Upper GI

Oesophageal diseases

The oesophagus is a muscular tube through which food, liquids and saliva passes from the mouth to the stomach. It is lined with a soft-moist tissue called, mucosa. The oesophagus has two sphincters, the lower oesophageal sphincter (LOS) and the upper oesophageal sphincter (UOS). The upper oesophageal sphincter (UOS) is a region of muscle located at the top of the oesophagus. It prevents the food and secretions from going down the windpipe. These UOS muscles are under conscious control and are involved in breathing, eating, belching, and vomiting. Another bundle of muscles called lower oesophageal sphincter (LOS), is located at the lower end of the oesophagus, just where it joins the stomach. As food enters the oesophagus, the LOS relaxes and allows the food to pass in to the stomach. The LOS muscles are not under voluntary control.

Disorders affecting the oesophagus include:

  • Heartburn: Heartburn is characterized by a burning type pain in the lower part mid-chest, behind the breast bone. It is caused by irritation of the oesophagus due to the reflux of acidic stomach contents into the oesophagus. The reflux occurs due to the incomplete closure of LOS.
  • Gastro oesophageal reflux disease (GORD): Gastroesophageal reflux disease is a condition where the stomach contents (food or liquid) rise up from the stomach into the oesophagus because of a weak or relaxed lower oesophageal sphincter (LOS). Heartburn is usually the main symptom. Other symptoms include belching, chronic sore throat, difficulty or pain when swallowing, sudden excess of saliva, hoarseness, sour taste in the mouth, inflammation of the gums, bad breath, and erosion of tooth enamel.
  • Oesophagitis: Oesophagitis is an inflammation of the oesophagus caused by irritation (as from reflux) or an infection.
  • Barrett’s oesophagus: Barrett’s oesophagus is a condition in which the lining of the oesophagus changes and resembles the stomach lining The cause for the Barrett’s oesophagus is not known but is commonly found in people with gastro-oesophageal reflux disease (GORD Barrett’s oesophagus increases the risk for oesophageal cancer.
  • Oesophagealulcer: It is erosion in the lining of the oesophagus often caused by chronic reflux.
  • Oesophagealstricture: Oesophageal stricture is narrowing of the oesophagus often caused by chronic reflux.
  • Achalasia: It is a rare disorder characterized by difficulty in swallowing and regurgitation of food. In this condition, the LOS does not relax appropriately.
  • Oesophagealcancer: It is a cancer that occurs in the oesophagus. It is rare and factors such as smoking, heavy drinking and chronic reflux increase the risk of developing oesophageal cancer.
  • Mallory-Weiss tear: It is a tear in the lining of the oesophagus. It is usually caused by forceful vomiting or chronic coughing. Symptoms may include bloody stools or vomiting of blood.
  • Oesophagealvarices: Oesophageal varices are enlarged veins in the walls of the oesophagus that balloon outward. This condition is common in people with cirrhosis of liver. Rupture of these veins may lead to life threatening bleeding.
  • Oesophagealring (Schatzki’s ring): It is an abnormal ring of tissue formed around the low end of the oesophagus. It is a birth defect of the oesophagus. Usually it does not cause any symptoms but in some it may cause difficulty in swallowing and the food feels stuck in the lower neck.
  • Oesophagealweb: These are small, thin growths of tissue that partially block the oesophagus. They usually occur in the upper oesophagus and cause no symptoms. In people with long-term (chronic) iron deficiency anemia, oesophageal web may lead to difficulty in swallowing. This condition is referred as Plummer-Vinson syndrome

Tests to diagnose these disorders may include upper endoscopy, oesophageal pH monitoring and barium swallow.

Treatment varies according to the type of disorder. Medications such as H2 blockers and proton pump inhibitors are prescribed to reduce stomach acid to improve GERD and oesophagitis. Surgical removal of the oesophagus (Oesophagectomy) is recommended for oesophageal cancer. Oesophageal dilation may be advised to dilate a stricture, web, or ring that interferes with swallowing. Oesophageal variceal banding may be used to treat oesophageal varices. In this procedure, rubber band-like devices are wrapped around oesophageal varices to make them clot, and thus reduce the chances of life threatening bleeding.

 

Achalasia

Achalasia, also known as oesophageal achalasia is a condition in which the oesophagus (a tube that carries food from the mouth to the stomach) is unable to move the food into the stomach. Lower oesophageal sphincter is a ring of muscle fibres that surrounds the lower-most end of the oesophagus where it joins the stomach. LOS acts like a valve between the oesophagus and stomach preventing food from moving backward into the oesophagus. In people with achalasia, the LOS fails to relax during swallowing resulting in the back up of food.

The main symptoms of achalasia include difficulty swallowing (dysphagia), regurgitation of food, heartburn, weight loss, chest pain, and cough.

Your doctor may order the following tests to diagnose achalasia:

Barium swallow test: The test involves swallowing a barium preparation while X-rays are taken. The barium coats the walls of the oesophagus and stomach and makes the abnormalities visible more clearly.
Endoscopy:This test allows the doctor to examine the inside of the patient’s oesophagus, stomach, and portions of the intestine, with an instrument called an endoscope, a thin flexible lighted tube.

