The condition
Gastroesophageal reflux is, as the word implies, the reflux of the stomach contents into the oesophagus. This content is food, stomach fluids (mainly gastric acids) and bile fluids (bile acids) which often reflux in the stomach, as the bile ends up in the duodenum just a few centimetres from the stomach. In fact, bile reflux is much more common and more severe in patients who have had cholecystectomy surgery and some types of stomach surgery.
Gastroesophageal reflux disease(GERD) is the most common condition in modern gastroenterology. It is responsible in the West for a very significant cost in health and hospital care.
Various studies show that about half of the people in the West have at least one episode of reflux monthly and 7-10% of the population have daily episodes of reflux.
The significant increase in the incidence of the disease today, particularly in Western societies, is largely due to what we call the Western lifestyle and diet. Sedentary life with little movement, obesity, a diet of mainly 1-2 large meals, foods with preservatives and habits such as smoking, alcohol, coffee and chocolate, soft drinks and fatty foods.
In most patients the disease is caused by their lifestyle and diet. But in a percentage of patients there are underlying causes. Diseases of the stomach and duodenum that cause delayed gastric emptying, diseases of the oesophagus that affect its mobility or the function of the lower oesophageal sphincter and various types of diaphragmatic hernia that disturb the normal anatomy of the area are the most common causes.
The importance of GERD lies in its temporality. In most patients the disease has flares and remissions and lasts for life. It’s essentially a dripping tap – it’s annoying, of course, it’s expensive, but most importantly of all, the glass eventually overflows. In fact, the main problem with GERD is its long-term complications – oesophageal strictures and oesophageal cancer (the incidence of which is nowadays, naturally, increasing).
The effects of GERD are esophagitis (ulcers in the esophagus), bleeding from the esophagus, esophageal strictures and Barrett’s esophagus (precancerous lesion). In fact, most patients with Barrett’s oesophagus have no symptoms of reflux.
The classic symptoms of GERD are:
- Heartburn behind the sternum, bitter or sour sensations in the mouth and the feeling that content is receding from the stomach to the mouth.
- Less common symptoms are nocturnal regurgitation of content that stains the pillow or wakes the patient due to a feeling of suffocation and intense salivation.
- A proportion of patients present with chest pain, typically posterior chest pain that may be reflected in the back, a pain similar to that of the heart.
- Another percentage of patients experience dysphagia, which is the feeling that their food is stuck in the oesophagus and does not pass into the stomach, so they drink water to move it along.
- Rarely, finally, pain during swallowing, i.e. painful swallowing, which is due to irritation of the affected esophagus by the food, may occur.
The currently accepted atypical manifestations of GERD are chronic irritation of the pharynx and larynx from reflux resulting in hoarseness, laryngitis, chronic dry cough, polyps of the vocal cords and cases of asthma with frequent attacks despite appropriate treatment.
A percentage of patients with GERD (often the most severe cases) never show symptoms and are discovered during endoscopies done for other reasons.
The diagnosis of GERD is based on the presence of the classic symptoms of the disease. Further testing with either oesophageal manometry or pachymetry is sometimes necessaryespecially in chronic or difficult cases :
- In patients with chronic discomfort
- In patients with recurrent discomfort
- In patients with worrying symptoms
- For monitoring purposes:
- Concerning symptoms are dysphagia, which may indicate oesophageal stricture and needs to be investigated without delay, and painful eating
- In chronic and relapsing cases, it is of interest both the existence of predisposing factors for causing reflux (diaphragmatic hernia, etc.) and the investigation of the effects of GERD on the
esophagus of patients (strictures, Barrett’s esophagus, etc.).
The treatment
The treatment of GERD has three parts:
1. Weight loss and lifestyle and diet modification – changes that either relieve the patient from the disease or usually reduce the frequency of disease flares and the frequency of medication.
2. Medication, which does not cure GERD but protects the oesophagus from the effects of reflux – taken for long periods of time during periods of disease flare-ups.
3. Endoscopic and surgical antipalindromic interventions.
The usual course of GERD is periods of exacerbations, when medication is given and intervals of shorter or longer periods without symptoms.
Cases of patients who are candidates for invasive treatment are:
- cases where the disease does not respond satisfactorily to treatment or relapses frequently
- young patients with persistent disease who are at risk of the effects of long-term medication
- patients with diaphragmatic hernia
- patients with Barrett’s oesophagus, or some other rarer conditions
The classic antipalindromic procedure is the Nissen tholoplasty surgery, which is nowadays performed laparoscopically. This procedure is irreplaceable (currently) in patients with large diaphragmatic hernias and in patients with Barrett’s esophagus. This operation folds the upper part of the stomach around the lower oesophagus like a life jacket, creating a mechanical barrier to reflux.
For patients with smaller diaphragmatic hernias (less than 2 cm) but also for the first two categories, there is nowadays the possibility of a similar antipalindromic procedure which is performed endoscopically (with gastroscopy), the Endoluminal Fundoplication (ELF). With this operation, which is also performed in Greece, the upper part of the stomach is internally folded around the lower esophagus, creating a similar life preserver with excellent results.
Endoscopy units
