Indigestion / Heartburn

HEARTBURN (ACID REFLUX)

GASTRO-OESOPHAGEAL REFLUX DISEASE (GORD)

Heartburn or Acid reflux - what is it?

Heartburn is a burning sensation which radiates from the stomach up the chest and the throat which occurs when stomach contents, particularly acids, rise up into the food pipe or gullet (oesophagus). Heartburn is the primary symptom of gastro-oesophageal reflux disease or GORD and is sometimes referred to as acid reflux. It is a very common condition which affects all age groups. Heartburn is most likely to occur in connection with the following activities:

  • After a heavy meal
  • Lifting a heavy object
  • Lying down particularly on your back
  • Bending forwards

Persistent acid reflux occurring twice a week is considered abnormal and is referred to as gastro-oesophageal reflux disease (GORD). This is a chronic condition and can lead to serious health problems as well as significantly poor quality of life.

What are the symptoms of Gastro-oesophageal Reflux Disease?

The typical symptoms of acid reflux or gastro-oesophageal disease are:

  • Heartburn - a burning pain situated in the middle of the chest, behind the breast bone which may occasionally be mistaken for  pain from a heart attack.
  • Pain in the upper abdomen (epigastrium)
  • Regurgitation of stomach contents into the back of the throat and mouth especially on bending forwards.
  • Some people may experience difficulty with swallowing (dysphagia) or pain on swallowing (odynophagia).
  • Atypical symptoms of acid reflux include dry cough, especially at nights, with disturbed night sleeps, asthma-like symptoms and choking sensations.

It is important to note that some people will have no symptoms despite having severe acid reflux and vice versa, so if you are worried about persistent symptoms you should consult your doctor for advice.

What causes gastro-oesophageal reflux disease or chronic "heartburn"?

It is still unclear why some people suffer from chronic heartburn more than others. Normally the lower gullet sphincter (valve) opens spontaneously for varying periods of the day leading to acid reflux which is not considered troublesome. However, studies do suggest that there are some structural abnormalities present in people with chronic heartburn or GORD that weakens the lower gullet valve (sphincter) keeping it open longer than usual while the rest of the gullet continues to work leading to excessive and troublesome acid reflux.

Some of these structural abnormalities may include sliding hiatus hernia which occurs when the upper part of the stomach and the lower oesophageal sphincter move through an opening (hiatus) in the muscle that separates the stomach from the chest known as the diaphragm. The diaphragm normally helps the lower oesophageal sphincter with the overall mechanism that stops acid from backing up into the gullet. The presence of hiatus hernia does not automatically equate to chronic acid reflux or GORD as many people with hiatus hernia do not have any symptoms from it and it is often present in otherwise healthy people, mainly aged 50 and over.

There are other contributing factors to GORD such as obesity, pregnancy and smoking. Certain foods may aggravate chronic acid reflux symptoms such as fatty foods, chocolate, spicy foods, caffeine-containing drinks and alcohol.

Are there any long-term complications of GORD?

Gastro-oesophageal disease is a chronic condition and can lead to serious complications if untreated. The acid exposure to the gullet causes inflammation (oesophagitis) and ulceration of the surface lining of the gullet. This can lead to tissue damage and scarring causing strictures (narrowing) of the gullet which makes swallowing difficult.

GORD may also cause an abnormal change in shape and colour (from pale pink to bright pink) of the lining cells of the gullet making them precancerous, a condition referred to as Barrett's oesophagus. Barrett's oesophagus occurs in 1 in 10 people with chronic acid reflux symptoms.

The exact reason Barrett's oesophagus develops in some people with GORD and not in others is unknown. However, it is twice more common in men than in women and is found much more commonly in white Caucasian males than in males of other races.

Barrett's oesophagus does not cause any specific symptoms but can increase the risk of a type of oesophageal (gullet) cancer known as adenocarcinoma. The incidence of adenocarcinoma of the gullet is rapidly rising in the Western world and may be related to GORD and obesity. The risk of developing this gullet cancer is 44 -125 times higher in people who has Barrett's oesophagus than in people who do not Barret's oesophagus.
The absolute risk of getting gullet cancer in those who have Barrett's oesophagus however, remains significantly small (less than 1% per annum).

How is GORD treated?

Initial management of GORD is medical and include:

Lifestyle changes
You can minimise the severity of your reflux symptoms by making some lifestyle changes such as

  • Stopping smoking
  • Lose excess body weight
  • Eat earlier in the evenings to avoid going to bed with full stomach - reflux tend be worse after meals
  • Sleeping with the bed propped up at the head end
  • Avoiding food and beverages that worsen symptoms
  • Wearing loose fitting clothes

Can I take any medication?

Antacids - which can be bought over the counter, relieve heartburn by neutralising the acid in the stomach. There may be some side-effects such as diarrhoea (especially the magnesium-based ones) or constipation (aluminium-based antacids). They are often used in combination with other medications such as H2 blockers for a more effective relief of heartburn.

