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Gastro-oesophageal reflux disease

This is a condition which typically presents with heartburn, acid brash and food or fluid regurgitation. It is caused by the reflux of gastric contents into the oesophagus from the stomach.

This occurs when the difference between the pressure inside the stomach and the pressure in the oesophageal body is greater than the pressure exerted by the lower oesophageal sphincter, at the lower end of the gullet which is designed to prevent reflux whilst at the same time allowing passage of food during swallowing (by relaxing transiently). The lining of the stomach is covered in a layer which secretes both acid and a layer of mucus which contains bicarbonate, which resists damage that would otherwise be caused to the stomach lining by the acid it produces. The lining of the oesophagus is much more like skin and is not resistant to the action of acidity. As a consequence when it is exposed to excess acid it becomes inflamed – resulting in appearences known as oesophagitis. However only a proportion of patients with acid reflux in excess of that which would be considered normal have appearances of oesophagitis at upper GI endoscopy. Many patients, particularly younger ones presenting with typical symptoms of reflux are treated with drugs to supress acid known as proton pump inhibitors without further  investigation, however in those where prolonged treatment is being considered or who have symptoms of food sticking in the oesophagus or weight loss endoscopy is indicated to rule out other causes.

Oesophagitis is a descriptive term used to describe the appearances of inflammation within the lining of the oesophagus. The commonest cause of oesophagitis is gastro-oesophageal reflux, however numerous other conditions may lead to inflammation within the oesophagus, including infection with fungi (candidal oesophagitis), viruses (Cytomegalovirus or herpes virus) or ingestion of caustic soda (chemical oesophagitis).

Hiatus Hernia

A hiatus hernia describes an abnormality when part of the stomach slips up through the hole where the oesophagus pierces the diaphragm. Usually the entirety of the stomach lies below the diaphragm, if either the hole through which the oesophagus comes gets bigger or / and the pressure in the abdominal cavity increase part of the stomach may slide through the hole and lie above the diaphragm. Usually hiatus hernias cause no symptoms. Occasionally they may cause a sensation of food not passing properly at the lower end of the oesophagus. If the stomach twists or the outlet of the hernia becomes obstructed this may cause sudden chest pain and vomiting. Whilst hiatus hernias do not cause reflux they may slightly increase the risk of it happening, because part of the barrier to prevent reflux is lost as the stomach slips above the diaphragm.

In general surgical correction is only attempted in patients with reflux that does not respond to conventional treatment, or where the hernia is causing recurrent episodes of pain. Unfortunately surgical repair is a significant operation and hernias may recur.

Hiatus Hernia;
Anatomy and types
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