benefits of surgery need to be discussed in detail. The risks
include a small mortality rate (0.1—0.5 per cent, depending on patient
selection), the risk of a failed operation (5—10 per cent) and the risk of
side effects such as dysphagia, gas bloat or abdominal discomfort (10 per
cent). With current operative techniques 85—90 per cent of patients should
be satisfied with the result of an antireflux operation. Patients who are
asymptomatic
on a PPI need a careful discussion of the risk side of the equation. Those who
are symptomatic on a PPI need a careful clinical review to make sure that they
will benefit from an operation. Reasons for failure on a PPI include
‘volume’ reflux (good indication for surgery), ‘hermit’ lifestyle in
which the least deviation from lifestyle rules leads to symptoms (good
indication), psychological distress with intolerance of minor symptoms (bad
indication — these patients are likely to be dissatisfied with surgery), poor
compliance (good indication if the reason for poor compliance is the side
effects of treatment, otherwise bad indication) and misdiagnosis of GORD.
Clinical trials are now in progress to compare the relative efficacy of
long-term medication and surgery, and it is hoped that the results will simplify
clinical decision making.
What operation?
There are many operations for GORD, but
essentially the choice is between total and partial fundoplication. The major
types of antireflux operation were all developed in the 1950s (Fig.
50.32).
Anatomical repair of hiatus hernia has been abandoned as it is ineffective.
Nissen described total fundoplication in which the fundus of the stomach is
wrapped completely around the lower oesophagus. The Belsey operation is a
thoracic procedure in which the oesophagus is sutured to the diaphragm and to
the fundus of the stomach to reduce any hiatus hernia and produce a 2400
anterior fundoplication. The Hill procedure is an operation in which the cardia
is tightened and fixed to the pre aortic fascia. The completed operation looks
very like a fundoplication.
Total
or partial fundoplication?
Done
correctly these are all effective operations. The disadvantage of the Nissen
fundoplication is that that it can produce an overcompetent cardia resulting in
dysphagia or the gas bloat syndrome in which belching is prevented. As a result
the stomach fills with air and the patient feels very full after meals and
passes excessive flatus. The problem of the overcompetent cardia has been
largely overcome by the floppy Nissen
in which the fundoplication is made very loose
The
Angelchik prosthesis is a different type of antireflux procedure in
which a silastic prosthetic collar is placed around the lower oesophagus. It
probably acts by limiting distension of the cardia which is the trigger zone for
TLOSRs and undoubtedly prevents reflux in the majority of cases in which it is
implanted. However, it has a tendency to cause troublesome dysphagia and is much
less popular than formerly.
In
some complicated cases, such as re operative problems, the effects of reflux can
be greatly reduced by performing a partial gastrectomy with a Roux-en-Y
reconstruction. This reduces gastric acid secretion and diverts bile and
pancreatic secretions away from the stomach. Thus the volume of potential
refluxate in the stomach is reduced and because of its changed composition it is
less damaging to the oesophagus.
What operative approach?
For many years the relative merits of the
thoracic and abdominal approaches were hotly debated. The advent of minimal
access surgery has overshadowed this debate and most antireflux operations are
now done with a laparoscopic approach. A small number of surgeons has used a
thoracoscopic or video-assisted thoracic
approach. In general the abdominal approach is preferred unless there is a
particular indication for opening the chest for safe surgery. Nowadays this is
seldom required since there are excellent on-table retractors that allow access
to the upper abdomen and lower mediastinum if necessary.
Laparoscopic fundoplication
Five cannulae are inserted in the upper
abdomen (Fig. 50.33). The cardia and lower oesophagus are separated from the
diaphragmatic hiatus. The fundus may be mobilised by dividing the short gastric
vessels that tether the fundus to the spleen. The hiatus is narrowed by sutures
placed behind the oesophagus. The fundus is drawn behind the oesophagus and then
sutured in front of the oesophagus. In the Nissen fundoplication fundus is
sutured, to fundus to encircle the oesophagus completely (Fig.
