What is the most likely diagnosis and what is your initial management plan?

What is your next management plan? Which investigations might you request?

Which pathogen is associated with reflux and dyspepsia symptoms? What investigations are available to test for it?

What is the appropriate management plan for the patient?

What treatment options would you discuss with this patient?

What investigations might you consider performing before undertaking surgery?

What do these blood tests reveal and what do they suggest?

What is the pathological condition seen at endoscopy and what should be done?

What is your next management strategy?

How would you further manage this patient?

A.1 Dyspepsia or reflux disease.

Patients with alarm symptoms, such as weight loss, recurrent vomiting, anaemia or dysphagia, should be referred for urgent investigation by upper gastrointestinal endoscopy. For most patients with uncomplicated dyspepsia the initial management is aimed at symptomatic treatment. Initially, general lifestyle changes are recommended, including smoking cessation, weight loss, minimizing alcohol and caffeine intake, reducing food intake before going to bed, and sleeping with the head of the bed raised. Over-the-counter antacid preparations and mucosal protecting agents may also provide some symptomatic relief. These measures alone may be sufficient to provide symptomatic control.

A.2 Patients with persistent symptoms require further evaluation. Patients older than 50 years should be considered for referral for an upper gastrointestinal endoscopy as the risk of an underlying malignancy is higher in this age group. For younger patients without alarm symptoms, an endoscopy is probably not indicated at this stage. A trial of acid suppression therapy may be advised. Proton pump inhibitors (PPIs) and histamine-2 receptor antagonists are widely used worldwide with a good safety profile, although the effects of long-term use are still not fully determined. Prokinetic agents, such as metoclopramide, may be also used to aid gastric emptying particularly when associated with gastro-oesophageal reflux.

A.3 Helicobacter pylori (H. pylori) is a Gram-negative bacillus that favours the conditions found within the gastric antrum. The organism promotes acid hypersecretion within the stomach and induces gastric inflammation and has been associated with dyspepsia and reflux symptoms.

Several methods have been developed to test for the presence of H. pylori.

Figure 11.2

A.4 It is essential that all patients are reviewed following eradication therapy to assess their response to treatment. Patients who are asymptomatic following treatment may be discharged and advised to continue with general healthy lifestyle recommendations. Patients with recurrent or persistent symptoms following eradication therapy should be re-tested for H. pylori infection. First-line eradication therapy successfully treats H. pylori infection in 70–80% of patients. If the repeat test is positive, a further course of second-line antimicrobial therapy would be indicated. If the repeat test was negative several options should be taken into account. Firstly, the diagnosis may be wrong. Consideration should be given to other causes of the symptoms, such a gallstone disease or bowel-related disorders. In older patients, for example 50 years or older, further thought should be given to whether the patient warrants an endoscopy if this has not already been performed. Finally, if all other factors have been considered and in an otherwise healthy young adult, the patient may be managed as functional dyspepsia.

A.5 In the first instance this patient should be encouraged to persist with medical therapy and use a higher dose of PPI. While the vast majority of patients with gastro-oesophageal reflux disease are managed quite satisfactorily with medical treatment a small proportion of patients will opt for surgical management. The usual reasons are a persistence of heartburn despite high dosage PPI therapy and/or volume reflux. A number of non-operative (endoscopic) procedures for the control of reflux have been promoted (e.g. radio-frequency scarification at the lower oesophageal sphincter, stapled fundoplication). Although some short-term success has been reported with these techniques none has yet shown any durability.

The advantages and disadvantages of other options should be discussed. The standard surgical approach currently offered to patients with troublesome GORD is laparoscopic fundoplication. The principles of the procedure include reduction and repair of any hiatal hernia combined with a partial or total fundoplication (a wrap of the fundus of the stomach around the intra-abdominal component of the oesophagus). The majority of patients who undergo fundoplication will have improvement or abolition of their symptoms and a recent randomized trial reported both improved symptom control and general well-being following anti-reflux surgery consistent with that achieved by best medical therapy. The potential side-effects following fundoplication of dysphagia, gas bloat and inability to belch or vomit must be discussed.

