Dr Stephen John Middleton MA MD FRCP FAHE
Gastro-oesophageal reflux disorder
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This is a common condition affecting approximately 10% of the population...
...and often causes the symptom of heart burn. The absence of heartburn however does not exclude reflux as many people have reflux without any symptoms at all. This so called “silent reflux” can be a problem as people are not aware and do not seek medical advice and treatment.
It has recently been realised that reflux can cause other conditions...
...such as a particular type of dental erosion, a dry persistent cough and also it may provoke asthma. In response to the presence of acid in the oesophagus the lining changes to become more like that of the stomach. This is called Barrett’s oesophagus after the person who described it. Although this can reduce the damage and the sensation of heartburn it causes a slight increase in the likelihood of developing oesophageal cancer so patients with this condition are often screened for early changes so that treatment can be given to prevent cancer developing.
The cause of reflux is not fully understood.
It is widely believed to be the result of a defective valve at the bottom end of the oesophagus which seems to relax too easily and at the wrong time and may also sometimes be very weak thus failing to stop the acid rising from the stomach when the pressure in the stomach is increased. Certain activities increase the pressure in the stomach, in fact anything that involves contraction of the abdominal muscles (tummy muscles) will increase the pressure in the stomach. Some of the worst activities for this are rowing and exercises such as sit ups and weight lifting.
Gastro-oesophageal reflux is often diagnosed on clinical grounds from symptoms...
...reported by patients, but where doubt exists it is possible to measure the amount of reflux. This measurement is called 24 hour ambulatory pH monitoring and can be conducted using a catheter which is passed through the nasal cavity into the oesophagus. This is connected to a recording box and patients are allowed to go home for 24 hours and return the next day when the catheter is removed and the recording box collected. The amount of acid entering the oesophagus is represented on a graph as seen in the illustration below (in last section below). There is a new method of measuring Reflux which is sometimes more convenient for patients and has the added benefit of allowing longer periods of recording without the discomfort of a nasal catheter. This system known as wireless pH monitoring is undertaken using the Medtronic “Bravo” system (in last section below). A small pH detector about the size of a tablet is attached to the side wall of the oesophagus at the time of gastroscopy. This sends wireless signals to the receiver system that the patient keeps on them. The small pH detector with fall off after 10 days or so and passes through the system and out when the patient uses the toilet to be discarded with the other waste. When in position the detector does not usually cause any discomfort.
Some patients develop a condition called Barrett’s oesophagus, which makes it slightly more likely to develop oesophageal cancer and these patients should be screened with endoscopy depending upon how much Barrett’s they have.
A 24 hour study of oesophageal pH
The graph below shows a patient with a normal result where there are a low number of reflux episodes recorded in the day time and these are not present at night (indicated by the light blue line). Hover the mouse over the graph to see an abnormal result which demonstrates excessive Gastro-oesophageeal acid reflux.