Manometry: It is a test that measures changes in pressures exerted by the oesophageal sphincter.

Treatment options for achalasia include:

  • Medications: Medications such as nitrates and calcium channel blockers are recommended to relax the lower oesophagus sphincter.
  • Botox: Botulinum toxin injection can be administered to help relax the sphincter muscles 
  • Balloon dilation (pneumatic dilatation): A small balloon is positioned at the LOS and inflated in order to widen the opening for food to enter the stomach. 
  • Myotomy: It is a surgical procedure in which the sphincter muscle is cut to allow the oesophagus to open.

Depending on your situation your doctor will decide which treatment is right for you.

 

GORD

Gastro-oesophageal reflux disease (GORD) is a condition where the stomach contents (food or liquid) rise up from the stomach into the oesophagus, a tube that carries food from the mouth to the stomach.

Normally the stomach contents do not enter the oesophagus due to constricted LOS. But in patients with GORD stomach content travels back into the oesophagus because of a weak or relaxed lower oesophageal sphincter (LOS). Lower oesophageal sphincter is a ring of muscle fibres that surrounds the lower-most end of the oesophagus where it joins the stomach. LOS acts like a valve between the oesophagus and stomach preventing food from moving backward into the oesophagus.

Heartburn is usually the main symptom; a burning-type pain in the lower part of the mid-chest, behind the breast bone. Other symptoms such as a bitter or sour taste in the mouth, trouble in swallowing, nausea, dry cough or wheezing, regurgitation of food (bringing food back up into the mouth), hoarseness or change in voice, and chest pain may be experienced.

The exact cause of what weakens or relaxes the LOS in GORD is not known, however certain factors including obesity, smoking, pregnancy, and possibly alcohol may contribute to GORD. Common foods that can worsen reflux symptoms include spicy foods, onions, chocolates, caffeine containing drinks, mint flavourings, tomato based foods and citrus fruits. Certain medications can also worsen the reflux.

There are several tests that can be performed to diagnose GORD and they include:

  • Endoscopy: This test allows the doctor to examine the inside of the patient’s oesophagus, stomach, and portions of the intestine, with an instrument called an endoscope, a thin flexible lighted tube.
  • Barium X-rays: These are diagnostic x-rays in which barium is used to diagnose abnormalities of the digestive tract. You are asked to drink a liquid that contains barium. The barium coats the walls of the oesophagus and stomach and makes the abnormalities visible more clearly. Then X-rays are taken to see if there are strictures, ulcers, hiatal hernias, erosions or other abnormalities.
  • Twenty four-hour pH monitoring – In this procedure, a tube will be inserted through the nose into the oesophagus and positioned above the LOS. The tip of the tube contains a sensor which can measure the pH of the acid content refluxed into oesophagus. A recorder, strap-like device that can be worn on wrist, will be connected to record the pH of the acid content. The tube will be left in place for 24 hours. Patients can also go back home and perform their regular activities and can record the pH of the acid content when they experience the symptoms. On the next day the recorder will be connected to a computer and the data will be analysed.
  • pH Capsule: It is a new method of measuring acid exposure in the oesophagus. A small wireless capsule which is introduced into the oesophagus by a tube through the nose or mouth. The tube is removed after the capsule is attached to the lining of the oesophagus. The pH sensor transmits signals to a computer which collects the data about the acid exposure over the usual 24 hours. The capsule falls off of the oesophagus with time and is passed in the stool.
  • Impedance study: This test is similar to pH test but requires two probes; one is placed in the stomach and the other just above the stomach. The dual sensor helps to detect both acidic and alkaline reflux.

Antacids are over-the-counter medicines that provide temporarily relief to heartburn or indigestion by neutralizing acid in the stomach. Other medications such as proton pump inhibitors and H2 antagonists may be prescribed to reduce the production of acid in the stomach.

Surgery may be an option for patients whose symptoms do not go away with the medications. Nissen’s fundoplication is a surgical procedure in which the upper part of the stomach is wrapped around the end of your oesophagus and oesophageal sphincter, where it is sutured into place. This surgery strengthens the sphincter and helps prevent stomach acid and food from flowing back into oesophagus.

Endoluminal gastroplication or endoscopic fundoplication technique requires the use of an endoscope with a sewing device attached to the end, known as EndoCinch device. This instrument place stitches in the stomach below the LOS to create a plate which helps reduce the pressure against the LOS and help strengthen the muscle.

Chronic GORD left untreated can cause serious complications such as inflammation of the oesophagus, oesophageal ulcer, narrowing of the oesophagus, chronic cough, and reflux of liquid into the lungs (pulmonary aspiration). Some people develop Barrett’s oesophagus, in which there is changes in the oesophageal lining that can lead to oesophageal cancer.

General measures the patient can take to reduce reflux are:

  • Avoid eating before going to bed as this may decrease the acid production
  • Eat smaller and more frequent meals
  • Lose weight if you are over weight
  • Elevate the head of the bed
  • Eliminate the foods that increases the reflux
  • Avoid smoking and use of alcohol
  • Check with the physician regarding side effects of prescription medications
  • Mater Hospital
  • Sydney Adventist Hospital
  • Norwest Private Hospital
  • FRACS
  • General Surgeons Australia
  • AMA