Gastro-esophageal reflux disease (GERD)

Gastro-oesophageal reflux disease is a common condition affecting millions of people worldwide. In healthy individuals, there is a very effective one-way valve mechanism between the gullet and the stomach, which prevents gastric acid from entering the gullet. Due to a variety of factors, the valve mechanism can fail, which will lead to the lining of the gullet being exposed to acid and the patient experiencing the symptom of heartburn.

The risk factors for developing GERD are:

• Obesity
• Smoking
• Exercising or strenuous activity, lying down, bending over, or straining after eating
• Excessive intake of alcohol, caffeine, carbonated drinks, chocolate or fried foods
• Hiatal hernia
• Pregnancy
• Diabetes
• Prior surgery, vagotomy
• Medications: anticholinergics, calcium channel blockers, theophylline, bronchial inhalers, and other asthma medications, nitrates, sildenafil (viagra)

What are the related symptoms of GERD?

Common GERD symptoms may include:

• Burning sensation in your chest, known as heartburn, which normally occurs after eating and may be worse at night
• Chest pain
• Difficulty swallowing
• Food regurgitation
• Lump in your throat
• Chronic cough
• Disrupted sleep
• Worsening or new asthma

Seek medical treatment if you have chest pain, especially if you experiencing shortness of breath, or jaw or arm pain as these may also be symptoms of a heart attack. See your doctor if you experience severe GERD symptoms or if over the counter heartburn medication fails.

If left untreated, GERD can lead to the following complications:

• Esophagitis
• Barret's oesophagus (a condition where the lining of the lower part of the gullet is replaced by cells better suited to handle acid exposure, but also more prone to develop cancer)
• Cancer of the oesophagus
• Stricturing of the oesophagus
• Extra-intestinal complications: hoarseness, asthma, nocturnal cough

The diagnosis of GERD can be made based on the history of the patient and if necessary, performing gastroscopy or a 24 hr pH (acid) monitoring test. Not all patients will need a gastroscopy, definite indications for a gastroscopy are:

• The presence of dysphagia (difficulty in swallowing)
• Pain on swallowing
• Weight loss
• Blood in stools or anaemia

What are the treatment options for GERD?

The mainstay of GERD treatment is medical therapy with a PPI (proton pump inhibitor: a type of drug highly effective in suppressing the secretion of gastric acid). Most patients will experience complete relief of their heartburn after initiating PPI therapy. Dr Cooper may recommend surgery for the following scenarios:

• Patients who have failed medical management (inadequate symptom control, severe regurgitation not controlled with acid suppression, or medication side effects)
• Patients may opt for surgery despite successful medical management (due to quality of life considerations, lifelong need for medication intake, the expense of medications, etc.)
• Presence of complications of GERD (e.g., Barrett's oesophagus, peptic stricture)
• Presence of extra-oesophagal manifestations (asthma, hoarseness, cough, chest pain, aspiration)

Anti-reflux surgery (if done for the correct indications) can produce excellent long- term relief of heartburn without the hassle and expense of taking daily medication. There are a variety of surgical procedures available to treat GERD of which the "Nissen fundoplication" is the most widely used.

• Nissen fundoplication
  During this procedure, Dr Cooper will wrap the top of your stomach around your lower oesophageal sphincter to tighten the muscles and help prevent reflux.

All of the currently available procedures are based on the same principle: the restoration of the normal barrier to gastric acid reflux while exposing the patient to the minimum risk of morbidity and mortality. Except in the presence of a clear contra-indication, all anti-reflux procedures should be done in a minimally invasive/laparoscopic manner.

Risks or complications following anti-reflux surgery include:

• Difficulty swallowing because the stomach is wrapped too tightly around the gullet.
• The oesophagus is sliding out of the wrapped portion of the stomach so that the valve (lower oesophageal sphincter) is no longer supported.
• Heartburn that recurs.
• Bloating and discomfort from gas buildup because the person is not able to belch.
• Excess flatulence.
• Risks of anaesthesia.
• Risks of surgery (infection, bleeding, pneumonia, etc).