Introduction
Cystitis is inflammation of the bladder. It's usually caused by an infection in the bladder, but can also be caused by irritation or damage (from friction during sex, for example).
Symptoms of cystitis are:
An urgent need to urinate often
Pain or stinging when you urinate
Cystitis usually passes within a few days, or sometimes may need treatment with antibiotics.
Untreated bladder infections can cause kidney infections.
Cystitis in women
Cystitis is more common in women because women have a short urethra (the tube that carries urine from the bladder out of the body). The urethra's opening is also located very close to the anus (bottom), which makes it easy for bacteria from the anus to reach the bladder and cause an infection.
Almost all women will have cystitis at least once in their lifetime. Around one in five women who have had cystitis will get it again (known as recurrent cystitis). Cystitis can occur at any age, but it is more common in:
Pregnant women
Sexually active women
Post-menopausal women (women who have been through menopause)
Cystitis in men
Cystitis is less common in men. It can be more serious in men because it could be caused by:
An underlying bladder or prostate infection, such as prostatitis
An obstruction in the urinary tract, such as a tumour, or an enlarged prostate (the gland located between the penis and the bladder)
Male cystitis is not usually serious if treated quickly, but it can be very painful. Sexually active gay men are more likely to get cystitis than other males.
Outlook
Mild cystitis usually clears up within 4-9 days. You can treat it at home by drinking plenty of water (around 1.2 litres or 6-8 glasses every day) and taking painkillers, such as paracetamol or ibuprofen. More severe cystitis can also cause abdominal pain or fever, and may need treatment with antibiotics.
Seeing Dr. B C Shah
Children and men should always see Dr. B C Shah if they have symptoms of cystitis. Women should always see Dr. B C Shah the first time they have the symptoms of cystitis. They should also return to him if they have the condition ore than three times in one year.
Symptoms of cystitis
Children and adults can get cystitis, and the symptoms can be different.
Symptoms in men and women
Cystitis in men and women can cause:
Pain, burning or stinging when you urinate
Needing to urinate often and urgently but passing only small amounts of urine
Urine that's dark, cloudy or strong smelling
Urine that contains traces of blood (haematuria)
Pain low in your belly (directly above the pubic bone), or in the lower back or abdomen
Feeling unwell, weak or feverish
Symptoms in children
Symptoms of cystitis in children may include:
Weakness
Irritability
Reduced appetite
Vomiting
Pain when urinating
Cystitis is usually treated easily.
Seeing Dr. B C Shah
The usual symptoms of cystitis could also be caused by other conditions, so it's important to see Dr. B C Shah the first time you have any of these symptoms. This means you can be treated correctly for whatever is causing your symptoms.
The symptoms caused by cystitis could also be caused by:
Sexually transmitted infections (STIs), such as gonorrhoea or chlamydia
Being infected with bacterium such as E-coli
Vaginal thrush, also known as candida (a yeast infection)
Inflammation of the urethra (urethritis)
Urethral syndrome (women only)
Inflammation of the prostate gland, also known as prostatitis (men only)
Causes of cystitis
The most common cause of cystitis is a bacterial infection. If bacteria reach the bladder, they can multiply and irritate the bladder lining, causing the symptoms of cystitis.
Cystitis can also result from damage or irritation around the urethra. The urethra is the tube that carries urine from the bladder out of the body. In men, the urethral opening (where urine leaves the body) is at the tip of the penis. In women it's just below the clitoris.
Bacterial infection
This happens when bacteria get into the bladder and multiply. It can happen if you don't empty your bladder properly. Try to empty your bladder fully each time you go to the toilet, to help prevent bacterial infection.
You may not be able to empty your bladder fully if:
You have a blockage somewhere in your urinary system: this could be caused by a tumour or, in men, an enlarged prostate (a gland located between the penis and the bladder)
You are pregnant, as pregnancy puts pressure on the pelvic area and the bladder
Bacterial infection can also happen when bacteria from the anus are transferred to the urethra. This is more common in women than in men, as the urethra is closer to the anus in women than it is in men.
In women, transferring bacteria in this way can happen when you are:
Having sex
Wiping after going to the toilet (you're less likely to transfer bacteria in this way if you wipe from front to back)
Inserting a tampon
Using a diaphragm (a soft dome made of latex or silicone) for contraception
In women who have had, or are going through, the menopause, the lining of the urethra and the bladder become thinner. This is due to a lack of the hormone oestrogen. The thin lining is more likely to become infected or damaged. Women also produce fewer vaginal secretions after the menopause, which means that bacteria are more likely to multiply.
Damage or irritation
Cystitis can also be caused by damage or irritation in the area around the urethra in both men and women. This could be the result of:
Damage or bruising caused by vigorous or frequent sex (this is sometimes called honeymoon cystitis)
Wearing tight clothing
Chemical irritants – for example, in perfumed soap or talcum powder
Other bladder or kidney problems, such as a kidney infection or prostatitis
Diabetes (a long-term condition caused by too much glucose in the blood)
Damage caused by a catheter (a tube inserted into the urethra to allow urine to flow into a drainage bag, which is often used after surgery)
Diagnosing cystitis
If you have had cystitis before, you may be able to recognise the symptoms and diagnose the condition yourself.
