Gastro-Oesophageal Reflux Disease, also known as GORD or simply ‘Reflux’ is a common condition in Australia. It is a condition where stomach acid and other gastric juices, sometimes along with undigested food, flow backwards and the wrong way from the stomach up the oesophagus (food-pipe or gullet). It is caused by a failure of one or more of several normal mechanisms that prevent reflux at the lower end of the oesophagus where it joins the stomach.
Patients suffering from reflux often report symptoms such as heartburn, waterbrash (a feeling of excess saliva in the mouth), indigestion or even regurgitation of gastric juices or partially digested food. This often occurs in bed at night or after a large meal. Sometimes GORD can cause other problems including respiratory issues such as a chronic cough and irritation of the oesophagus leading to Barrett’s Oesophagus.
Most cases of GORD can be managed with medications alone, however in some situations surgery is required and, in these situations, it is generally very effective. The operation performed is a Laparoscopic (key-hole) Fundoplication. Hiatus Hernia can also lead to reflux and can also be managed with a surgical procedure to fix the hernia and the reflux simultaneously.
Gallstone disease is a very common problem in Australia, with around 25% of the population developing gallstones before the age of 50 years. There is no universal cause for gallstones however there a number of known risk factors which include:
Most people with gallstones, approximately 90%, do not develop symptoms. The remaining 10% develop symptoms which vary in severity and seriousness (see below).
The treatment of gallstone disease is surgery. Cholecystectomy is the removal of the gallbladder, usually by laparoscopy (keyhole surgery). Complications are uncommon, and most people are able to go home after one night in hospital for elective surgery.
Biliary colic is pain from gallstones and typically comes on after eating, especially after rich or fatty meals. The pain usually comes on minutes to hours after the meal and resolves on its own, usually within 4 hours of starting. Biliary colic is benign, it won’t cause any harm, but can be very uncomfortable for the sufferer. Some people are able to minimise symptoms by avoiding any fatty foods in their diet, however the definitive treatment is having your gallbladder removed via surgery.
Cholecystitis is inflammation of the gallbladder. The triggering event is usually a gallstone getting stuck in the outlet of the gallbladder which causes a chemical change in the bile and an inflammatory response. This inflammation may subsequently develop a secondary bacterial infection. Symptoms of cholecystitis are similar to biliary colic but tend not to improve with time. These patients may get initially get better with antibiotics, but ultimately will need surgery to remove their inflamed gallbladder.
Cholangitis is an infection in the bile duct which is the main drainage duct that connects the liver (where bile is made) to the first part of the small bowel, the duodenum, where bile is used for digestion. This infection is usually caused by a gallstone in the bile duct that blocks the drainage of the liver. This blockage allows bacteria to multiply in the bile duct and is often associated with jaundice (turning yellow). Cholangitis is a potentially life-threatening emergency that needs urgent treatment in a hospital.
Pancreatitis is inflammation of the pancreas caused by pancreatic digestive juices attacking the pancreas itself. The most common cause of pancreatitis is gallstones. Once a person has developed pancreatitis from gallstones, it is strongly recommended that their gallbladder be removed by surgery.
Pancreatic cancer represents the 11th most common cancer in Australia and the 6th most common cause of cancer-related death. There are some known risk factors for pancreatic cancer such as family history, smoking and alcohol, but no clearly identified cause. The most common type of pancreatic cancer is Pancreatic Ductal Adenocarcinoma (PDAC) which makes up for 85% of cases. The remaining 15% of cases are a variety of other subtypes of cancers.
Pancreatic cancer can present in a number of different ways. It may present with vague abdominal symptoms such as bloating and discomfort. Pancreatic cancer may also present with pain, jaundice (turning yellow) or even diabetes. The diagnosis is generally made from the patients history, blood tests and specialised imaging such as CT or MRI scans of the pancreas. A biopsy is often required and may be performed by Endoscopic Ultrasound (EUS) or Endoscopic Retrograde Cholangio-Pancreatography (ERCP).
The mainstay of treatment for pancreatic cancer is surgery. There are two main operations that are performed for pancreatic cancer, the most common is a Pancreaticoduodenectomy (Whipple procedure) and the alternative is a Distal Pancreatectomy.
