Gastro-oesophageal Reflux Disease (GORD) is a
common condition, and one of the most frequent causes of indigestion and heartburn.
It occurs when acid from the stomach regurgitates into the oesophagus
(gullet). This irritates and damages the delicate lining of the oesophagus.
Normally the sphincter, a muscle at the junction between the oesophagus and
stomach, tightens up to stop acid refluxing into the gullet. Acid reflux
occurs when this sphincter does not work very well, or when the stomach is
very full (for example, after a large meal). The oesophagus can cope with a
small amount of stomach acid, and some people are more sensitive to it than
others. Most of us experience acid reflux from time to time as heartburn or
indigestion. However, if acid refluxes a lot it can damage the sensitive
lining of the oesophagus. This is when simple heartburn becomes GORD. If the
damage to the oesophagus leads to inflammation (soreness and swelling), this
is called oesophagitis. You can have GORD with or without having
oesophagitis, but the longer your acid reflux is untreated, the more likely
you are to have damage to your oesophagus and develop oesophagitis.
of Gastro-oesophageal Reflux Disease (GORD)
The main symptom of GORD is heartburn. Heartburn
is a form of indigestion. It is usually felt as a burning pain behind the
breastbone (in the front of your chest, over the heart), and occurs when
stomach acid damages the inside of the gullet (oesophagus). Heartburn often
occurs after a meal when the stomach is full, or when one lies down, which
allows acid to flow upwards more easily. Heartburn is more common in smokers,
and people who are overweight or pregnant.
Other symptoms of GORD can include:
Pain/difficulty in swallowing
If you are very sensitive to acid, you can
develop symptoms without much reflux. However, some people are less affected
by acid, and can have a lot of reflux without showing many symptoms.
of Acid Reflux
There is a sphincter (diaphragm muscle) at the
junction between your stomach and the oesophagus. It relaxes to let food into
your stomach but then tightens to stop stomach acid coming back up into your
oesophagus. In some people, the sphincter does not work very well, and this
causes acid reflux. Having a hiatus hernia can also cause poor sphincter
control. In this type of hernia, part of the stomach pokes through the
diaphragm which is the main breathing muscle under the lungs. The muscles in
the diaphragm are then stretched and don’t allow the sphincter to close, so
acid can escape from the stomach back up into the oesophagus. Smoking relaxes
the sphincter muscles, so makes acid reflux more likely. Some people find
that particular foods, such as fatty foods, chocolate, or oranges, relax the sphincter,
while others such as coffee and tomatoes directly irritate the oesophagus.
If you have the typical symptoms of GORD and acid
reflux your GP will make a diagnosis based on your symptoms without any
tests. If you have severe or unusual symptoms, or if they do not get better
when treatment is started, you may need to have some tests. These may
include: 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, 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, 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 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.
the Risks of inadequate management of GORD?
If you have severe inflammation of the
oesophagus, it can cause scarring and narrowing at the lower end of the
oesophagus. This is called stricture and can lead to problems with food
sticking when you swallow. It is quite rare and can be treated with surgery,
but you should tell your doctor if you have pain or difficulty swallowing.
Oesophagitis (inflammation of the oesophagus) can
lead to the formation of painful ulcers inside your oesophagus. These may
bleed and can lead to anaemia, due to blood loss.
People who have acid reflux frequently, over a
long period of time, also have a slightly increased risk of developing cancer
of the oesophagus. Some people who have GORD find that it greatly affects the
quality of their life. This can lead to mental health problems such as
The Treatment Options for GORD
The following treatment options are available for
people with GORD or oesophagitis:
Proton Pump Inhibitors, for example,
esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole.
Proton Pump Inhibitors (PPIs) reduce the amount of acid produced by your
stomach, and are usually the first line treatment for GORD. PPIs work quickly
and effectively. A six weeks course is normally enough to clear up the
symptoms. Sometimes a further month of treatment is needed, or if symptoms
are severe, a one month course at double the strength may be prescribed. It
is common for symptoms to come back within a year – you can treat these with
further courses of PPI. Alternatively, you can take a low dose of the PPI all
the time to control your symptoms. If you have complicated oesophagitis or
GORD, (for example, with a history of strictures, ulcers and/or haemorrhage),
a higher strength PPI may be used all the time.
H2 receptor antagonists, for example, cimetidine,
famotidine, nizatidine, ranitidine.
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.
Motility stimulants for example, domperidone, metoclopramide. 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.
Alginates and Antacids
Alginates and antacids are usually available without a prescription.
Alginates contain a foaming agent that forms a layer that floats on top of
your stomach contents. This stops the reflux of stomach acid and protects
your oesophagus lining. Alginates are best taken when symptoms occur, such as
after meals and at bedtime, so the foam layer can form on top of your stomach
contents when you aren’t going to be eating again for a while. Antacids such
as magnesium trisilicate, magnesium hydroxide and aluminium hydroxide
neutralise the acid in your stomach (make it less acidic). They are also best
taken when symptoms occur, such as after meals and at bedtime. Although
evidence for their effectiveness has been limited general measure like
cessation of smoking, weight loss, propping up the bed-head and avoiding
foods like coffee, alcohol, fatty foods and NSAID’s have traditionally helped
patients. H2 receptor antagonists are associated with an overall healing rate
of 50% in oesophagitis falling to 20-40% in severe disease. PPI’s achieve a
70%-90% healing rate. Endoscopic follow-up after initial treatment of
patients with mild oesophagitis has shown that about half heal and have no
further episodes of oesophagitis while a quarter progress to more severe
Surgery to prevent reflux which is increasingly
performed using the laparoscopic approach improves oesophagitis and can
control symptoms in around 90% of people. The patho-physiology of reflux is
centred on the lower oesophageal sphincter incompetence and recent evidence
indicates that the diaphragmatic crural fibres surrounding the oesophageal
hiatus act as an external sphincter in concert with the intrinsic lower
oesophageal sphincter in avoiding reflux. Surgical treatment would appear
logical as it aims at re-enforcing this mechanism rather than decreasing acid
production in the stomach.
Advantage of Surgery for Reflux disease:
The potential advantages of Nissen fundoplication include removing the need
for life long medication and an excellent success rate which does not
decrease significantly with time. DeMeester, reported 91% of patients had
their symptoms controlled 10 years after surgery. Laparoscopic approach
offers a better cosmetic result, quicker recovery, shorter hospital stay and
a quicker return to work. One has to however consider these benefits along
side the small but measurable risk of complications from this procedure.
Indications for Surgery:
Patients that should be considered for surgical treatment are:
· Those with a poor response to medical treatment where failure to
suppress acid reflux is confirmed
· Persisting Volume reflux
· Regurgitation of gastric contents occurring especially at night with
risks of aspiration
· Difficult benign strictures
· Patient choice especially those requiring long term maintenance
treatment, including patients with Barrett’s oesophagus
Keyhole surgery, also known as laparoscopic
fundoplication surgery – for this procedure, small incisions are made and a
small camera (telescope) is passed into the abdomen to let the surgeon view
the affected area. Fine instruments are used to tighten up the sphincter
muscle between the oesophagus and stomach. The patients are discharged within
48 hours of the procedure which is carried out under a General Anaesthetic.
Patients do have difficulty in swallowing soon after the operation which
improves with time. Not all patients are suitable for surgery and it is
important to discuss this with your consultant. Studies that have been
carried out show that surgery can have many benefits for people who have
GORD, particularly those who have chronic symptoms. Surgery can help reduce
acid reflux, make heartburn less severe, and can also make the lining of the
oesophagus less acidic.