Gastroesophageal reflux disease

What is GORD?

Gastroesophageal reflux disease (GORD) is a more serious form of gastroesophageal reflux (GOR), which is a very common condition. GOR occurs when stomach contents rise up into the oesophagus. GOR is also called acid reflux or acid regurgitation, because digestive juices—called acids—rise up with the food. The oesophagus is the tube that carries food from the mouth to the stomach by the action of peristalsis. The lower oesophageal sphincter (LOS) is a ring of muscle at the bottom of the oesophagus that acts as a valve between the oesophagus and stomach.

When acid reflux occurs, food or fluid can be tasted in the back of the mouth. When reflux occurs, stomach acid touches the lining of the oesophagus it may cause a burning sensation in the chest or throat called heartburn or acid indigestion. Occasional GOR is common and does not necessarily mean one has GORD. Persistent reflux that occurs more than twice a week is considered GORD, and it can eventually lead to more serious health problems. People of all ages can have GORD.

 What are the symptoms of GORD?

The main symptom of GORD in adults is heartburn, also called acid indigestion—burning-type pain in the lower part of the mid-chest, behind the sternum, and in the epigastrium. People may experience symptoms at anytime. They are common at night and people may wake up with symptoms

 What causes GORD?

The precise cause of  GORD remains unclear.  Research has demonstrated that in people with GORD, the LOS relaxes inappropriately while the rest of the oesophagus is working. Anatomical abnormalities such as a hiatus hernia may also contribute to GORD. A hiatus hernia occurs when the upper part of the stomach and the LOS move above the diaphragm. When a hiatus hernia is present, acid reflux can occur more easily. A hiatus hernia can occur in people of any age and is most often a normal finding in otherwise healthy people over age 50. Most of the time, a hiatus hernia produces no symptoms.

Other factors that may contribute to GORD include

Obesity

Pregnancy

Smoking

Common foods that can worsen reflux symptoms include;

Citrus fruits

Chocolate

Caffeine containing drinks or alcohol

Fatty and fried foods

Garlic and onions

Mint flavorings

Spicy foods

Tomato-based foods, like spaghetti sauce, salsa, chili, and pizza

How is GORD treated?

If you have had symptoms of heartburn and have been using antacids or other over-the-counter reflux medications for more than 2 weeks you should see your GP. He or She may decide to refer you to a gastroenterologist, a doctor who treats diseases of the stomach and intestines. Depending on the severity of your GORD, treatment may involve one or more of the following lifestyle changes, medications, or even in very severe cases, surgery.

 Lifestyle Changes

If you smoke, stop.

Avoid foods and beverages that worsen symptoms (see above)

Lose weight if needed.

Eat small, frequent meals.

Avoid lying down for 3 hours after a meal.

Raise the head of your bed 6 to 8 inches by securing wood blocks under the bedposts. Just using extra pillows will not help.

 Medications

Your GP may recommend over-the-counter antacids or medications that stop acid production or help the muscles that empty your stomach (a motility agent). You can buy many of these medications without a prescription.

Antacids, such as Alka-Seltzer or Maalox are usually the first drugs recommended to relieve heartburn and other mild GORD symptoms. Many brands on the market use different combinations of three basic salts—magnesium, calcium, and aluminum—with hydroxide or bicarbonate ions, which help to neutralize the acid in your stomach. Antacids, however, can have side effects. Magnesium salt can lead to diarrhea, and aluminum salt may cause constipation. Aluminum and magnesium salts are often combined in a single product to balance these effects.

Foaming agents, such as Gaviscon, work by covering your stomach contents with foam to prevent reflux.

H2 blockers, such as cimetidine (Tagamet HB), famotidine (Pepcid AC), and ranitidine (Zantac 75), decrease acid production. They are available in prescription strength and over-the-counter strength. These drugs provide short-term relief and are effective for about half of those who have GORD symptoms.

Proton pump inhibitors include omeprazole (losec), lansoprazole (zoton), pantoprazole, rabeprazole, and esomeprazole (nexium), which are only available by prescription. Proton pump inhibitors are more effective than H2 blockers and can relieve symptoms and heal the esophageal lining in almost everyone who has GORD.

Prokinetics help strengthen the LOS and make the stomach empty faster. This group includes domperidone (motilium) and metoclopramide (maxolon). Metoclopramide also improves muscle action in the digestive tract. Prokinetics may have side effects that limit their usefulness—fatigue, sleepiness, depression, anxiety, and problems with physical movement.

People who get heartburn after eating may take both antacids and H2 blockers. The antacids work first to neutralize the acid in the stomach, and then the H2 blockers act on acid production. By the time the antacid stops working, the H2 blocker will have stopped acid production. Your GP or specialist is the best source of information about how to use medications for GORD.

 What if GORD symptoms persist despite medication or I develop side effects with medication?

If your symptoms do not improve with lifestyle changes or medications, you may need additional tests.

 Gastroscopy; the endoscope allows the doctor to see the surface of the oesophagus and search for abnormalities. If you have had moderate to severe symptoms and this procedure reveals injury to the oesophagus, usually no other tests are needed to confirm GORD.

 pH monitoring studies involves the insertion of a small tube into the oesophagus that will stay there for 24 to 48 hours. While you go about your normal activities, the device measures when and how much acid comes up into your oesophagus. This test can be useful if combined with a carefully completed diary, which allows the doctor to see correlations between symptoms and episodes of reflux (low oesophageal pH).

 Surgery

Surgery is an option when medicine and lifestyle changes do not help to manage GORD symptoms.

Fundoplication is the standard surgical treatment for GORD. Usually a Nissen fundoplication, is performed. During the Nissen fundoplication, the upper part of the stomach is wrapped around the LOS to strengthen it and prevent acid reflux, and repair a hiatus hernia.

The Nissen fundoplication may be performed using a laparoscope, an instrument that is inserted through tiny incisions in the abdomen. The doctor then uses small instruments that hold a camera to look at the abdomen and pelvis. When performed by experienced surgeons, laparoscopic fundoplication is safe and effective in people of all ages, including infants. The procedure is reported to have the same results as the standard fundoplication, and people can leave the hospital in 1 to 3 days and return to work in 2 to 3 weeks.

 What are the long-term complications of GORD?

Chronic GORD can cause serious complications. Inflammation of the oesophagus from refluxed stomach acid can damage the mucosa and cause bleeding or ulcers (Oesophagitis). Scarring can lead to strictures—narrowing of the oesophagus—that leads to significant problems with swallowing (dysphagia). Some people develop Barrett’s oesophagus, in which cells in the oesophageal lining take on an abnormal appearance. Over time, the cells can lead to oesophageal cancer. Persons with GORD and its complications should be monitored closely by a physician and are often placed on a surveillance programme, undergoing annual or bi-annual endoscopy whilst being maintained on acid –suppression with a PPI.

Studies have shown that GORD may worsen or contribute to asthma, chronic cough, and pulmonary fibrosis.

Points to Remember

Frequent heartburn, also called acid indigestion, is the most common symptom of GORD in adults. Anyone experiencing heartburn twice a week or more may have GORD.

You can have GORD without having heartburn. Your symptoms could include a dry cough, asthma symptoms, or trouble swallowing. If you have needed to use antacids for more than 2 weeks, it is sensible to see your GP. Most doctors can treat GORD with appropriate acid suppression medication. Your GP may refer you to a gastroenterologist, a doctor who treats diseases of the stomach and intestines. GPs will usually recommend lifestyle and dietary changes to relieve symptoms of GORD. Many people with GORD also need medication. Surgery may be considered as a treatment option.