However, men and children with cystitis symptoms should always see Dr. B C Shah. Men, women and children should see Dr. B C Shah if:
This is the first time you've had cystitis symptoms
There's blood in your urine (haematuria)
You have a high temperature (fever) of 38ºC (100.4ºF)
You're in a lot of pain
You've had cystitis three times in one year
Dr. B C Shah should be able to diagnose cystitis from asking about your symptoms. In some cases, they may also use a dipstick (a chemically treated strip of paper) to test a sample of your urine. The paper will react to certain bacteria by changing colour, showing which kind of infection you have.
Urine culture
Dr. B C Shah may wish to send a sample of your urine to a laboratory for further testing. This sample is called a urine culture. This may be necessary if:
you have recurrent cystitis (more than three times in one year)
it is possible that you may have a kidney infection – cystitis can be a symptom of this
you are on immunosuppressant medication(medication that suppresses your immune system) – these affect your body’s defences so you may be more prone to infection
you have diabetes (a long-term condition caused by too much glucose in the blood) – cystitis can be a complication of diabetes
you may have a sexually transmitted infection(STI) – such as gonorrhoea and chlamydia
it is possible that you have another infection, such as thrush (candida)
The urine culture will confirm which bacteria are causing your cystitis. Alternatively, it may reveal that your cystitis is caused by another condition. Dr. B C Shah can advise you about the most appropriate treatment for you.
Further tests
If you have recurrent cystitis that does not respond to antibiotics, even after a urine culture has been tested,you may need to have some other tests, such as:
An ultrasound scan
An X-ray
A cystoscopy
A cystoscopy is when a tiny fibre-optic camera, called a cystoscope, is used to examine your bladder. The cystoscope is a very thin tube that has a light and a camera at one end. It is inserted into your urethra (the tube that carries urine from your bladder out of your body) and transmits images of the inside of your bladder to a screen.
Any further tests that you need will be explained to you by Dr. B C Shah treating you.
Treating cystitis
Children and men should always see Dr. B C Shah if they have cystitis symptoms. Women should always see Dr. B C Shah the first time they have cystitis symptoms, and also if they have the condition more than three times in one year.
The symptoms of cystitis usually clear up without treatment within 4-9 days. There are some self-help treatments that can ease the discomfort of any symptoms, or Dr. B C Shah may prescribe antibiotics.
Self-help treatments
If you've had cystitis before and you're sure that you have mild cystitis and don't need to see Dr. B C Shah, there are treatments that you can try yourself.
Over-the-counter (OTC) painkillers, such as paracetamol or ibuprofen. These can reduce pain and discomfort. Always read the label and check with your pharmacist first, particularly if you have any other medical condition, you are taking other medicines, or you're pregnant or breastfeeding.
Drinking plenty of water is often recommended as a treatment for cystitis. There's no evidence that this is helpful, although drinking around 1.2 litres (6-8 glasses) of water a day is generally good for your health. Also avoid alcohol.
Don't have sex until your cystitis has cleared up because having sex can make it worse.
Some people find that using urine alkanising agents, such as sodium bicarbonate or potassium citrate, for a short period of time may help to relieve pain when urinating. However, there is currently a lack of clinical evidence for their effectiveness. Check with Dr. B C Shah first if you are taking any other medication.
Drinking cranberry juice is not thought to help relieve pain but may help to prevent outbreaks of recurrent cystitis.
Antibiotics
If your symptoms are moderate or severe, Dr. B C Shah may prescribe a short course of antibiotics. This will usually involve taking a tablet 2-4 times a day, for three days.
For a more complicated case of cystitis, such as cystitis with another underlying infection, you may be given antibiotics for 5-10 days.
If your cystitis symptoms are only mild, Dr. B C Shah may prefer not to prescribe antibiotics to avoid ‘antibiotic resistance’. This is when the bacteria that cause cystitis adapt and learn to survive the antibiotics. Over time, this means that the treatment becomes less effective.
Recurring cystitis
If you keep getting cystitis (known as having recurring cystitis) your doctor may prescribe stand-by antibiotics or continuous antibiotics. A stand-by antibiotic is a prescription for you to take the next time you have cystitis, without needing to visit Dr. B C Shah again.
Continuous antibiotics are antibiotics that you take for several months to prevent further episodes of cystitis. These may be prescribed for two reasons:
If your cystitis usually occurs after having sex, you may be given a prescription for antibiotics to take within two hours of having sex
If your cystitis is not related to having sex, you may be given a low-dose antibiotic to take for a trial period of six months
Complications
Most cases of cystitis clear up on their own or with antibiotics. However, untreated bladder infections can cause kidney infections, which can be serious.
Although cystitis usually clears up on its own or with antibiotics, some people experience almost constant symptoms or recurring episodes. If no cause can be found, and the cystitis doesn't respond to antibiotics, you may have interstitial cystitis.
