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Gastro-oesophageal reflux disease

  • Affects approximately 40% of the adult population
  • Due to acid or bile reflux
  • Delayed oesophageal clearance also important
  • Gastric hypersecretion rarely implicated
  • Poor correlation between symptoms and endoscopic evidence of oesophagitis
  • 20% patients with oesophagitis are symptom free
  • Most gain symptomatic relief with conservative treatment
  • 30% of patients with symptoms have no endoscopic evidence of mucosal injury

Natural barriers to gastro-oesophageal reflux

Lower oesophageal sphincter

  • Basal tone
  • Adaptive pressure changes
  • Transient lower oesophageal sphincter relaxation

External mechanical factors

  • Flap valve mechanism
    • Cardio-oesophageal angle
    • Diaphragmatic pinchcock
    • Mucosal rosette
  • Distal oesophageal compression
    • Phreno-oesophageal ligament
    • Transmitted abdominal pressure

Investigation

  • Endoscopy - provides histological confirmation and grading
  • Savary-Miller grading of oesophagitis
    • Grade 1 - Erythema
    • Grade 2 - Linear erosions
    • Grade 3 - Confluence of erosions
    • Grade 4 - Stricture

severe oesophagitis

  • 24-hour pH monitoring - probe placed 5 cm above lower oesophageal sphincter (LOS)
  • Oesophageal manometry

Conservative treatment

Lifestyle modification

  • Stop smoking
  • Avoid alcohol
  • Loose weight
  • Raise head of bed

Drug treatment

  • H2 antagonists
    • Provide symptomatic relief in 60% at 6 weeks
    • Endoscopic evidence of healing seen in only 40%
  • Proton pump inhibitors
    • 80% healing at 8 weeks in H2 antagonist resistant disease
    • More than 20% relapse despite maintenance therapy
    • Life-long therapy often required

Endoscopic appearance of a benign oesophageal stricture

Surgical options

  • Indications:
    • Recurrent symptomatic relapse
    • Bile reflux
    • Documented evidence of deficient LOS
  • Fundoplication is operation of choice - performed as open or laparoscopic procedure
  • Important features are:
    • Mobilisation of gastric fundus
    • A tension free wrap ? around 50 Fr oesophageal bougie
    • A wrap suture line of less than 3 cm
  • 3% develop dysphagia
  • 11% develop gastric bloat
  • Partial fundoplication is associated with less dysphagia and fewer gas related symptoms

Types of fundoplication

Bibliography

Barbezat G O.  Reflux Oesophagitis.  Br J Hosp Med 1995; 54: 583 - 586.

Broeders J A J l,  Mauritz F A,  Ahmed Ali U et al.  Systematic review and meta‐analysis of laparoscopic Nissen (posterior total) versus Toupet (posterior partial) fundoplication for gastro‐oesophageal reflux disease.  Br J Surg 2010;  97:  1318-1330

Fox M,  Forgaes I.  Gastro-oesophageal reflux disease.  BMJ 2006;  332:  88-93

Jalal P K,  Heatley R V.  Medical treatment of gastro-oesophageal reflux disease.  Hosp Med 2000;  61:  478-482

Lundell L.  Surgery for reflux oesophagitis and quality of life after fundoplication.  In Johnson C D,  Taylor I eds.  Recent advances in surgery 23.  Edinburgh, Churchill Livingstone, 2000:  1-10.

Moayyedi P,  Talley N J.  Gastro-oesophageal reflux disease.  Lancet 2006; 367:  2086-2100.

Navaratnam R M,  Clayman C,  Winslet M C.  Clinical advances in the evaluation of oesophageal disease.  Hosp Med 2000;  61:  201-203.

Navaratnam R M,  Winslet M C.  Gastro-oesophageal reflux:  the disease of the millennium.  Hosp Med 1998;  59:  646-649.

Richter J E.  Oesophageal motility disorders.  Lancet 2001;  358:  823-828.

Smith C D.  Antireflux surgery.  Surg Clin North Am 2008; 88:  943-958

Spechler S J,  Lee E,  Ahnen D et al.  Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease.  JAMA 2001;  285:  2331-2338.

Watson D I,  Jamieson G G.  Antireflux surgery in the laparoscopic era.  Br J Surg 1998;  85:  1173-1184.

 

 
 

Last updated: 03 January 2011

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