The oesophagus is a narrow tube that passes food from the mouth to the stomach. At the junction of the stomach, the oesophagus is surrounded by ring shaped muscles called the lower oesophageal sphincter (LES), which acts as a valve, ensuring the one-way movement of food.
Gastric reflux, also called gastro-oesophageal reflux disease (GORD), is a condition where the stomach's contents (food or liquid) rise up from the stomach into the oesophagus, a tube that carries food from the mouth to the stomach. Food mixed with the stomach’s digestive acids can irritate and damage the oesophagus.
Normally, the stomach's contents are retained in the stomach with the help of the lower oesophageal sphincter (LES), a muscle that contracts and relaxes to maintain the one-way movement of food. However, gastric reflux occurs when the LES weakens. The exact cause of this is not known, however, certain factors including obesity, smoking, pregnancy and possibly alcohol, may contribute to GORD. Common foods such as spicy foods, onions, chocolates, caffeine- containing drinks, mint flavourings, tomato-based foods, citrus fruits and certain medications can worsen gastric reflux.
Heartburn is usually the main symptom of GORD, characterised by a burning-type pain in the lower part of the mid-chest, behind the breast bone. Other symptoms include a bitter or sour taste in the mouth, trouble swallowing, nausea, dry cough or wheezing, regurgitation of food (bringing food back up into the mouth), hoarseness or change in voice and chest pain.
Your doctor may order some of the following tests to diagnose gastric reflux:
- Endoscopy: Allows the doctor to examine the inside of your oesophagus, stomach and portions of the intestine with an instrument called an endoscope, a thin flexible lighted tube
- Barium X-rays: Involves swallowing a barium preparation, which can be detected through X-rays
- Twenty- four-hour pH monitoring: Involves inserting a tube through your nose into the oesophagus, and positioning it above the LES. The tip of the tube contains a sensor which can measure the pH of the acid content refluxed into the oesophagus. The tube will be left in place for 24 hours.
- pH capsule: Allows measuring acid exposure in the oesophagus. A small wireless capsule is introduced into the oesophagus by a tube through the nose or mouth. The tube is removed after the capsule is attached to the lining of the oesophagus. The pH sensor transmits signals to a computer which collects the data about the acid exposure over the next 24 hours. The capsule eventually falls off the oesophagus lining and is safely passed in the stool.
- Impedance study: Requires two probes; one is placed in the stomach and the other just above the stomach. The dual sensor helps to detect both acidic and alkaline reflux.
Treatment aims at reducing reflux, relieving symptoms and preventing damage to the oesophagus. Some of the treatment options include:
- Antacids: Over-the-counter medicines that provide temporary relief to heartburn and indigestion by neutralising acid in the stomach
- Other medications: Reduce the production of acid in the stomach
- Endoluminal gastroplication or endoscopic fundoplication technique: Minimally-invasive method that requires the use of an endoscope with a sewing device attached to the end, known as an EndoCinch device. This instrument places stitches in the stomach below the LES to create a plate which helps reduce the pressure against the LES and strengthen the muscle.
- Nissen’s fundoplication: Is a surgical procedure in which the upper part of the stomach is wrapped around the end of your oesophagus and oesophageal sphincter, where it is sutured into place. This surgery strengthens the sphincter and helps prevent stomach acid and food from flowing back into the oesophagus.
If conservative treatment options fail to resolve your GORD, your doctor may recommend a surgical procedure called Nissen Fundoplication. Nissen Fundoplication surgery reinforces the lower oesophageal sphincter's ability to close and helps to prevent gastro-oesophageal reflux from occurring. This surgery can be performed laparoscopically through tiny incisions in the abdomen or through an open approach, which requires a large abdominal incision.
Nissen Fundoplication is performed on an outpatient basis under general anaesthesia. Steps involved in Nissen Fundoplication procedure include:
- Your surgeon makes a small incision in the upper abdomen and inserts a tube called a trocar through which the laparoscope is introduced into the abdomen. A laparoscope is a long, narrow telescope with a light source and video camera at the end. The scope is passed through a tiny incision into the abdomen where images from the camera are projected onto a large monitor for the surgeon to view. Laparoscopes have channels inside the scope enabling your surgeon to pass gas in and out to expand the viewing area or to insert tiny surgical instruments for treatment purposes.
- Additional small incisions may be made for other surgical instruments.
- With the images from the laparoscope as a guide, your surgeon wraps the upper part of the stomach, the fundus, around the lower oesophagus to create a valve, suturing it in place.