Interstitial cystitis
Interstitial cystitis causes recurring discomfort in the bladder and pelvic area. Like cystitis, it can cause an urgent and frequent need to urinate. Other symptoms, and the level of pain it causes, can vary from person to person.
Some people may find it more painful when their bladder is full, or more painful when they urinate. Women may find the condition more painful during their period.
How is it treated?
Treatment can include:
Medications, including painkillers and antidepressants
Bladder distension – when the bladder is filled with water to increase its volume
Bladder instillation – the bladder is filled with a solution that includes medication to reduce inflammation of the bladder walls
Surgery, if other treatments haven't worked
If you're diagnosed with interstitial cystitis, Dr. B C Shah will explain the condition and the treatment options in more detail.
Dr. B C Shah may use the term 'painful bladder syndrome' (PBS) to describe a condition that causes pain but doesn't meet the criteria to be diagnosed as interstitial cystitis.
Bladder
The bladder is a small organ near the pelvis that holds urine until it is ready to be passed from the body.
Inflammation
Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.
Pain
Pain is an unpleasant physical or emotional feeling that your body produces as a warning sign that it has been damaged.
Painkillers
Painkillers (analgesics) are medicines that relieve pain. For example paracetamol, aspirin and ibuprofen.
Preventing cystitis
It's not always possible to prevent cystitis, but you can take some steps to help avoid the condition:
Don't use perfumed bubble bath, soap, or talcum powder around your genitals – use plain, unperfumed varieties
Have a shower, rather than a bath, to avoid exposing your genitals to the chemicals in your cleaning products for too long
Always empty your bladder fully when you go to the toilet
Don't wait to go if you need to urinate: delaying it can place extra stress on your bladder and could make it more vulnerable to infection
Wear underwear made from cotton rather than synthetic material such as nylon
Avoid wearing tight jeans and trousers
Always wipe from the front of your genital area to the back, not back to front, when you go to the toilet
Some people find certain types of food and drink make their cystitis worse: for example, coffee, fruit juice or spicy foods. If there is anything that triggers your cystitis, you may wish to avoid it
Cranberry products
Although cranberry products are not effective at treating cystitis, they may help to prevent recurrent attacks. High-strength capsules, which contain 200mg of cranberry extract, are available in shops .
Cranberry capsules may be a more effective treatment than drinking cranberry juice, as you need to drink a lot of juice for it to benefit you, and not everyone likes the taste. Cranberry capsules are not recommended if you are taking warfarin (blood-thinning medication).
Cystitis and sex
Try these tips if your cystitis is triggered by having sex:
Wash your genital area and your hands before and after sex
Use a lubricant during sex to avoid damaging your genital area through friction (use a water-based lubricant if you're using latex condoms, as oil-based lubricant can make latex condoms less effective)
If you're a woman and you use a diaphragm for contraception, you may wish to change to another method of contraception
After having sex, empty your bladder as soon as possible to get rid of unwanted bacteria
There is currently no evidence that oestrogen products, used to treat women after the menopause, can prevent cystitis.
People who have catheters need special advice about how to change them without damaging the area. Ask the healthcare professional who is treating you to show you how to do this.

Introduction
Non-alcoholic fatty liver disease (NAFLD) is the term for a wide range of conditions caused by a build-up of fat within the liver cells. It is usually seen in people who are overweight or obese.
A healthy liver should contain little or no fat. Most people with NAFLD only carry small amounts of fat, which doesn't usually cause any symptoms and isn't harmful to the liver. This early form of the disease is known as simple fatty liver, or steatosis.
Simple fatty liver is very common, reflecting the number of people who are obese or overweight.
However, just because simple fatty liver is harmless, it doesn't mean it is not a serious condition:
In some people, if the fat builds up and gets worse, it can eventually lead to scarring of the liver
As the disease is linked to being overweight or obese, people with any stage of the disease are more at risk of developing a stroke or heart attack
NAFLD is often diagnosed after liver function tests (a type of blood test) produce an abnormal result and other liver conditions, such as hepatitis, are ruled out.
This page explains:
The four stages of NAFLD and the symptoms at each stage
Who is affected, and the causes of NAFLD
Living with NAFLD
Four stages of NAFLD
NAFLD is very similar to alcoholic liver disease, but it is caused by factors other than drinking too much alcohol. The four stages are described below.
Stage 1: simple fatty liver (steatosis)
Hepatic steatosis is stage 1 of the condition. This is where excess fat builds up in the liver cells but is considered harmless. There are usually no symptoms and you may not even realise you have it until you receive an abnormal blood test result.
Stage 2: non-alcoholic steatohepatitis (NASH)
Only a few people with simple fatty liver go on to develop stage 2 of the condition, called non-alcoholic steatohepatitis (NASH).
NASH is a more aggressive form of the condition, where the liver has become inflamed. Inflammation is the body's healing response to damage or injury and, in this case, is a sign that liver cells have become damaged.
A person with NASH may have a dull or aching pain felt in the top right of their abdomen (over the lower right side of their ribs).
