Gastro-oesophageal reflux disease
(GERD) is a discomforting condition
encountered by many. Besides
treating the symptoms, it is important
to know the extent of injury due
to acid reflux and exclude a premalignant
condition known as
Barrett’s oesophagus at the distal
gullet. Treatment ranges from
using simple antacids to surgery,
depending on the extent and severity
of the condition. Oesophageal cancer
surveillance is also recommended for
patients with Barrett’s oesophagus.
What is GERD?
Gastro-oesophageal reflux disease
(GERD) is a highly prevalent
gastrointestinal (GI) disorder and is
one of the most common GI
conditions encountered in our
clinical practice. GERD refers to a
combination of signs and symptoms
resulting from the reflux of
stomach and duodenal contents
into the gullet, also known as the
oesophagus. These symptoms may
be severe in nature and may occur
frequently enough to negatively
impact a patient’s quality of life.
Patients with GERD frequently
experience interrupted sleep at
night. Their performance at work
and social life may also be
affected.
Symptoms
- Heartburn and regurgitation,
where a hot, burning sensation
in the chest or throat is usually
experienced and corresponds
mainly to the amount of gastric
content being propelled upwards
from the stomach into the
oesophagus, which induces local
inflammation.
- Sour taste and throat discomfort.
- Although a majority of patients
experience all of the above
symptoms, others may have
unusual presentations including
angina-like chest pains or
airway-related problems such
as asthma.
Besides these disturbing symptoms,
one major concern is the presence
of oesophageal erosions caused by
gastric acid. The other worry is the
development of a pre-malignant
condition at the distal oesophagus,
known as Barrett’s oesophagus,
associated with the acid reflux in
patients suffering from GERD.
The main reason for gastric
contents returning to the
oesophagus may be related to
either an incompetent valve at the
distal oesophagus, known as the
lower oesophageal sphincter or an
abnormal relaxation of this valve.
The resultant two-way movement of
food content, coupled with any
increase in the intra-abdominal
pressure due to various conditions,
may result in a significant amount
of gastric acid gushing back into the
oesophagus. Depending on the
frequency and extent of this
regurgitation, oesophageal injuries
of varying degrees may occur.
Diagnosis
To diagnose GERD, the most
practical way is a thorough and
accurate review of the patient’s
history. Typical symptoms of
heartburn or regurgitation will
provide the basis for diagnosis in
most cases. In the absence of these
symptoms, a short course of acid
suppression treatment with proton
pump inhibitors (PPIs) may be
employed as a strategy to aid in the
diagnosis.
Tan Tock Seng Hospital (TTSH)
offers one-stop direct access
endoscopy every Wednesday.
For more information on direct
access endoscopy, please contact
Endoscopy Centre at 9720 8601
(Mon - Fri: 8.30am - 5.30pm).
In more difficult cases, more
elaborate investigations including a 24-hour pH and impedance study
may be required to confirm acidic
or weakly-acidic reflux.
Besides arriving at the diagnosis,
one frequent challenge faced in the
management of GERD is to estimate
the extent of oesophageal injury.
This information is crucial in
deciding the long-term management
plan.
Unfortunately, the magnitude and
duration of symptoms do not
necessarily correlate well with the
actual physical injury in the
oesophagus. Patients with more
severe symptoms may have minimal
or no oesophageal injury, while
others with mild or minimal
symptoms may suffer from severe
oesophageal erosions.
The other challenge is to have an
effective way to filter out cases
that exhibit a higher risk of
developing lower oesophageal
cancer due to Barrett’s oesophagus.
Upper Gastrointestinal
Tract Endoscopy
(Gastroscopy)
Through a simple and quick
procedure like upper
gastrointestinal tract endoscopy
(gastroscopy or OGD), physicians
can directly inspect the oesophagus
and stomach to determine the
extent of injury due to acid reflux.
Gastroscopy involves inserting a
flexible video endoscope through
a patient’s mouth and oesophagus
into the stomach under direct vision. This procedure can be
completed within 10-15 minutes
with minimal risk or discomfort.
Light sedation may be given before
the procedure, although it may not
be necessary.
With the gastroscope being flexible
and steerable, the physician is able
to inspect the oesophagus, stomach
and the first two segments of the
duodenum in a single setting. Tissue
samples can also be taken via the
working channel of the scope for
histological analysis when necessary.
This allows the extent of injury and
the presence of Barrett’s oesophagus
to be confirmed to guide the
subsequent management and
surveillance strategy.
Treatment
The goals in the treatment of GERD
are to relieve recurring symptoms
and prevent any serious
complications.
Simple measures including lifestyle
modifications such as raising the
head of the bed when sleeping and
over-the-counter medication like
antacids may help. In established
cases, on-demand PPI treatment
driven by patients’ symptoms may
be one of the common strategies
employed by healthcare
professionals. In more advanced
cases, long-term medicine or even
surgery may be required to
alleviate symptoms and prevent
further complications.
It is not uncommon for patients
with GERD to undergo repeated
upper endoscopy at regular
intervals, to look for any malignant
tissue transformation from
Barrett’s oesophagus.
This is usually performed at
intervals of two to three years,
depending on the clinical and
preceding histological findings.
In the event of early malignant
transformation, endoscopic therapy
or surgery may be required as part
of the definitive treatment.
Dr Quan Wai Leong
Dr Quan Wai Leong is a Consultant in
the Department of Gastroenterology
and Hepatology and the Director of the
Endoscopy Centre at Tan Tock Seng Hospital.
His area of interests include endoscopic
retrograde cholangiopancreatography
(ERCP), spyglass cholangioscopy, endoscopic
mucosal resection (EMR), enteral stenting,
double-balloon enteroscopy (DBE) and video
capsule endoscopy (VCE).