- The hole in the diaphragm through which the oesophagus passes is then tightened with sutures.
- The laparoscope and other instruments are removed and the gas released.
- The tiny incisions are closed and covered with small bandages.
As with any surgery, Nissen Fundoplication may involve certain risks and complications which include infection, injury to blood vessels, stomach or oesophagus, swallowing difficulties, gas embolism (gas bubbles in the bloodstream) and the need for a laparotomy (performed through a larger abdominal incision). Sometimes, the new valve weakens or loosens months or years after the surgery, causing symptoms again. If symptoms are severe, the surgery may need to be repeated.
Frequently Asked Questions
What is GORD?
Gastric reflux, also called gastro-oesophageal reflux disease (GORD), is a condition where the stomach's contents (food or liquid) rise up from the stomach into the oesophagus.
What causes GORD?
The exact cause of this is not known, however, certain factors including obesity, smoking, pregnancy and possibly alcohol, may contribute to GORD. Common foods such as spicy foods, onions, chocolates, caffeine- containing drinks, mint flavourings, tomato-based foods, citrus fruits and certain medications can worsen gastric reflux.
What are the symptoms of GORD?
Heartburn is usually the main symptom of GORD, characterised by a burning-type pain in the lower part of the mid-chest, behind the breast bone. Other symptoms include a bitter or sour taste in the mouth, trouble swallowing, nausea, dry cough or wheezing, regurgitation of food (bringing food back up into the mouth), hoarseness or change in voice and chest pain.
What are the conservative treatments for GORD?
Conservative treatment options include:
- Lifestyle modification: This can include dietary changes, quitting smoking and alcohol use, losing excess weight and not eating 3 hours before bed.
- Antacids: These medications neutralise the acid in the stomach and provide temporary relief for heartburn symptoms.
- H2 antagonists or histamine receptor blockers: These medications reduce the production of acid in your stomach by blocking a signal that leads to acid secretion.
- Proton pump inhibitors: Proton pump inhibitors (PPIs) are a group of prescription medications that prevent the release of acid in the stomach and intestines. Doctors prescribe PPIs to treat people with heartburn (acid reflux), ulcers of the stomach or intestine, or excess stomach acid.
How is the anti-reflux surgery performed?
Anti-reflux surgery also known as Nissen Fundoplication is an effective surgical procedure to correct reflux. This surgery is performed under general anaesthesia and involves wrapping the upper portion of the stomach around the base of the oesophagus to reinforce the strength of the lower oesophageal sphincter. Until recently, the procedure required a large abdominal incision. A laparoscopic Nissen Fundoplication is a minimally invasive approach that involves specialised video equipment and instruments that allow a surgeon to perform the procedure through four tiny incisions, most of which are less than a half-centimetre in size. However, in rare cases the laparoscopic approach is not possible because it becomes difficult to visualise or handle organs effectively. In such instances, the traditional incision may need to be made to safely complete the operation.
What happens if left untreated?
If left untreated, chronic GORD can cause serious complications such as inflammation of the oesophagus, oesophageal ulcers, narrowing of the oesophagus, chronic cough and reflux of liquid into the lungs (pulmonary aspiration). Some people develop Barrett’s oesophagus, a condition characterised by changes in the oesophageal lining, which can lead to oesophageal cancer.
How is the recovery after the procedure?
Your surgeon may give you a prescription pain medicine or recommend non-steroidal anti-inflammatory drugs (NSAIDs) for the first few days to keep you comfortable. Your surgeon may instruct you about your diet and activity restrictions. Care should be taken with your wound. You are advised not to lift heavy objects for 8 to 12 weeks.
When can I resume my regular activities?
Shortly after surgery, you can gradually resume your daily activities. You are encouraged to start walking as early as possible to reduce the risks of blood clots and pneumonia. You will be able to get back to work in 2 to 3 weeks.
What are the advantages of laparoscopic surgery?
One advantage of this method is a brief hospitalisation. Most of the time it will require an overnight stay. Other advantages include less pain, fewer and smaller scars, and a shorter recovery time.
What complications can occur after surgery?
As with any surgery, anti -reflux surgery may involve certain risks and complications which include infection, injury to blood vessels, stomach or oesophagus, swallowing difficulties, gas embolism and the need for a laparotomy (performed through a larger abdominal incision). Sometimes, the new valve weakens or loosens months or years after the surgery, causing symptoms again. If symptoms are severe, the surgery may need to be repeated.