Stage 3: fibrosis
Some people with NASH go on to develop fibrosis, which is where persistent inflammation in the liver results in the generation of fibrous scar tissue around the liver cells and blood vessels. This fibrous tissue replaces some of the healthy liver tissue, but there is still enough healthy tissue for the liver to continue to function normally.
Stage 4: cirrhosis
At this most severe stage, bands of scar tissue and clumps of liver cells develop. The liver shrinks and becomes lumpy. This is known as cirrhosis.
Cirrhosis tends to occur after the age of 50-60, after many years of liver inflammation associated with the early stages of the disease.
People with cirrhosis of the liver caused by NAFLD often also have type 2 diabetes.
The damage caused by cirrhosis is permanent and can't be reversed. Cirrhosis progresses slowly, over many years, gradually causing your liver to stop functioning. This is called liver failure. Learn more about cirrhosis of the liver, including the warning signs.
Who is affected?
You are more likely to develop NAFLD if you:
Are obese or overweight
Have type 2 diabetes (this causes an increased uptake of fat into the liver cells)
Are over the age of 50
Have high blood pressure
Have high cholesterol
Have experienced rapid weight loss, for example after weight loss surgery or after being malnourished
Living with NAFLD
Most people with NAFLD do not develop serious liver problems and just have stage 1 of the disease (simple fatty liver).
Simple fatty liver may go away if the underlying cause is tackled. For example, losing excess weight or controlling diabetes better can make fatty liver go away.
Many people do not have symptoms, although it's common to feel tired and some people have a persistent pain in the upper right part of their abdomen (where their liver is).
It is important to make lifestyle changes to prevent the disease progressing to a more serious stage and to lower your risk of having a heart attack or stroke.
Losing weight and exercising
The most important thing that people with NAFLD can do is to go on a gradual weight loss programme and exercise regularly. This helps in two ways: by reducing the amount of fat in your liver cells and by lowering your risk of stroke and heart attack. Start losing weight.
Losing weight is particularly important if you have type 2 diabetes.
Stopping smoking
If you smoke, it's really important to give up, as this will also help to reduce your risk of heart attack and stroke.Take steps now to stop smoking.
Medication
If you have high blood pressure or high cholesterol, you may need medical treatment for these.
If you have type 2 diabetes, you may need medicines that reduce high levels of blood sugar. At first, this will usually be in the form of tablets, sometimes a combination of more than one type of tablet. It may also include injections of insulin. Learn more about the medical treatment of type 2 diabetes.
Alcohol
NAFLD is not caused by alcohol, but drinking alcohol may make the condition worse. It's therefore advisable to stop drinking alcohol.

Introduction
Gastro-oesophageal reflux disease (GORD) is a common condition where stomach acid leaks out of the stomach and into the oesophagus (gullet). The oesophagus is a long tube of muscle than runs from the mouth to the stomach.
Common symptoms of GORD include:
Heartburn – burning chest pain or discomfort that occurs after eating
An unpleasant sour taste in the mouth – caused by stomach acid coming back up into the mouth (known as regurgitation)
Dysphagia – pain and difficulty swallowing
Many people experience occasional episodes of GORD, but if people have persistent and reoccurring symptoms it is normally regarded as a condition that needs treatment.
Treatment
A step-by-step approach is usually recommended for GORD. This means that relatively uncomplicated treatments, such as changing your diet, will be tried first.
If this fails to help control symptoms then a person can be 'stepped up' to more complex treatments such as antacids, which help neutralise the effects of stomach acid.
In cases where medication fails to control symptoms, surgery may be required.
Causes
It is thought that GORD is caused by a combination of factors. The most important factor is the lower oesophageal sphincter (LOS) muscle not working properly.
The LOS acts like a valve, opening to let food fall into the stomach and closing to prevent acid leaking out of the stomach and into the oesophagus. In cases of GORD, the LOS does not close properly, allowing acid to leak up, out of the stomach.
Known risk factors for GORD include:
Being overweight or obese
Being pregnant
Eating a high-fat diet
Complications
A common complication of GORD is that the stomach acid can irritate and inflame the lining of the oesophagus, which is known as oesophagitis.
In severe cases of oesophagitis, ulcers (open sores) can form which can cause pain and make swallowing difficult.
A rarer and more serious complication of GORD is cancer developing inside the oesophagus (oesophageal cancer).
Who is affected
GORD is a common digestive condition. It is estimated that one in five people will experience at least one episode of GORD a week, and that 1 in 10 people experience symptoms of GORD on a daily basis.
GORD can affect people of all ages, including children. However, most cases affect adults aged 40 or over. GORD is thought to affect both sexes equally, but males are more likely to develop complications.
Outlook
The outlook for GORD is generally good, and most people respond well to treatment with medication.
However, relapses are common, with around half of people experiencing a return of symptoms after a year. As a result, some people may require a long-term course of medication to control their symptoms.
Symptoms of gastro-oesophageal reflux disease
The three most common symptoms of gastro-oesophageal reflux disease (GORD) are:
Heartburn
Regurgitation of acid into your throat and mouth
Dysphagia (difficulty swallowing
These symptoms are discussed in more detail below.
