Reflux Oesophagitis

What is heartburn and reflux?

Does reflux occur in healthy people?

Why does the oesophagus become inflamed and not the stomach?

What causes heartburn & reflux oesophagitis?

The causes may be divided into two groups - those with a normal lower oesophageal sphincter and those with poorly functioning oesophageal sphincter.

Increases in the pressure in the abdomen can overcome the strength of a normal valve. Such pressure increases may be associated with pregnancy, obesity, bending when the stomach is full, large amounts of free fluid in the abdomen (ascites), physical exertion including coughing, vomiting, or straining, and sometimes very tight clothing.

Impairment of sphincter pressure function can be caused by some foods including coffee, chocolate, peppermint, fried and fatty foods, and alcohol; some pharmaceutical medications. Cigarette smoking relaxes the valve. The importance of hiatus hernia is controversial.

What is the role of hiatus hernia?

When the upper part of the stomach moves up into the chest through the diaphragm, the person is said to have a hiatus hernia. In its normal position the gastro-oesophageal valve has additional support from the muscles of the diaphragm. When the stomach is not in its preferred position with loss of diaphragmatic support there is lowering of the pressure available to prevent reflux.

Many healthy people have a small hiatus hernia. Hiatus hernia is more common as we age and it can be shown by x-ray examination in most people over 50. Many with a hiatus hernia have no symptoms and are unlikely to ever have symptoms. It is argued that hiatus hernia is a normal aging change and not a disease.

However, hiatus hernia is associated with more reflux oesophagitis than would be expected suggesting that the loss of the effect of the muscles in the diaphragm and the change of the angle in which the oesophagus enters the stomach, sufficiently weakens the effect of the sphincter mechanism to play a significant part in many with oesophageal reflux disease.

What are the symptoms of heartburn & reflux oesophagitis?

Heartburn is the characteristic symptom. Described as a burning pain behind the breastbone, it most commonly occurs after eating. It can, however, occur on bending, lying down, straining, after coffee, and even with emotional stress. It may last up to two hours and is often relieved by taking an antacid.

While heartburn means reflux oesophagitis, it can occur with spasm of the oesophageal muscle without inflammation. It can be confused with heart pain. There are differences between heart pain and oesophageal pain. Heart pain usually is associated with exercise and the pain radiates into the left arm.

Other symptoms are a feeling of food coming back into the mouth, leaving an acid or bitter taste. There may be a feeling of delay in the passage of food with discomfort associated with swallowing. Waking at night with coughing, a feeling of tightness in the chest and a wheeze may occur due to refluxed stomach contents being inhaled.

How is reflux oesophagitis diagnosed?

Endoscopy is the gold standard for diagnosis. The appearance can be photographed and a biopsy obtained.

Because the symptoms are characteristic, and providing heart disease can be reasonably excluded, some argue that for milder symptoms, treatment on the history alone is safe and cost effective. This advice can be endorsed providing if treatment is unsatisfactory, the endoscopy is then done.

What is the treatment for heartburn & reflux oesophagitis?

Treatment should consider lifestyle factors, consideration of drug treatment, and surgery.

What lifestyle changes?

• Reduce or remove foods and beverages that are known to reduce the strength of the valvular mechanism - chocolate, coffee, peppermint, fried and fatty foods, and alcohol.
• Decrease foods that irritate inflammed tissue - citrus fruits and juices, pepper, and some tomato products.
• Stop smoking
• Lose weight if overweight and decrease the size of mealtime portions.
• Consider elevation of the head of the bed to aid better drainage from the stomach.

What drug options are available?

Antacids taken regularly can neutralise acid in the oesophagus and stomach. For very mild symptoms this is the simplest satisfactory medication. Usually the relief is temporary and too much antacid can have its own side effects.

More specific is to reduce the acid production of the stomach. Histamine 2 receptors antagonists are capable of reducing the gastric acid output by 70 or 90 percent. Four members of this group are available - Cimetidine, Ranitidine, Famotidine, and Nizatidine. These can be used intermittently or for long maintenance programmes.

Almost total suppression of acid can be obtained by using a proton pump inhibitor. These are used almost exclusively for the very severe diseases. There are three proton pump inhibitors in New Zealand - Omeprazole, pantopraxole, and lansoprazole.

Other treatments which may be considered are prokinetic agents which aid clearance of fluid from the oesophagus and improve the strength of the lower oesophageal sphincter. There are three of these agents available - metoclopramide, domperidone, and cisapride.

What about surgery?

Surgery for reflux oesophagitis has been controversial. Surgeons have always had a place in the management of disease unresponsive to drug treatment and disease with complications. The recent advances in laproscopic surgery techniques - a less invasive procedure than open surgery - have renewed interest in surgery for the less severe forms of the disease. A procedure known as fundoplication, modifies the angle between the oesophagus and the stomach, making it more acute thus creating a valve action which closes when pressure in the stomach is increased.

A feeling of fullness (early satiety), abdominal distention, and food sticking in the gullet (dysphagia) are early symptoms with surgery. These settle quickly in most, but a small number may continue with distension, some difficulty in swallowing, and occasional diarrhoea.

What are the complications of heartburn & reflux oesophagitis?

Sometimes serious complications develop. Bleeding may occur. Ulcers can develop leading to scarring and narrowing (stricture) of the oesophagus. Cancer is a remote possibility which cannot be ignored.

Conclusion

Reflux oesophagitis is a disorder with a wide spectrum of symptom intensity which spoils quality of life and which, for a few, can cause severe life threatening illness. Because of the potential for serious complications the symptoms should never be ignored as trivial. The treatment options usually advance along the lifestyle, pharmaceutical drugs and finally to the surgical options. Laparoscopic fundoplication surgery is being considered earlier than in the recent past.