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What causes gastro-oesophageal reflux?
Most of us have suffered from this condition at some point or other in our lives either because of something we have eaten, how we have eaten it, or a combination of the above. All of us will get a degree of reflux if we eat hot, spicy or acidic food, or consume caffeinated products, carbonated drinks, alcohol, or nicotine, particularly late at night.
But for some patients and individuals this is a chronic problem that can be quite debilitating and can in the long-term lead to not just reduction of quality of life, but also changes within the oesophagus that can eventually become precancerous and then cancerous. This sort of reflux is often associated with hiatus hernias which are weaknesses within the central portion of the diaphragm, which is the muscle that separates the chest from the abdomen. We all have a defect within the central part of the diaphragm which allows our oesophagus to traverse the chest and enter into the abdomen.
However, for those with hiatus hernia in the top section of the stomach, this part of the stomach actually resides in the chest cavity, and this leads to the valve between the oesophagus and the stomach not working correctly and therefore leading to mechanical reflux. This leads to reflux of acidic contents as well as volume reflux of liquid from the stomach into the oesophagus. Sometimes this goes all the way up to the voice box or larynx that can lead to changes in voice, hoarse voice and a bitter taste in the mouth.
Reflux is often mechanical and therefore worse when you lean forward or lie down. This is also why reflux is often worse at night because of this mechanical affect; gravity is helpful for patients with mechanical and volume reflux. Weight also plays a significant factor as being overweight or obese lead to changes in adiposity around the gastro-oesophageal junction and therefore leads to this valve not working properly. For many patients, a small amount of weight loss that is consistent and sustained may significantly help reflux symptoms.
Reflux is also made worse by dietary triggers as described above. But certain things in our diet and the way that we eat also can cause bloating. This sort of bloating or distended stomach, and for those patients who have a faulty valve between the oesophagus and the stomach, will result in worse reflux, which can be acid reflux, volume reflux or both. Avoidance of such dietary triggers and eating slowly so that one does not swallow too much air, known as aerophagia, can also help.
What can I do to alleviate my reflux symptoms?
Medications can help with reflux symptoms, for example over-the-counter liquids and tablets such as Gaviscon and Rennie. Acid suppression medication such as proton pump inhibitors like omeprazole and lansoprazole can help to reduce the amount of acid produced by the stomach. This can help reflux symptoms considerably, however most patients do not want to be on life-long medication for this sort of symptomatology and therefore often would like to explore other solutions other than lifestyle, diet and medications.
What are the surgical options?
Minimally invasive surgery can potentially offer solutions where laparoscopy / keyhole surgery is used to fix the hiatus hernia and also to bring the lower oesophagus back into the abdominal cavity where it was designed to be, and then create a new valve between the stomach and oesophagus. This would be done either with the patient’s own tissues, or with magnetic sphincter augmentation, a procedure known as Linx.
How do I know if I can have surgery?
In order to decide which patients are suitable candidates for this sort of surgery, reflux sufferers need to see a reflux expert who will be able to go through a full history, perform a dietetic background check and go through your medical and surgical history. Mental health factors are also very important as stress, anxiety and depression as well as life events can also cause reflux to become acutely worse. Following on from an assessment by a reflux expert, most patients will need investigating with upper gastrointestinal endoscopy, and oesophageal function testing such as manometry and pH studies will be able to tell the clinician whether the oesophagus is functioning properly and objectively how much acid is getting into the oesophagus from the stomach. Often contrast studies such as a barium swallow may be needed, and if bloating and belching are a feature then testing for bacterial overgrowth with a breath test would be carried out. Testing for Helicobacter pylori will be indicated along with blood tests.
If the patient is considering surgery and deemed to be a good candidate for this sort of minimally invasive, enhanced recovery surgery, then this will be discussed with the patient at length and usually images, videos and supporting material are used to be able to explain the procedure. Most cases will be carried out as a day case or a one night stay.
The best outcomes usually come from a combination of therapies with some change in lifestyle modification. Some modest weight loss and a trial of pharmacotherapy prior to surgery is advised, and continuing sensible and healthy dietary habits post-surgery essential to maintain the benefits of the procedure.
For patients who may already have had treatment at other centres and their reflux has returned then an anti-reflux specialist unit such as ours is perfectly placed to investigate and then help you to treat recurrent reflux. We would also rule out any other potential causes for your symptoms. For both the primary cases and the revisional cases, a very experienced multidisciplinary team approach is used involving an upper gastrointestinal surgeon, gastroenterologist, anaesthetist, dietician, aar nose and throat specialist, and gastrointestinal physiologist. With this approach and multimodal diagnostics our treatment for this very common condition can be personalised with huge effectiveness and long-term symptom reduction.
Written by Sanjay Purkayastha, Consultant General Surgeon specialising in bariatric and upper GI surgery.