Heartburn
Heartburn is a burning pain or a feeling of discomfort that develops just below your breastbone. The pain is usually worse after eating, or when bending over or lying down.
Regurgitation
Regurgitation of acid usually causes an unpleasant, sour taste at the top of your throat or the back of your mouth.
Dysphagia
Around one in three people with GORD has problems swallowing (dysphagia). It can occur if the stomach acid causes scarring of the oesophagus, which leads to the oesophagus narrowing, making it difficult to swallow food.
People with GORD-associated dysphagia say it feels like a piece of food has become stuck somewhere near their breastbone.
Less common symptoms of GORD
GORD can sometimes have a number of less common symptoms associated with the irritation and damage caused by stomach acid.
Less common symptoms of GORD include:
Feeling sick
Persistent cough, often worse at the night
Chest pain
Wheezing
Tooth decay
Laryngitis (inflammation of the larynx), which causes throat pain and hoarseness
If you have asthma and GORD, your asthma symptoms may get worse as a result of stomach acid irritating your airways.
When to seek medical advice
If you are only experiencing symptoms such as heartburn once or twice a month, then you probably do not need to seek treatment from Dr. B C Shah.
You should be able to control symptoms by making a number of lifestyle changes and using over-the-counter medication as and when symptoms occur.
You should see Dr. B C Shah if you are having frequent or severe symptoms and finding yourself using over-the-counter medication on a weekly or daily basis. You may require prescription medication to control symptoms and prevent complications.
Causes of gastro-oesophageal reflux disease
It is thought that most cases of gastro-oesophageal reflux disease (GORD) are caused by a problem with the lower oesophageal sphincter (LOS) muscle. The LOS is located at the bottom of the oesophagus (gullet), the tube that runs from the back of the throat to the stomach.
The LOS works in a similar way to a valve. It opens to let food into your stomach, and it closes to prevent acid leaking back up into your oesophagus.
However, in people with GORD, the LOS can become weakened, which allows stomach acid to pass back into the oesophagus. This causes symptoms of heartburn, such as a burning pain or a feeling of discomfort in your stomach and chest.
Exactly what causes the LOS to become weakened is not always clear, but a number of risk factors have been identified.
These are outlined below.
Risk factors
Being overweight or obese – this can place an increased pressure on your stomach, which in turn can weaken the LOS
Having a diet high in fatty foods – the stomach takes longer to dispose of stomach acids after digesting a fatty meal
Consuming tobacco, alcohol, coffee, or chocolate – it has been suggested that these four substances may relax the LOS
Being pregnant – changes in hormone levels during pregnancy can weaken the LOS and increase pressure on your stomach
Having a hiatus hernia – a hiatus hernia is where part of your stomach pushes up through your diaphragm (the sheet of muscle used for breathing)
Stress
There is also a condition called gastroparesis, where the stomach takes longer to dispose of stomach acid. The excess acid can push up through the LOS.
Gastroparesis is common in people who have diabetes, because high blood sugar levels can damage the nerves that control the stomach.
Medication
There are a number of medications that can relax the LOS, leading to the symptoms of GORD.
These include:
Calcium-channel blockers – a type of medication used to treat high blood pressure
Non-steroidal anti-inflammatory drugs (NSAIDs) – a type of painkiller, such as ibuprofen
Selective serotonin reuptake inhibitors (SSRIs) – a type of antidepressant
Corticosteroids (steroid medication) – which are often used to treat severe symptoms of inflammation
Bisphosphonates – used to treat osteoporosis(weakening of the bones)
Nitrates – a medication used to treat angina (a condition that causes chest pain)
Diagnosing gastro-oesophageal reflux disease
In most cases, Dr. B C Shah will be able to diagnose gastro-oesophageal reflux disease (GORD) by asking questions about your symptoms.
Further testing for GORD is usually only required if:
You have dysphagia (difficulty swallowing)
Your symptoms do not improve despite taking medication
Further testing aims to confirm or disprove the diagnosis of GORD while checking for any other possible causes of your symptoms, such as irritiable bowel syndrome.
Endoscopy
An endoscopy is a procedure where the inside of your body is directly examined using an endoscope.
An endoscope is a long, thin flexible tube that has a light source and video camera at one end so that images of the inside of your body can be sent to an external monitor.
To confirm a diagnosis of GORD, the endoscope will be inserted into your mouth and down your throat. The procedure is usually done while you are awake, and you may be given a sedative to help you to relax.
An endoscopy is used to check whether the surface of your oesophagus has been damaged by stomach acid. It can also rule out more serious conditions that can also cause heartburn, such as stomach cancer.
Manometry
If an endoscopy does not find any evidence of damage to your oesophagus, you may be referred for a further test called manometry.
Manometry is used to assess how well your lower oesophageal sphincter (LOS) is working by measuring pressure levels inside the sphincter muscle.
During manometry, one of your nostrils will be numbed using a topical anaesthetic. A small tube will then be passed down your nostril and into your oesophagus to the site of the LOS. The tube contains a number of pressure sensors, which can detect the pressure generated by the muscle, then send the reading to a computer.
