Gastric Reflux

What if I have Heartburn or Reflux?

Heartburn occurs when stomach acid refluxes back into the oesophagus and burns its sensitive lining.

Obesity itself is a risk factor for this. Another common reason to have heartburn is if you have a hiatus hernia - a common condition in obesity.

A hiatus hernia occurs when the normal opening in the diaphragm for the oesophagus becomes stretched and enlarged, allowing the upper part of the stomach to slide up into the chest. This causes the one-way valve between the oesophagus and stomach to become faulty.

We routinely look for and repair a hiatus hernia if one is found during your weight loss surgery.

As a result, it is usually possible to get rid of your heartburn completely.

Many of our patients who have suffered from years of heartburn requiring medication to control and have had their symptoms alleviated as soon as they awake from surgery, and no longer need medication.

The Condition

Description

Gastric reflux, also called gastro-oesophageal reflux disease (GORD), is a condition where the stomach’s contents rise up from the stomach into the oesophagus. Food mixed with the stomach’s digestive acids can irritate and damage the oesophagus.

Causes

Normally, the stomach contents are retained in the stomach with the help of the lower oesophageal sphincter (LOS), a muscle that contracts and relaxes to maintain the one-way movement of food. However, gastric reflux occurs when the LOS 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 alcohol, spicy foods, onions, chocolates, caffeine-containing drinks, mints, tomato-based foods, citrus fruits and certain medications can worsen gastric reflux.

Impact

Living with gastric reflux is inconvenient as symptoms can severely interfere with your life. You may have to follow certain dietary restrictions and reflux occurring in the night can hinder a good nights sleep, thereby affecting alertness and productivity the next day.

Anatomy

Food travels from the mouth through the oesophagus, a long, narrow tube that opens into the stomach. This food pipe is lined by muscles that expand and contract to push food down the tube, a process called peristalsis. The stomach secretes acid and other digestive enzymes for the digestion of food and stores food before it enters into the intestine.

A band of muscle called the lower oesophageal sphincter (LES) are present at the junction of the oesophagus and the stomach. This acts as a valve, preventing the reflux of acid from the stomach into the oesophagus. A simple anatomical diagram would be sufficient here.

Symptoms

Heartburn is usually the main symptom of GORD, characterised by a burning-type pain in the lower part of the mid-chest, behind the breastbone. Other symptoms include a bitter or sour taste in the mouth, trouble swallowing, nausea, dry cough or wheezing, regurgitation of food, hoarseness or change in voice and chest pain.

Diagnosis

We 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 telescope
24-hour pH monitoring: involves inserting a tube through your nose into the oesophagus and positioning it above the LOS. 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.
Oesophageal Manometry. A tube placed into the oesophagus measures how well the muscles of the oesophagus work which is helpful in assessing the problem
Barium swallow: special X-ray to assess the length and the function of oesophagus

Treatments

Treatment is aimed 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 neutralizing acid in the stomach
Other medications: PPI drugs (like: Somac or Nexium) reduce the production of acid in the stomach
Fundoplication: is a key-hole surgical procedure in which the upper part of the stomach is wrapped around the lower end of your oesophagus where it is sutured into place. This surgery strengthens the sphincter and helps prevent stomach acid and food from flowing back into the oesophagus.

Prognosis

The outcome of treatment varies from person to person. Some may experience mild symptoms while for others, treatment can be very successful. Most people respond well to lifestyle changes and medications. However, a relapse is very common after cessation of medications, so the condition does require maintenance.

When medications fail to resolve symptoms or it is your preference not to take medication, surgery is recommended.

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 may develop Barrett’s oesophagus, a condition characterised by changes in the oesophageal lining, which that can lead to oesophageal cancer.

The Treatment

Surgery

If conservative treatment options fail to resolve your GORD, we may recommend a surgical procedure called Fundoplication.

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 in most people.

Procedure

Fundoplication is performed under general anaesthesia and most patients spend a couple of nights in the hospital.

Steps involved in Fundoplication procedure include:

Dr Maani makes five small incisions in the upper abdomen and inserts telescope and a number of other instruments into the abdomen. The procedure is done watching a monitor.
With the images from the laparoscope as a guide, Dr Maani wraps the upper part of the stomach, (called 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 then closed.

Postoperative Information

After the surgery, the wounds are covered with waterproof dressings so you can shower. They should be removed after 7 days. You may feel soreness around the incision areas. As (during the procedure) the abdomen was distended with gas, you may experience discomfort in the abdomen, chest, or shoulder area for a couple of days.

Contact your doctor immediately if you have a fever, chills, increased pain, bleeding or fluid leakage from the incisions, chest pain, and shortness of breath, leg pain or dizziness.

Benefits of this Approach

Laparoscopy is much less traumatic to the muscles and soft tissues than the traditional method of surgically opening the abdomen with long incisions. It is also associated with a shorter hospital stay, less post-operative pain and faster recovery.

Outcome

Surgery is found to be beneficial in approximately 90% of patients. However, as with any surgery, Fundoplication may involve certain side effects. These can include trouble swallowing, inability to burp or vomit, bloating and passing more wind. These side effects do not occur in everyone.

Post-op Stages of Recovery and Care Plan

Our team may give you a prescription pain medicine or recommend non-steroidal anti-inflammatory drugs (NSAIDs) for the first few days to keep you comfortable. Dr Maani 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 6 weeks.

Downtime - Lifestyle or Off Work Duration

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 1-2 weeks.