Introduction
Reflux (Gastro-Oesophageal Reflux Disease – GORD) is a very common condition, affecting 15-20% of the Australian population. It is variably referred to as heartburn, indigestion or acid reflux. It is usually mild, intermittent and caused by lifestyle factors (overeating, smoking, excess alcohol, being overweight). It usually responds to medicines (proton pump inhibitors, ‘PPIs’) which decrease the amount of stomach acid produced. If symptoms are severe, affecting your sleep and quality of life, laparoscopic fundoplication becomes a very good treatment option. This involves repairing any associated hiatus hernia and reinforcing the natural antireflux valve.
Causes
Reflux is caused by dysfunction of the natural barriers to reflux of stomach acid into the oesophagus (food swallowing pipe). In the healthy state, stomach acid production increases after food, but the lower oesophageal sphincter muscle (valve) between the oesophagus and stomach prevents acid from refluxing back up into the oesophagus. This balance can be affected by the following:
- hiatus hernia: the junction between the oesophagus and stomach, containing the sphincter valve, slips up into the chest, reducing the valve’s function.
- oesophageal dysmotility: dysfunction of the food pipe’s ability to contract and push food and refluxed acid back into the stomach.
- overweight and obesity: being overweight increases the pressure in your abdominal cavity. This makes reflux of stomach acid more common, but also makes it harder for your food pipe to push food and acid back down into the stomach. Furthermore, hiatus hernias become much more common when people are overweight.
Symptoms
Reflux symptoms are generally divided as follows:
Typical
- heartburn: burning behind the breastbone.
- regurgitation: stomach contents flushing back up into the food pipe or throat.
- dysphagia: swallowing difficulty, due to inflammation and dysfunction of the food pipe.
Atypical
- chest pain.
- ear pain.
- throat pain / laryngitis.
- voice hoarseness.
- sinus problems.
- chest infections, pneumonia, asthma, lung damage.
- throat clearing: a constant need to clear your throat and swallow.
- dry, sore throat.
- tooth damage.
- burning or metallic taste in the mouth; bad breath.
Tests
All patients with severe reflux should have an upper endoscopy to assess for hiatus hernia and Barrett’s oesophagus. This is a simple, 5-minute day procedure performed under sedation. It requires you to be fasted for 6 hours prior, and to have someone to go home with you afterwards.
Depending on these results and your symptoms, more detailed testing may be necessary:
- Oesophageal pH studies (acid testing) and manometry (pressure testing): these clarify more accurately whether or not reflux disease or food pipe dysfunction are causing your symptoms.
- Barium swallow: dye swallowing test done in an Xray department.
- Nuclear Medicine study: used when looking for laryngopulmonary reflux (LPR), when other tests have been normal.
Diagnosis
Diagnosis of reflux can usually be made from a detailed history. If your symptoms are atypical, don’t respond to PPI medicines, and endoscopy test is normal, the diagnosis can sometimes be more difficult to make. This is when more advanced testing is required.