During the test, you will be asked to swallow some food and liquid to check how effectively your LOS is functioning.
A manometry test takes around 20 to 30 minutes to complete. It is not painful, but you may have minor side effects including:
A nosebleed
A sore throat
However, these side effects should pass quickly once the test has been completed.
Manometry can be useful for confirming a diagnosis of GORD, or for detecting less common conditions that can disrupt the normal workings of the LOS, such as muscle spasms or achalasia (a rare swallowing disorder).
Barium swallow
If you are experiencing symptoms of dysphagia then you may be referred for a test known as a barium swallow.
The barium swallow test is one of the most effective ways of assessing your swallowing ability and finding exactly where the problems are occurring. The test can often identify blockages or problems with the muscles used during swallowing.
As part of the test, you will be asked to drink some barium solution. Barium is a non-toxic chemical that is widely used in tests because it shows up clearly on an X-ray. Once the barium moves down into your upper digestive system, a series of X-rays will be taken to identify any problems.
If you need to have a barium meal X-ray, you will not be able to eat or drink anything for at least six hours before the procedure so that your stomach and duodenum (top of the small intestine) are empty. You may be given an injection to relax the muscles in your digestive system.
You will then lie down on a couch and your specialist will give you a white, chalky liquid to drink which contains barium. As the barium fills your stomach, your specialist will be able to see your stomach on an X-ray monitor, as well as any ulcers or abnormal growths. Your couch may be tipped slightly during the test so that the barium fills all the areas of your stomach.
A barium swallow usually takes about 15 minutes to perform. Afterwards you will be able to eat and drink as normal, although you may need to drink more water to help flush the barium out of your system. You may feel slightly sick after a barium meal X-ray, and the barium may cause constipation. Your stools may also be white for a few days afterwards as the barium passes through your system.
24-hour pH monitoring
If the manometry test cannot find problems with your oesophageal sphincter muscles, another test known as 24-hour pH monitoring can be used (pH is a unit of measurement used in chemistry, and describes how acidic a solution is). The lower the pH level, the more acidic the solution is.
The 24-hour pH monitoring test is designed to measure pH levels around your oesophagus. You should stop taking medication used to treat GORD for seven days before having a 24-hour pH test because the medication could distort the test results.
During the test, a small tube containing a probe will be passed through your nose to the back of your oesophagus. This is not painful but can feel a little uncomfortable.
The probe is connected to a portable recording device about the size of an MP3 player, which you wear around your wrist. Throughout the 24-hour test period, you will be asked to press a button on the recorder every time you become aware of your symptoms.
You will be asked to complete a diary sheet by recording when you have symptoms upon eating. Eat as you normally would to ensure an accurate assessment can be made.
After the 24-hour period is over, the probe will be removed so measurements on the recorder can be analysed. If test results indicate a sudden rise in your pH levels after eating, a confident diagnosis of GORD can usually be made.
Treating gastro-oesophageal reflux disease
A number of self-care techniques may help relieve symptoms of gastro-oesophageal reflux disease (GORD). They are described below.
If you are overweight, losing weight may help reduce the severity and frequency of your symptoms because it will reduce pressure on your stomach.
If you are a smoker, consider quitting. Tobacco smoke can irritate your digestive system and may make symptoms of GORD worse.
Eat smaller, more frequent meals, rather than three large meals a day. Make sure you have your evening meal three to four hours before you go to bed.
Be aware of triggers that make your GORD worse. For example, alcohol, coffee, chocolate, tomatoes, or fatty or spicy food. After you identify any food that triggers your symptoms, remove them from your diet to see whether your symptoms improve.
Raise the head of your bed by around 20cm (8 inches) by placing a piece of wood, or blocks under it. This may help reduce your symptoms of GORD. However, make sure your bed is sturdy and safe before adding the wood or blocks. Do not use extra pillows because this may increase pressure on your abdomen.
If you are currently taking medication for other health conditions, check with DR. B C Shah to find whether he may be contributing to your symptoms of GORD. Alternative medicines may be available. Do not stop taking a prescribed medication without consulting Dr. B C Shah first.
Medication
A number of different medications can be used to treat GORD. These include:
Over-the-counter medications
Proton-pump inhibitors (PPIs)
H2-receptor antagonists
Prokinetics
Depending on how your symptoms respond, you may only need medication for a short while or alternatively on a long-term basis.
These are described below.
Over-the-counter medications
A number of over-the-counter medicines can help relieve mild to moderate symptoms of GORD.
Antacids are medicines that neutralise the effects of stomach acid. However, antacids should not be taken at the same time as other medicines because they can stop other medicines from being properly absorbed into your body. They may also damage the special coating on some types of tablets. Ask Dr. B C Shah for advice.
Alginates are an alternative type of medicine to antacids. They work by producing a protective coating that shields the lining of your stomach and oesophagus from the effects of stomach acid.
Proton-pump inhibitors (PPIs)
If GORD fails to respond to the self-care techniques described above, Dr. B C Shah may prescribe a one month course of proton-pump inhibitors (PPIs) for you. PPIs work by reducing the amount of acid produced by your stomach.
