- Affects approximately 40% of the adult population
- Due to acid or bile reflux
- Delayed oesophageal clearance also important
- Gastric hypersecretion rarely implicated
- Poor correlation between symptoms and endoscopic evidence of oesophagitis
- 20% patients with oesophagitis are symptom free
- Most gain symptomatic relief with conservative treatment
- 30% of patients with symptoms have no endoscopic evidence of mucosal injury
Natural barriers to gastro-oesophageal reflux
Lower oesophageal sphincter
- Basal tone
- Adaptive pressure changes
- Transient lower oesophageal sphincter relaxation
External mechanical factors
- Flap valve mechanism
- Cardio-oesophageal angle
- Diaphragmatic pinchcock
- Mucosal rosette
- Distal oesophageal compression
- Phreno-oesophageal ligament
- Transmitted abdominal pressure
Investigation
- Endoscopy - provides histological confirmation and grading
- Savary-Miller grading of oesophagitis
- Grade 1 - Erythema
- Grade 2 - Linear erosions
- Grade 3 - Confluence of erosions
- Grade 4 - Stricture
- 24-hour pH monitoring - probe placed 5 cm above lower oesophageal sphincter (LOS)
- Oesophageal manometry
Conservative treatment
Lifestyle modification
- Stop smoking
- Avoid alcohol
- Loose weight
- Raise head of bed
Drug treatment
- H2 antagonists
- Provide symptomatic relief in 60% at 6 weeks
- Endoscopic evidence of healing seen in only 40%
- Proton pump inhibitors
- 80% healing at 8 weeks in H2 antagonist resistant disease
- More than 20% relapse despite maintenance therapy
- Life-long therapy often required
Surgical options
- Indications:
- Recurrent symptomatic relapse
- Bile reflux
- Documented evidence of deficient LOS
- Fundoplication is operation of choice - performed as open or laparoscopic procedure
- Important features are:
- Mobilisation of gastric fundus
- A tension free wrap ? around 50 Fr oesophageal bougie
- A wrap suture line of less than 3 cm
- 3% develop dysphagia
- 11% develop gastric bloat
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