Gastroesophageal reflux disease (GORD) / Acid Reflux

Definition

Gastro-oesophageal reflux disease (GORD) is defined as reflux of gastroduodenal contents into the oesophagus, causing symptoms that are sufficient to interfere with quality of life. People with GORD often have symptoms of heartburn and acid regurgitation.

The oesophagus carries food from the mouth to the stomach. The lower oesophageal sphincter is a ring of muscle at the bottom of the oesophagus that acts like a valve between the oesophagus and stomach.

Gastro Oesophageal reflux disease, or GORD, is a chronic disease that occurs when the lower oesophageal sphincter does not close properly and stomach contents leak back, or reflux, into the oesophagus.

When refluxed stomach acid touches the lining of the oesophagus, it causes a burning sensation in the chest or throat called heartburn. The fluid may even be tasted in the back of the mouth, and this is called acid indigestion. Occasional heartburn is common but does not necessarily mean one has GORD. Heartburn that occurs more than twice a week may be considered GORD, and it can eventually lead to more serious health problems.

Anyone, including infants, children, and pregnant women, can have GORD.

Incidence / Prevalence

Surveys from Europe and the USA suggest that 20–25% of the population have symptoms of GORD, and 7% have heartburn daily.

What causes GORD/Acid reflux

Obesity is reported to be a risk factor for GORD. Smoking and alcohol are also thought to predispose to GORD. It has been suggested that some foods, such as coffee, mints, dietary fat, onions, citrus fruits, or tomatoes, may predispose to GORD. Drugs that relax the lower oesophageal sphincter, such as calcium channel blockers, may promote GORD and there may be a genetic predisposition to GORD.

• Hiatal hernia- hiatal hernia occurs when the upper part of the stomach is above the diaphragm, the muscle wall that separates the stomach from the chest
• Alcohol use
• Overweight
• Pregnancy
• Smoking

Symptoms

The main symptom of GORD is heartburn. Heartburn often happens after a meal when your stomach is full, or when you lie down, which allows acid to flow upwards more easily. Heartburn is more common if you are a smoker, overweight or pregnant.

Other symptoms of GORD can include:

• An acidic, sour taste in your mouth
• Burning pain in your throat
• Bloating and belching
• Stomach pains
• Burning pain in your throat and oesophagus when you swallow hot drinks
• Regurgitating food (when food comes out of your stomach and back up your oesophagus)
• Nausea and vomiting, and
• Vomiting blood

Diagnosis

1. Endoscopy - a thin tube with a microscope on the end is passed down your oesophagus towards your stomach. It enables doctors to see whether the inside of your oesophagus is red and inflamed.
   
   
2. Acidity test on the inside of the oesophagus – the test is performed for a 24-hour period and involves a thin wire being passed through your nose and into your oesophagus. The wire measures how acidic your oesophagus is and displays the results electronically.
   
   
3. Barium swallow – a substance called barium, which shows up white on an X-ray, is swallowed to enable doctors to identify any abnormalities in your oesophagus. or
   
   
4. Radiolabelled technetium – in some hospitals radioisotope imaging may be used to demonstrate gastro-oesophageal reflux. The technique uses very small doses of technetium-sulphur colloid to help confirm a diagnosis.

Prognosis

GORD is a chronic condition, with about 80% of people relapsing once medication is discontinued. Many people therefore require long term medical treatment or surgery.

Aims of intervention

To relieve reflux symptoms, increase healing rates, and reduce the complications of GORD, such as stricture formation; to improve quality of life; to minimise adverse effects of treatment.

Treatment

Conservative treatment

• Life style modification
• Medications including antacids, Foaming agents, H2 receptor blockers, Proton Pump inhibitors

Medical Treatment

1. Proton Pump Inhibitors - Proton Pump Inhibitors (PPIs) reduce the amount of acid produced by your stomach, and are usually the first treatment for GORD. Omeprazole is the only type that is available without a prescription, and is mainly used for the short-term treatment of indigestion.
   
   
2. H2 receptor antagonists - H2 receptor antagonists also reduce the amount of acid produced by your stomach. However, PPIs tend to be used more commonly to treat this condition.
   
   
3. Motility stimulants - These medicines speed up the rate at which your stomach empties. They also improve the squeezing of the sphincter muscle, to help stop stomach contents being brought back up into your oesophagus. Motility stimulants are normally used as an additional treatment to reduce symptoms such as bloating and a feeling of fullness soon after you start a meal.
   
   
4. Alginates and Antacids - Alginates and antacids are usually available without a prescription and are best taken when symptoms occur, such as after meals and at bedtime.

Surgical Treatment - ‘Fundoplication’

If medicines do not help to control the symptoms of GORD, surgery may be considered. The operation is called ‘Fundoplication’. The aim of surgery is to make it harder for stomach contents to re-enter your oesophagus so that there is less reflux.

A number of different surgical procedures are available. You should discuss the alternatives with your specialist so that you are fully aware of what is required and understand the pros and cons of each procedure. The two main types of procedure are:

• Open anti-reflux surgery – where a large incision (cut) is made to allow the surgeon to gain access to your oesophagus, and
  
  
• Keyhole surgery, also known as laparoscopic surgery – for this procedure, a small incision is made and a small camera (telescope) is passed down your oesophagus to let the surgeon view the affected area.

What does ‘fundoplication’ involve?

Where there is a hiatus hernia, the surgeon will bring the stomach back into its original position under the diaphragm, then wrap the upper few centimetres of the stomach around the oesophagus to make a new valve. This prevents acid reflux and heartburn recurring. Permanent stitches are used to keep the stomach in place.

Prevention

There are some lifestyle changes you can make to help prevent GORD developing, or stop simple heartburn turning into GORD. These include:

• Quitting smoking
• Avoiding foods that you find bring on heartburn
• Eating small, regular meals
• Changing your medication if you think it could be causing symptoms. Make sure you speak to your GP before stopping or starting any medication
• If you are overweight try losing weight, to reduce pressure on your stomach
• Avoid altering your posture – don’t wear tight belts and waistbands, and try not to leaning forward a lot during the day, and
• If you have symptoms at night, try not eating three hours before bed, and not drinking two hours before. If you must have a drink, sip water or milky drinks, and avoid caffeine