Reflux and Barrett's Oesophagus

Reflux

What is Reflux?

Reflux, also known as gastro-oesophageal reflux disease (GORD), is a condition where stomach acid flows back into the oesophagus, causing irritation and discomfort. 

The oesophagus is a tube that connects the mouth to the stomach. The lower esophageal sphincter (LES) is a muscle that acts as a valve to prevent stomach acid from flowing back into the stomach oesophagus. 

When the LES is weakened or relaxed, stomach acid can flow back into the oesophagus, causing symptoms such as heartburn, regurgitation of food or acid, and a sour taste in the mouth.

How Does Reflux Impact Your Anatomy and Health?

Reflux can lead to a burning sensation in the chest or throat, a sour taste in the mouth, hoarseness, or a chronic cough. If left untreated, reflux can cause damage to the oesophagus, leading to ulcers, strictures, or Barrett’s oesophagus.

What are the Types of Reflux?

There are two types of reflux: symptomatic reflux and silent reflux. 

Symptomatic reflux is characterised by heartburn, chest pain, or regurgitation of food or acid. On the other hand, silent reflux does not cause any symptoms, but acid reflux can still cause damage to the oesophagus. 

What are the Causes and Risk Factors of Reflux?

Reflux occurs when the LES fails to close properly, allowing stomach acid to flow back into the oesophagus. The causes of LES malfunction are not fully understood, but several factors can contribute to it, including:

• Obesity: Excess weight can pressure the stomach, causing stomach acid to flow back into the oesophagus.
• Pregnancy: The increased pressure on the abdomen during pregnancy can relax the LES, allowing stomach acid to flow back into the oesophagus.
• Smoking: Smoking weakens the LES and increases the production of stomach acid, making it easier for acid to flow back into the oesophagus.
• Diet: Eating a diet high in fat, spicy or acidic foods, chocolate, caffeine, or carbonated drinks can increase the risk of developing reflux.
• Hiatal hernia: A hiatal hernia occurs when a portion of the stomach protrudes through the diaphragm into the chest, allowing stomach acid to flow back into the oesophagus.
• Medical conditions: Certain medical conditions, such as scleroderma or gastroparesis, can increase the risk of developing reflux.
• Family history: Having a family history of reflux or related conditions, such as Barrett’s oesophagus, can increase the risk of developing reflux.

What are the Symptoms of Reflux?

The most common symptoms of reflux include:

• Heartburn: a burning sensation in the chest or throat that can last several hours and may worsen after eating, lying down, or bending over.
• Regurgitation: the sensation of acid or food returning to the mouth or throat.
• Sour taste: a sour or bitter taste in the mouth.
• Chest pain: chest pain or discomfort that can be mistaken for a heart attack.
• Difficulty swallowing: feeling like food is stuck in the throat or chest.
• Chronic cough: a persistent cough that may worsen at night or after meals.
• Hoarseness: a change in the voice, often characterised by a raspy or rough voice.
• Nausea or vomiting: feeling nauseous or vomiting may occur in severe cases of reflux.

What are the Stages of Reflux?

Reflux is classified into four stages, ranging from mild to severe. 

• In stage one, patients experience occasional reflux symptoms that can be managed with lifestyle changes or over-the-counter medications. 
• In stage two, patients experience reflux symptoms more frequently and may require prescription medication. 
• Patients experience frequent reflux symptoms in stage three and may develop complications such as ulcers or strictures. 
• In stage four, patients have severe reflux symptoms that do not respond to medication and may require surgery.

How is Reflux Diagnosed?

A gastroenterologist can diagnose reflux through a physical exam, medical history review, and diagnostic tests such as an endoscopy or pH monitoring.

How can Reflux be Treated?

Reflux can be treated through lifestyle changes, medication, and, in some cases, surgery. The treatment plan depends on the severity of the condition and the presence of complications.

