When the drugs don’t work: Diagnostic & surgical options for GORD (Gastro-oesophageal reflux disease)

Chronic reflux, known as Gastro-oesophageal reflux disease (GORD) is on the rise in Western societies. It can occur when the valve which usually prevents the contents of the stomach being released after we swallow fails or weakens, allowing stomach acid and other corrosive substances including bile and the powerful enzyme Pepsin to travel up into the oesophagus.

Reflux symptoms can go far beyond heartburn. Laryngopharyngeal reflux (LPR), where these substances reach the throat, can cause multiple symptoms from a sore throat and irritated voice box to a chronic cough and swallowing difficulty.

Up to 10% of the population regularly take PPIs

Studies suggest GORD now affects as many as 30% of people in the US and Europe and that 10% of the adult population regularly take some form of antacid medication known as Proton Pump Inhibitors (PPIs).

‘Reflux can be a very debilitating condition,’ says Nicholas Boyle, consultant surgeon at the world-renowned King Edward VII’s Hospital in London and a leading expert in the surgical management of GORD. ‘There have actually been studies done that show if you’ve got bad reflux symptoms, it can affect you just as much as other serious chronic illnesses, such as kidney disease or diabetes.’

Boyle urges anyone suffering from new or persistent symptoms to have them checked by a medical professional. GORD can have multiple causes. It is often associated with Hiatus Hernia, where the upper stomach loses its usual attachment to diaphragm leading to failure of the oesophageal valve. More recently, small intestine bacterial overgrowth (SIBO), which in some cases can lead to malnutrition, has also been implicated. But reflux symptoms can be caused by serious conditions, so medical advice should always be sought when they occur for the first time.

If left untreated, GORD can also result in complications such as a pre-cancerous condition called Barrett’s oesophagus, which requires regular monitoring.

Highly effective surgical treatments are available but, says Boyle, it is crucial to get an accurate diagnosis and for many patients this can prove elusive.

‘A lot of the time the standard treatment is to just give people PPIs. These can be very powerful, and they really work for some people but about 20% to 30% of patients won’t respond to this treatment and they can cause side effects, such as changes in the gut microbiome. This can actually contribute to SIBO, so some patients end up going round in circles in a cycle of frustration for many years,’ he says.

At King Edward VII’s specialist reflux centre, the focus is on achieving a precise diagnosis to ensure targeted treatment.

Getting a diagnosis for chronic reflux

Diagnosis can often be made by discussing symptoms and taking a detailed clinical history but in complex cases, a variety of specialist tests are available.

An endoscopy, where a small flexible camera is inserted into the oesophagus and stomach, can be used to identify structural issues with the valve. To get a more detailed picture, this can be combined with the BRAVO PH test. A small capsule is attached to the lining at the bottom of the oesophagus to measure acidity levels over a number of days and send the results wirelessly via a Bluetooth recorder. Patients can also press a button on the recorder when they get a particular symptom which enables the team to see if there is an association between acid levels and a reflux event.

‘Outcomes are entirely dependent on reaching the right diagnosis,’ says Boyle. ‘We have a multi-disciplinary team of consultants and clinicians which allows us to make sure patients see the right person, get the right diagnosis and achieve the best possible outcome.’

Although only around 10% to 15% of patients will require an operation, surgical management can offer the best solution for those who don’t respond to PPIs or who don’t want to take medication long-term. Keyhole techniques mean surgery is minimally invasive and doesn’t require an overnight stay in hospital or lengthy recovery period.

Importantly, says Boyle, advances in surgical management mean patients can now be offered a choice of procedures to suit their needs.

Pioneering new techniques and treatments for Reflux

Fundoplication, where a piece of the stomach is wrapped around the bottom of the oesophagus to strengthen the bowel, remains one of the most common and effective surgical solutions but can cause side-effects.

Boyle and his team have also pioneered alternatives. They are the leading UK centre for LINX sphincter augmention, which involves placing a small bracelet of magnets around the bottom of the oesophagus to strengthen the valve. This day case procedure is just as effective in treating reflux symptoms but tends not to cause the side effects associated with fundoplication.

In the last year Boyle has also led the development of RefluxStop in the UK. During this procedure, the normal valve is strengthened and a small silicone ball implanted in the wall of the stomach to help keep it below the diaphragm.

‘Our early results are very encouraging and RefluxStop seems to cause significantly fewer swallowing difficulties in the short term than fundoplication,’ says Boyle.

‘We are fortunate that we can provide a multi-disciplinary approach to diagnosis and offer a comprehensive set of options for treatment. And the evidence is really clear that people’s quality of life is better after surgery than when they just take long-term PPIs.’

More information

• If you suffer with chronic reflux symptoms , speak to your GP about possible treatments and having a BRAVO pH test. (Don’t have a GP?)
• King Edward VII’s Gastroenterology Department is a fully equipped unit, staffed by experts with access to the most up to date tests and treatments, including the BRAVO pH test, LINX and more
• Mr Nick Boyle is an expert in Upper GI surgery and chronic reflux and can provide expert treatment, advice and guidance. Make an enquiry.