H2 Blockers - H2 blockers work by blocking stomach acid production. They are more effective than antacids in relieving acid reflux symptoms, however, their use is very limited in severe and chronic heartburn or GORD. They are often used in combination with proton pump inhibitors. H2 blockers are available in both prescription and over the counter lower strengths. Examples of H2 blockers are cimetidine (tagamet), ranitidine (zantac) and famotidine.

Proton pump inhibitors (PPIs) - PPIs are particularly effective in shutting down stomach acid production to a minimum and do relieve heartburn as well as promote healing of any gullet inflammation (oesophagitis) caused by acid reflux. There are different types of PPIs such as omeprazole, lansaprozole, pantoprazole, rabeprazole and esomeprazole. Overall PPIs are safe drugs but they can be associated with side effects in some patients such as abdominal cramps, dizziness, diarrheoa, headaches, aches and pains.

Surgery

Surgery is indicated when:

  • Adequate medical therapy fails
  • Chronic heartburn or GORD is complicated by strictures and Barrett's oesophagus
  • Volume reflux, ie regurgitation of gastric contents
  • Intolerance of medications
  • Need to avoid long-term medical treatment

What happens before surgery?

Your assessment by your surgeon will include camera examination of your gullet and stomach (gastroscopy) to confirm the diagnosis of chronic acid reflux and assess for any associated complications such as gullet narrowing (stricture), Barrett's oesophagus. The camera examination will also assess for the presence of hiatus hernia as well as rule out any other serious pathology. You will also undergo further tests to assess the muscle function of your gullet as well as the integrity of the lower oesophageal sphincter (valve). A fine tube will be inserted into the upper gullet to determine, over a 24hour period the amount of acid you reflux.

You will have a number of blood tests in preparation for the operation. You will be admitted on the day of the operation.

Laparoscopic Anti-Reflux Surgery

In recent years this has become increasingly the preferred surgical option because it is minimally invasive. The procedure is performed under general anaesthetic. It is performed through five small puncture wounds in the upper abdomen. The image of the abdominal cavity transmitted from a tiny camera to a television screen is magnified many times over and the surgeon is able to perform the operation safely using special long instruments inserted through the small incisions. The upper part of the stomach is mobilised and passed behind the lower gullet and sutured onto itself in front of the gullet (fundoplication) to stop acid reflux. Hiatus hernia defect is also repaired at the same time using non-absorbable sutures. In some selected cases, mesh material may be necessary to strengthen the hiatus hernia repair.

The advantages of the laparoscopic (keyhole) anti-reflux surgery include:

  • Shorter hospital stay (1-2nights)
  • Less postoperative pain - ordinary pain killers will be prescribed for approximately 5days and after this time they are rarely necessary
  • Quicker physical recovery (10 - 14days) hence faster return to work
  • Significantly less wound scarring and therefore better cosmetic result

Occasionally it may not be possible to complete the procedure using the keyhole technique. This may be due to poor visualisation of abdominal organs as a result of either bleeding or adhesions (scar tissue) from previous surgery although this in itself does not preclude keyhole surgery but may make it more challenging. This usually means converting the procedure to an open approach. This is not a complication but considered safe and sound clinical judgement and will be discussed with you before surgery.

What happens after surgery?

You will be recovered in the adjacent recovery room and returned to the ward afterwards. You may feel abdominal and shoulder tip discomfort which can easily be managed with ordinary painkillers. You should start drinking fluids on the day of the operation and commenced on soft diet on the first day after your surgery. Fizzy drinks and lumpy foods especially bread should be avoided for at least 4-6 weeks after surgery. Our specialist dieticians will provide you with the appropriate diet sheet before discharge from hospital.
You should stop your anti- reflux medications after surgery. The skin wounds are usually closed with dissolving stitches which will not be visible and these will be covered with five little dressings. These dressings may be removed by the fifth day after your surgery.

Potential Risks of Laparoscopic anti-reflux surgery:

Complications of laparoscopic anti-reflux surgery are significantly less than those of open operation. Apart from general anaesthetic complications, there are risks of bleeding, injury to internal organs particularly the gullet, stomach and the spleen although these are very rare. Chest and wound infections may occur following laparoscopic anti-reflux surgery but these are rare.

Side Effects of Laparoscopic Anti-Reflux Surgery:

Increased passage of wind (flatulence) from the back passage may occur following laparoscopic anti-reflux surgery due to reduced ability to vent wind upwards. This may be a permanent situation in some patients.
A small minority of people may experience slight sensation of food sticking immediately after laparoscopic anti-reflux surgery however, this generally tend to be transient. It is essential to eat slowly and chew your food thoroughly.

You should call your doctor immediately if you experience severe pain or severe inability to swallow while at home.