Most people tolerate PPI well and side effects are uncommon.
When they do occur they are usually mild and may include
Headaches
diarrhoea
feeling sick
abdominal pain
constipation
dizziness
skin rashes
In order to minimise any side effects, Dr. B C Shah will prescribe the lowest possible dose of PPIs that they think will be effective in controlling your symptoms. Therefore, inform Dr. B C Shah if he can prescribe PPIs for you that prove ineffective. A stronger dose may be needed.
Sometimes, the symptoms of GORD can return after a course of PPIs has been completed. Go back to see Dr. B C Shah if you have further or persistent symptoms.
In some cases you may need to take PPIs on a long-term basis.
H2-receptor antagonists
If PPIs cannot control your symptoms of GORD, another medicine known as an H2-receptor antagonist (H2RA) may be recommended to take in combination with PPIs on a short-term basis (two weeks), or as an alternative to them.
H2RAs block the effects of the chemical histamine, used by your body to produce stomach acid. H2RAs therefore help reduce the amount of acid in your stomach.
Side effects of H2RAs are uncommon. However, possible side effects may include:
Diarrhoea
Headaches
Dizziness
Tiredness
A rash
Some types of H2RAs are available as over-the-counter medicines. These types of HR2As are taken in a lower dosage than the ones available on prescription. Ask Dr. B C Shah if you are not sure whether these medicines are suitable for you.
Prokinetics
If your GORD symptoms are not responding to other forms of treatment, Dr. B C Shah may prescribe a short-term dose of a prokinetic.
Prokinetics speed up the emptying of your stomach, which means there is less opportunity for acid to irritate your oesophagus.
A small number of people who take prokinetics have what is known as ‘extrapyramidal symptoms’. Extrapyramidal symptoms are a series of related side effects that affect your nervous system. Extrapyramidal symptoms include:
Muscle spasms
Problems opening your mouth fully
A tendency to stick your tongue out of your mouth
Slurred speech
Abnormal changes in body posture
If you have the above symptoms while taking prokinetics, stop taking them and contact Dr. B C Shah or out-of-hours doctor immediately. He may recommend your dose is discontinued.
Extrapyramidal symptoms should stop within 24 hours of the medicine being withdrawn.
Prokinetics are not usually recommended for people under 20 years old because of an increased risk of extrapyramidal symptoms.
Surgery
Surgery is usually only recommended in cases of GORD that fail to respond to the treatments listed above.
Alternatively, you may wish to consider surgery if you have persistent and troublesome symptoms but do not want to take medication on a long-term basis.
While surgery for GORD can help relieve your symptoms, there are some associated complications that may result in you developing additional symptoms, such as:
Dysphagia (difficulty swallowing)
Flatulence
Bloating
An inability to belch (burp)
Discuss the advantages and disadvantages of surgery with Dr. B C Shah before making a decision about treatment.
Surgical procedures that are used to treat GORD include:
Laparoscopic nissen fundoplication (LNF)
Endoscopic injection of bulking agents
Endoluminal gastroplication
Endoscopic augmentation with hydrogel implants
Endoscopic radiofrequency ablation
These procedures are discussed below.
Laparoscopic nissen fundoplication (LNF)
Laparoscopic nissen fundoplication (LNF) is one of the most common surgical techniques used to treat GORD.
LNF is a type of keyhole surgery that involves the surgeon making a series of small incisions (cuts) in your abdomen (tummy). Carbon dioxide gas is then used to inflate your abdomen to give the surgeon room to work in.
During LNF, the surgeon will wrap the upper section of your stomach around your oesophagus and staple it in place. This will contract (tighten) your lower oesophageal sphincter (LOS), which should prevent any acid moving back out of your stomach.
LNF is carried out under general anaesthetic, which means you will not feel any pain or discomfort. The surgery takes 60 to 90 minutes to complete.
After having LNF, most people can leave hospital once they have recovered from the effects of the general anaesthetic. This is usually within two to three days. Depending on the type of job you do, you should be able to return to work within three to six weeks.
For the first six weeks after surgery, it is recommended you only eat soft food, such as mince, mashed potatoes or soup. Avoid eating hard food that could get stuck at the site of the surgery, such as toast, chicken or steak.
Common side effects of LNF include:
Dysphagia (difficulty swallowing)
Belching
Bloating
Flatulence
These side effects should resolve over the course of a few months. However, in about 1 in 100 cases they can be persistent. In such circumstances, further corrective surgery may be required.
New surgical techniques
In the last decade, a number of new surgical techniques have been introduced for the treatment of GORD.
All techniques discussed below are non-invasive, which means no incisions need be made into your body. Therefore, they can usually be performed under local anaesthetic on a day surgery basis, so you should not have to spend the night in hospital.
Endoscopic injection of bulking agents
Endoscopic injection of bulking agents involves the surgeon using an endoscope to find the site where stomach and oesophagus meet (known as the gastro-oesophageal junction).
