Gastrooesophageal reflux disease - Disorders of the oesophagus

Disorders of the oesophagus

Gastrooesophageal reflux disease

Definition

Reflux of acidic gastric contents into the oesophagus via the lower oesophageal sphincter.

Aetiology

Factors include hiatus hernia, pregnancy, obesity, excessive alcohol ingestion, cigarette smoking, coffee, red wine, anticholinergic drug, oesophageal dysmotility and systemic sclerosis.

Pathophysiology

The lower oesophageal sphincter is formed of the distal few centimeters of the oesophageal smooth muscle. Normally after the passage of a food bolus the muscle rapidly contracts preventing reflux. Sphincter tone can increase in response to a rise in intraabdominal or intragastric pressure.

Reflux results from low resting tone of the lower oesophageal sphincter and failure of increase in tone to rises in pressure further down the GI tract.

The normal squamous epithelium of the oesophagus is sensitive to the effects of acid and thus acute inflammation may be caused, called reflux oesophagitis. Continuing inflammation may manifest as ulceration, scaring, fibrosis and stricture formation.

Continuing inflammation may result in glandular epithelial metaplasia (a change from the normal squamous epithelium to glandular epithelium) termed Barrett’s oesophagus, which predisposes to neoplasia.

Clinical features

Patients complain of symptoms of dyspepsia  particularly heartburn, a retrosternal burning pain aggravated by bending or lying down. Effortless regurgitation of food and acid (waterbrash) into the mouth may occur.

Investigations

Patients should be investigated as for dyspepsia including upper GI endoscopy where appropriate.

·        Barium swallow may show a hiatus hernia, true reflux of barium must be demonstrated to be diagnostic. A negative test however does not exclude reflux.

·        24-hour intraluminal pH monitoring is a gold standard test for acid reflux.

Management

 Patients are managed as for dyspepsia, i.e. patients under the age of 55 years without ‘alarm symptoms and signs’ are treated without endoscopy.

Older patients and those with suspicious features should undergo endoscopy prior to commencing treatment. Although H. pylori infection is no more likely to be present in patients with gastrooesophageal reflux disease compared to the normal population, patients are tested as part of the investigation of dyspepsia and treated if found to be positive. See also Dyspepsia and H. pylori .

·        Patients should be advised to lose weight if obese, and avoid precipitating factors such as alcohol and coffee. Raising the head of the bed may be of benefit.

·        The most effective relief is provided by proton pump inhibitors; however, many patients have adequate symptom control from antacids, alginates, H2 antagonists or prokinetic agents such as domperidone or metoclopramide. An initial course of 4 weeks of treatment is used.

·        Indications for antireflux surgery include continued symptoms despite high dose proton pump inhibitor therapy for at least 6 months, complications or high grade oesophagitis in young/fit patients and reflux after previous upper gastrointestinal tract surgery. A fundoplication (open or laparoscopic) is performed in which the mobilised gastric fundus is wrapped completely or partially around the lower end of the oesophagus. Endoscopic techniques are now available. Oesophageal strictures may require endoscopic dilatation to stretch the stricture to achieve a luminal diameter of 10–15 mm. Complications include haemorrhage, perforation and bacteraemia.