Prior to any surgery, your surgeon will discuss the treatment plan with a group of cancer specialists in a multi-disciplinary team meeting. These meetings discuss the role of chemotherapy, radiotherapy, surgery and other management options in the treatment of any individual patient. Chemotherapy may play a role prior to, after or both before and after surgery, with the approach tailored to the individual. Increasingly chemotherapy (and occasionally radiotherapy) is being used prior to surgery. This is referred to as neoadjuvant treatment.
Pancreatic cysts are becoming increasingly recognised and diagnosed. Pancreatic cysts exhibit a wide variety of behaviour from being completely benign (non cancerous) to lesions that harbour a cancerous component. Some pancreatic cysts will turn into a cancer if left for long enough. Pancreatic cysts are often asymptomatic however may present with symptoms such as abdominal discomfort, weight loss or jaundice (turning yellow). The most common type of pancreatic cyst is a pseudocyst which results from a previous attack of pancreatitis. Other types of pancreatic cysts include a serous cystadenoma (SCA), mucinous cystadenoma (MCA) and Intra-ductal papillary mucinous neoplasm (IPMN). The diagnosis of the type of cyst is normally made via a combination of imaging tests (CT and MRI) and other specialised tests such as an Endoscopic Ultrasound (EUS).
Pancreatitis is inflammation of the pancreas which may be either acute or chronic. There are many causes of acute pancreatitis however the most common causes in our community are gallstone disease and alcohol. Acute pancreatitis is often rapidly self limiting with significant improvement over a few days. Acute pancreatitis, however, can be a life threatening illness and require admission to the Intensive Care Unit (ICU) with a prolonged hospital stay. The management of pancreatitis is based on supportive care until the inflammation in the pancreas settles down. Your doctor will try to determine the cause of the pancreatitis and will most likely suggest having your gallbladder removed if gallstones seem to be the cause. Avoidance of alcohol is important if this has been the triggering factor.
The most common primary cancer of the liver is hepatocellular carcinoma, or HCC. This cancer is related to cirrhosis which may be caused by excessive alcohol, Non-Alcoholic Steato-Hepatitis (NASH, also known as Fatty Liver) or Hepatitis B or C infection.
Colorectal cancer may also spread to the liver (metastasise). This is not a true liver cancer, but represents a large proportion of cancers for which liver surgery is performed in Australia.
In addition to cancer, there are a wide variety of benign conditions that may be detected on imaging performed for other regions and be mistaken for cancer.
The diagnosis of liver tumours is based on a combination of the patient history, blood tests, specialised imaging such as a CT or MRI scan of the liver and only occasionally with a biopsy. Once the diagnosis is made, there are a variety of treatment options available. Surgery is normally the gold standard treatment and, when appropriate, can be performed by either laparoscopy (keyhole surgery) or open surgical approaches.
Liver transplant is a treatment option available for some people with liver cancer who meet certain criteria.
Liver cysts may be found in up to 5% of the population however most liver cysts do not cause symptoms. They are more often found in females and are the most common benign (non cancerous) lesion in the liver. Liver cysts may also be caused by a variety of infections such as Hydatid disease. In general, a simple liver cyst that is not causing symptoms is left alone. Cysts may be removed however if they are causing symptoms or if it is not clear they are benign (non cancerous). The diagnosis of a liver cyst is normally via a combination of the history, blood tests and specialised imaging tests such as a CT or MRI. Liver cysts may be removed via the laparoscopic (key hole) or open technique.
Gastric Cancer is uncommon in Australia but is more common in places such as Japan and Korea. The biggest risk factor in Australia is infection with Helicobacter pylori which is the bacteria that has been shown to cause stomach ulcers. The most common type of gastric cancer is adenocarcinoma which makes up about 95% of cases. The remaining 5% of cases are made up from a variety of other types.
The symptoms of gastric cancer tend to be fairly vague and the diagnosis is made with a gastroscopy (telescope test with a camera passed down the gullet) and a biopsy. The definitive treatment for gastric cancer is surgery, however chemotherapy may play a role in treatment before, after or instead of an operation.