• Specific Lifestyle Changes can help manage reflux symptoms. These include:
• Losing weight if you are overweight or obese
• Eating smaller, more frequent meals
• Avoiding trigger foods, such as spicy or fatty foods, caffeine, and carbonated drinks
• Avoiding eating late at night or lying down immediately after eating
• Elevating the head of the bed during sleep
• Quitting smoking
• Medications can help reduce the stomach's acid and relieve reflux symptoms. Over-the-counter antacids and/or alginates, such as Mylanta and Gaviscon, can immediately relieve mild reflux symptoms. H2 blockers, such as famotidine, can reduce the amount of acid the stomach produces. In contrast, proton pump inhibitors (PPIs), such as Somac or Nexium, can provide long-term relief by blocking acid production. Each medication has its advantages and disadvantages. 
• Surgery may be necessary in severe cases of reflux that do not respond to lifestyle changes or medication. Fundoplication involves wrapping the upper part of the stomach around the lower esophageal sphincter to reinforce the valve and prevent acid reflux.

What if Reflux is Untreated?

Long-term untreated reflux can cause damage to the oesophagus and increase the risk of developing Barrett's oesophagus, a serious condition that can progress to cancer. Therefore, it is essential to seek medical attention if you experience reflux symptoms, mainly if they occur frequently or are severe. A gastroenterologist can evaluate your symptoms and recommend an appropriate treatment plan to manage your reflux and prevent long-term complications.

Barrett’s Oesophagus

What is Barrett’s Oesophagus?

Barrett’s Oesophagus is a long-term complication due to chronic inflammation in a small proportion of people (10%) with GORD. 

Barrett’s Oesophagus is characterised by tissue resembling the intestinal lining replacing the usually present oesophageal tissue.

How Does Barrett’s Oesophagus Impact Your Anatomy and Health?

Barrett’s oesophagus can increase the risk of developing oesophageal cancer, so diagnosing and treating Barrett’s oesophagus early is crucial.

Who Does Barrett’s Oesophagus Effect?

Barrett’s Oesophagus is nearly two-three times more common in men than women. 

The mean age of affected older people is 55 or above. It is rarely found in children.

The criteria for people who should be screened for Barrett’s Oesophagus include the following:

• GORD
• Obesity
• white men over the age of 50, 
• with a history of smoking and
• a family history of either Barrett’s Oesophagus or oesophageal cancer. 

How Does Barrett’s Oesophagus Occur?

GORD is associated with gastric acid and stomach contents washing back into the oesophagus.

The acid damages the esophageal lining and triggers tissue changes, resulting in Barrett’s oesophagus. 

Symptoms of Barrett’s Oesophagus

Barrett’s oesophagus may not initially cause symptoms, but patients may experience difficulty swallowing, chest pain, and persistent heartburn as the condition progresses.

Stages of Barrett’s Oesophagus

Barrett’s oesophagus is classified according to the degree of change in the oesophageal tissue. This includes:

• No dysplasia – Tissue change is present, but no precancerous transformations exist.
• Low-grade dysplasia – Tissue change is present with a few signs of precancerous changes
• High-grade dysplasia – The tissue transformation exhibits many pre-cancerous changes, and oesophageal cancer will likely occur next.

How is Barrett’s Oesophagus Diagnosed?

Barrett’s oesophagus is diagnosed through an endoscopy, where a gastroenterologist examines the oesophagus with a tiny camera attached to a flexible tube. During the endoscopy, a biopsy may be taken to determine if abnormal cells are present.

How is Barrett’s Oesophagus Treated?

Your gastroenterologist decides the best approach on a case-by-case basis and the severity of the symptoms. 

The treatment plan always includes medication to control stomach acid and treatment of GORD. 

Lifestyle changes such as 

• cessation of smoking, 
• exercise and 
• removing food responsible for heartburn, such as coffee or chocolate, also controls GORD.

In the case of:

• No dysplasia – GORD is treated, and routine endoscopy is scheduled to monitor the condition of the oesophagus.
• Low-grade dysplasia – Your doctor will treat GORD and may recommend removing damaged oesophageal cells by endoscopic resection or radiofrequency ablation. A follow-up endoscopy will be performed after a few months.
• High-grade dysplasia – The chances of esophageal cancer are very high at this stage. Your doctor will treat GORD and perform an endoscopic resection (such as EMR or ESD) of the damaged cells or radiofrequency ablation. In extreme cases, surgery may be needed to remove the damaged segment of the oesophagus.

What If Barrett’s Oesophagus Is Untreated?

If Barrett's oesophagus is left untreated, the abnormal cells in the oesophagus may continue to change and develop into cancerous cells, leading to oesophageal cancer. This severe condition can be life-threatening if not diagnosed and treated early. Therefore, diagnosing and treating Barrett's oesophagus as soon as possible is crucial to prevent cancer development.