A thin tube called a catheter is then passed down the endoscope, and used to inject a combination of plastic and liquid into the junction. This narrows the junction and helps to prevent acid leaking up from the stomach.
The most common side effect of this type of surgery is mild to moderate chest pain. This develops in around a half of all cases.
Other side effects include:
Dysphagia
Feeling sick
High temperature of 38ºC (100.4ºF) or above
These side effects should resolve within a few weeks.
Endoluminal gastroplication
Endoluminal gastroplication involves the surgeon using an endoscope to sow a series of pleats (folds) into the LOS. The pleats should restrict how far the LOS can open, preventing acid leaking up from your stomach.
Side effects of this type of surgery include:
Chest pain
Abdominal (tummy) pain
Vomiting
Sore throat
These side effects should improve within a few days.
Endoscopic augmentation with hydrogel implants
Endoscopic augmentation with hydrogel implants is a similar technique to an endoscopic injection, except the surgeon uses hydrogel to narrow your gastro-oesophageal junction. Hydrogel is a type of flexible plastic gel very similar to living tissue.
The most common complication arising from this procedure is that the hydrogel starts to come out of the gastro-oesophageal junction. One study found this happened in one in five cases. However, this is a relatively new technique and success rates may well improve in future.
Endoscopic radiofrequency ablation
In endoscopic radiofrequency ablation, the surgeon passes a balloon down an endoscope to the site of your gastro-oesophageal junction. The balloon is then inflated.
Tiny electrodes are attached to the outside of the balloon and small pulses of heat generated. This creates small scars in the tissue of your oesophagus, causing it to narrow and making it more difficult for stomach acid to leak out of your stomach.
Out of all the new surgical techniques mentioned, there is little known about the safety of endoscopic radiofrequency ablation. Possible complications and side effects may include:
Chest pain
Dysphagia
Injury to the oesophagus
LINK Reflux Management System
A new type of surgery introduced in 2011, is the LINK Reflux Management System.
This type of keyhole surgery uses magnetic beads to reinforce the LOS muscle.
The magnetic force of the beads helps keep the LOS closed when at rest, preventing stomach acid leaking upwards. The LOS opens normally when swallowing.
This type of surgery appears effective and safe in the short-term but as it is a new technique, its long-term effectiveness and safety are unclear.
Complications of gastro-oesophageal reflux disease
Oesophageal ulcers
The excess acid produced by gastro-oesophageal reflux disease (GORD) can damage the lining of your oesophagus (oesophagitis) which can lead to the formation of ulcers. The ulcers can bleed, causing pain and making swallowing difficult. Ulcers can usually be successfully treated by controlling the underlying symptoms of GORD.
Medications used to treat GORD can take several weeks to become effective, so it is likely Dr. B C Shahwill recommend additional medication to provide short-term relief from your symptoms.
Two types of medication that can be used are:
antacids to neutralise stomach acid on a short-term basis
alginates, which produce a protective coating on the lining of your oesophagus
Both antacids and alginates are over-the-counter medications available from pharmacists. The pharmacist will advise you on the types of antacid and alginate most suitable for you.
Antacids are best taken when you have symptoms, or when symptoms are expected, such as after meals or at bedtime. Alginates are best taken after meals.
Side effects for both medications are uncommon but include:
diarrhoea
vomiting
flatulence
Oesophageal stricture
Repeated damage to the lining of your oesophagus can lead to the formation of scar tissue. If the scar tissue is allowed to build up, it can cause your oesophagus to become narrowed. This is known as oesophageal stricture.
An oesophageal stricture can make swallowing food difficult and painful. Oesophageal strictures can be treated by using a tiny balloon to dilate (widen) the oesophagus. This procedure is usually carried out under a local anaesthetic.
Barrett’s oesophagus
Repeated episodes of GORD can lead to changes in the cells lining of your lower oesophagus. This is a condition known as Barrett’s oesophagus.
It is estimated that 1 in 10 people with GORD will develop Barrett’s oesophagus. Most cases of Barrett’s oesophagus first develop in people aged 50-70 years old. The average age at diagnosis is 62.
Barrett’s oesophagus does not usually cause noticeable symptoms other than those associated with GORD.
The concern is that Barrett’s oesophagus is a pre-cancerous condition. This means that while changes in the cells are not cancerous, there is a small risk they could develop into ‘full blown’ cancer in the future. This would then trigger the onset of oesophageal cancer (see below).
Oesophageal cancer
Risk factors that increase the risk of cells in the lining of your oesophagus turning cancerous include:
Being male
Having the symptoms of GORD for longer than 10 years
Having three or more episodes of heartburn and related symptoms a week
Smoking
Obesity
If it is thought that you have an increased risk of developing oesophageal cancer, it is likely you will be referred for regular endoscopies to monitor the condition of the affected cells.
If oesophageal cancer is diagnosed in its initial stages, it is usually possible to cure the cancer using a treatment called photodynamic therapy (PDT).
PDT involves injecting your oesophagus with a medication that makes it sensitive to the effects of light. A laser attached to an endoscope is then placed inside your oesophagus and burns away the cancerous cells.