Gastrectomy is the removal of all or part of the cancer-affected stomach along with the lymph nodes where cancer tends to spread to first. The digestive system is then reconstructed by bringing the small intestine up to the remaining oesophagus or upper stomach so that food can pass through the digestive tract.
Oesophageal Cancer is an uncommon cancer in Australia. It is most often associated with long-term reflux and Barrett’s Oesophagus. It is more common in heavy drinkers and heavy smokers, but it is known that after cessation the risk begins to fall.
Symptoms of oesophageal cancer are typically related to difficulty swallowing, initially with solid food and eventually with fluids as well. It is important to understand that difficulty swallowing may also be related to a number of other conditions and people with these symptoms should see their doctor.
After a diagnosis of oesophageal cancer is made, a number of further tests will be performed to help determine the best treatment for an individual patient. These tests may include some or all of, a laparoscopy (keyhole surgery), a repeat gastroscopy (telescope camera test down the gullet), a CT scan and a PET scan. Treatment may include chemotherapy, radiotherapy and surgery, and the treatment will be tailored to each individual patient after discussing their case with a variety of relevant cancer specialists. Oesophagectomy involves removal of the cancer-affected oesophagus and then reconstructing the oesophagus, usually by dragging the stomach up to the remaining oesophagus through a combination of surgery through the abdomen and the chest.
Acute appendicitis is one of the most common diseases requiring surgery seen in patients admitted through the Emergency Department. Approximately 7% of people will be affected by this problem and, although it is most common in teenagers, it is seen in people of any age, from little babies through to people in their 90’s.
The appendix is a small worm shaped extension of the first part of the large bowel (the caecum). Acute appendicitis begins when the appendix becomes blocked at its opening to the bowel, the contents of the appendix do not adequately drain and the worm-shaped organ begins to swell. Eventually, the pressure inside the appendix builds up and the ability of the tiny blood vessels to supply the tissue with oxygen from the blood is compromised and the appendix can become gangrenous. If this occurs then the appendix will eventually perforate, or burst, and this will make the sufferer even more sick.
Typical symptoms of appendicitis come on over 6-24 hours, but are sometimes a little faster or slower. Symptoms tend to include generalised abdominal pain which localises to the right lower corner of the abdomen. Other symptoms include a loss of appetite, fevers, loose bowels and feeling generally unwell. Children (and adults) often report that the pain is worst with sudden movement such as going over bumps in the car.
The only proven treatment for appendicitis is surgery, which is typically performed by laparoscopy (keyhole surgery), although a traditional open operation is sometimes better in small children. There is some evidence that, in certain circumstances, appendicitis may be managed with antibiotics alone, however, there are reasonably high early and delayed failure rates and identifying which patients may get better with antibiotics alone remains a challenge. The standard of care in Australia remains surgery however you may discuss your treatment options with your surgeon. Most people go home the day after their operation.
This is a condition in which the opening in the diaphragm that the oesophagus passes through (the oesophageal hiatus) stretches. This allows the stomach or other organs to slip up and into the chest cavity. These hernias can be categorised into four types:
95% are Type 1 and can often be managed with medications alone. Large hiatus hernias can cause reflux, cardiac (heart) symptoms and respiratory (lung) symptoms. These larger hernias often require repair and this is done with key-hole (laparoscopic) surgery, usually combined with a Fundoplication (see Gastro-Oesophageal Reflux section).
Achalasia is a benign (non-cancerous) condition of the oesophagus that causes difficulty swallowing. It is caused by a problem with the nerves and muscles of the oesophagus that leads to failure of the lower end of the oesophagus to relax with swallowing. This failure prevents the normal passage of food through the lower oesophagus and causes symptoms of dysphagia (difficulty swallowing) or heartburn symptoms similar to reflux. The symptoms usually progress slowly with time and have often been present for years before the sufferer decides to see a doctor for it.
Treatment aims at improving swallowing by decreasing the pressure, or tension, in the lower oesophageal sphincter. This can be achieved by injection of a chemical to relax the muscle, by stretching the muscle fibres (dilation) or by cutting the muscle fibres (myotomy) through either keyhole surgery or a procedure known as Per-Oral Endoscopic Myotomy (POEM).
None of these treatments fix the underlying problem with the nerves, but aim to improve the symptoms which are bothering the individual.