50.34a). In the
Toupet partial fundoplication, which is a popular procedure, the fundus is
sutured to the oesophagus on each side leaving a strip of exposed oesophagus
anteriorly (Fig. 50.34b). If the operation cannot be completed safely or
effectively by the laparoscopic method the abdomen is opened with an upper
midline incision and the procedure is completed.
Complications
of GORD
Stricture
Reflux-induced strictures (Fig. 50.30) are common, usually in late middle age and the elderly, but they may occur even in children. It is important to distinguish a benign reflux-induced stricture from a carcinoma. This is nor usually difficult, but sometimes a cancer spreads under the oesophageal mucosa at its upper margin producing a surprisingly benign looking stricture on first sight.
Day-case
dilatation and PPI for peptic stricture
Peptic strictures generally respond well to dilatation and long-term treatment with a PPI. Since most of the 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 and fitter patients. It should be borne in mind that antireflux surgery may be difficult technically in stricture patients because of associated oesophageal shortening.
Oesophageal shortening
With long-standing reflux oesophagitis the
oesophagus has a tendency to contract longitudinally producing a secondary
hiatus hernia. This does not matter in a patient being treated by medication,
but it may cause difficulty during antireflux surgery. The shortening may be a
minor problem that simply requires mobilisation of the oesophagus. If a good
segment of intra-abdominal oesophagus cannot be restored without tension a
Collis gastroplasty can be done (Fig. 50.35). This
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 gastrooesophageal
reflux (Fig. 50.36). One of the great mysteries of GORD is why some people
develop oesophagitis and others develop Barrett’s oesophagus often without
significant oesophagitis. In Barrett’s oesophagus the junction between
squamous oesophageal mucosa and gastric mucosa moves proximally. It may be
difficult to distinguish a Barrett’s oesophagus from a tubular sliding hiatus
hernia during endoscopy since the two often coexist (Fig. 50.37). The key is where the gastric mucosal folds end. The mucosa
in the body of the stomach has longitudinal folds. The columnar lining in
Barrett’s oesophagus is smooth. If a peptic stricture occurs in Barrett’s
oesophagus it always occurs at the new squamocolumnar junction (Fig.
50.38). A
different type of stricture may occur in the columnar segment after healing of a
Barrett’s ulcer (see below).
Intestinal
metaplasia, the important factor
Several
types of gastric-type mucosa may be found in the lower oesophagus. When intestinal
metaplasia occurs there is an increased risk of adenocarcinoma of the
oesophagus of the order of 25 times that of the general population (Figs 50.39
and 50.40). Patients who are found to have Barrett’s oesophagus may be
submitted to regular screening endoscopy with multiple biopsies every year or
two in the hope of finding dysplasia or in
situ cancer rather than allowing invasive cancer to develop and cause symptoms. There is as
yet no general agreement about the benefits of screening endoscopy, nor about
the ideal frequency of endoscopy. A significant problem is that the incidence of
Barrett’s oesophagus in the community is estimated to be at least 10 times the
incidence discovered by endoscopy in dyspeptic patients referred for endoscopy.
Thus adenocarcinoma in Barrett’s oesophagus often presents with invasive
cancer without any preceding reflux symptoms.
Until
recently Barrett’s oesophagus was not diagnosed until there was at least 3 cm
of columnar epithelium in the distal oesophagus. With the better appreciation of
the importance of intestinal metaplasia Barrett’s oesophagus may be diagnosed
if there is any intestinal metaplasia
in the oesophagus.
When
Barrett’s oesophagus is discovered the treatment is that of the underlying
GORD. Several methods of ablation of Barrett’s mucosa are under active study,
including laser,
Barrett’s
ulcer is an ulcer in the columnar-lined portion of a Barrett’s oesophagus (Fig.
50.41). These are distinct from the more usual erosions of reflux
oesophagitis that always occur at or just above the squamocolumnar junction.
Barrett’s ulcers may be deep and prone to bleeding or, rarely, perforation.
Uncomplicated reflux oesophagitis almost never gives rise to severe haemorrhage.