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“IT BURNS!” HEARTBURN,
INDIGESTION AND REFLUX
BY CONOR MAGEE MD FRCS, CONSULTANT SURGEON
I’m currently watching the television- not BBC4, I’m afraid but
Hollyoaks! During the break I chanced on advert that informed me
there are liquids you can buy for “both kinds of indigestion. This
brought a wry smile to my face- indigestion is just one name for a
wide variety of symptoms patients can present with. At medical school
we learnt of “dyspepsia”- simply meaning “disturbed digestion”. The
difficulty with dyspepsia is that it’s different for everybody, fortunately
the commonest cause for dyspepsia is simple to diagnose and can be
treated very effectively.
Most patients will have “Gastro-oesophageal Reflux Disease- GORD”.
This describes the condition when contents from the stomach “reflux”
(or head back) to the oesophagus (gullet). The oesophagus is the tube
between your throat and the stomach whose function is to propel
food down in to the stomach. The stomach then digests your food-
it’s a muscular organ that churns food and secretes hydrochloric
acid to break down proteins. The stomach has a protective layer to
help prevent the acids attacking it- this layer is not present in the
oseophagus. Normally there is a valve at the bottom of the oesophagus
that stops the stomach contents from re-entering the oesophagus.
People who have GORD have a weak valve and this allows acid-rich
stomach contents to reflux into the sensitive oesophagus causing a
characteristic burning sensation in the centre of the upper abdomen
that can radiate into the chest. It can be especially problematic at
night- often in combination with a hot curry and alcohol- because
when you lie flat it is easier for the acid to reflux back. In extreme cases
the valve is so weak, patients will vomit undigested food at unexpected
times! Often patients will also have an “hiatus hernia”. A hiatus hernia
simply means that part of the stomach slides into the chest alongside
the gullet. It’s incredibly common, but important to realise it is not
a hernia in the abdominal wall- there won’t be a lump to feel- many
times patients have asked me why they can’t feel their hiatus hernia!
Before talking about how to treat reflux it is of vital importance
that patients should seek advice from their GP first. In some cases,
reflux can be seen in patients with oesophageal or stomach cancer-
any patient, particularly in their 50s or older, with new onset reflux
must see their GP!! For many patients the symptoms are mild and
can respond to simple liquids that soothe the lining of the gullet (e.g.
Gaviscon) or tablets that help neutralize stomach acid (e.g. Rennies).
NISSEN FUNDOCPLICATION SHOWING STOMACH
WRAPPED AROUND GULLET TO MAKE TIGHTER VALVE
General Practitioners often prescribe tablets that can reduce the amount
of acid the stomach secretes or even abolish it completely - however
it is prudent that patients should undergo a gastroscopy (telescope
examination of the gullet and stomach) before starting treatment. Not
only can this identify the inflamed oesophagus (oesophagitis) that is
characteristic of GORD but it can rule out dangerous conditions such as
cancer, or spot conditions that can give rise to cancer if left unchecked.
Many patients worry about having a gastroscopy, but it is a simple
procedure that often doesn’t require sedation (I have had one and can
say it was little more than uncomfortable!). But where do I as a surgeon
come into this? Well, there are patients who continue to have severe
GORD despite acid treatment- symptoms that rapidly become difficult
to live with. I can perform an operation that will tighten up the valve at
the bottom of the gullet. It involves freeing up the top of the stomach and
wrapping it around the lower gullet. This operation is known as a “Nissen
Fundoplication” and used to require a very long cut on the abdomen.
Today I perform this using a keyhole technique- patients are able to go
home within 1-2 days instead of weeks!! It’s important that the wrap is
given time to bed in and this means avoiding heavy meals and carbonated
drinks for a few weeks after surgery. The results from fundoplication are
dramatic- patients can sleep and not wake with a mouthful of acid or -
and durable. There is a real feeling of pride when I perform this elegant
operation and patients get results that improve their lives immensely.
Mr Magee operates at Spire Murrayfield Hospital and can be contacted
there. He can be followed on Twitter @mageefrcs.
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