A.6 An endoscopy allows identification of any oesophagitis that may be present along with confirmation by histological analysis. The presence of an associated hiatus hernia can also be assessed and any co-existent disease, such as peptic ulceration, may be identified. In selected cases a barium swallow and meal allows assessment of upper gastrointestinal tract function, particularly with respect to the assessment of swallowing propagation and volume reflux. A contrast study is particularly helpful in delineating the anatomy of large paraoesophageal hernias.

Oesophageal manometry and pH studies are commonly performed investigations prior to surgery. Manometry allows analysis of oesophageal contractions, both resting and on swallowing, and measurement of the lower oesophageal sphincter (LOS) pressure. It may be possible to identify abnormal oesophageal contractions which have developed secondary to acid-induced irritability of the oesophagus. Poor oesophageal motility might indicate a partial rather than a total fundoplication would be the preferred option to reduce the risk of postoperative dysphagia. High resting LOS pressures and poor peristalsis may suggest a motility disorder and may influence surgical suitability. Twenty-four-hour ambulatory pH recordings provide information on the amount of acid exposure in the lower oesophagus. In the 24-hour period, those who have an oesophageal pH of less than 4 for more than 5–7% of the time are deemed to have significant reflux. Correlation between symptoms and low pH strengthens the diagnosis.

A typical history of reflux, endoscopic evidence of oesophagitis, and symptomatic response to acid suppression are strong indicators for a good surgical outcome.

A.7 These tests demonstrate anaemia with a low MCV, in keeping with iron deficient anaemia. With his past history of heartburn and dyspepsia he may be bleeding from somewhere in the upper digestive tract.

A.8 The endoscopic photograph demonstrates a tongue of columnar-lined epithelium running up the oesophagus. The patient has Barrett’s oesophagus. This is a well-recognized complication of chronic gastro-oesophageal reflux, occurring in around 10% of patients. Other complications of reflux include peptic strictures and iron deficiency anaemia.

The area of Barrett’s should be biopsied and carefully examined for evidence of dysplasia. Barrett’s oesophagus is considered a pre-malignant disease. Surveillance in such patients is, however, controversial. There is no good evidence to support the concept that the prevention of acid reflux reverses the metaplasia or malignant risk. However, current thinking suggests that if no dysplasia is present then 5-yearly endoscopy is reasonable. If dysplasia is detected, then more frequent endoscopy at 3–6-month intervals is indicated, depending on the degree of dysplasia. PPIs should be prescribed for such patients.

A.9 Treatment with high dose acid suppression therapy may have contributed to the overall improvement from high grade dysplasia to low grade dysplasia (or this might represent sampling error). However, the nodular area is a worrying feature and histology has identified carcinoma in situ. The patient should be staged to assess the extent of the disease. Initial staging investigations would include endoscopic ultrasound (EUS) and a CT of the chest and abdomen. EUS is the best staging modality for the loco-regional assessment of oesophageal tumours (T and N stage). CT is used to identify distant metastatic disease, especially lung and liver (M stage). Additional staging modalities, such as bone scans and positron emission tomography (PET), may be used in selected cases.

A.10 Without further treatment the nodular lesion will likely progress to invasive carcinoma. Further management is therefore concerned with removing the diseased area. In this scenario, this could involve either a local resection or undertaking an oesophagectomy. Endoscopic mucosal resection (EMR) allows localized removal of the abnormal area (Figure 11.2). Saline or adrenaline is injected into the submucosal layer to elevate the abnormal mucosal segment. A suction cap is then applied and cautery is used to remove the abnormal nodule. The specimen is sent for histological evaluation to ensure complete resection. This option is favourable in terms of morbidity and potential mortality that is associated with oesophagectomy. However, in some patients the option of oesophagectomy may be preferred if there are multiple areas of high-grade dysplasia, there is invasion into the submucosa on the EMR specimen, or the suspicion of invasive carcinoma with nodal involvement is high.

Radiofrequency ablation and photodynamic therapy are treatments under investigation for Barrett’s oesophagus.