Gastro-oesophageal Reflux Disease

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.

Symptoms 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:

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.

Patho-Physiology 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.

Diagnosis

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.

What are 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 depression.

The Treatment Options for GORD

Medical Treatment

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 disease.

Surgical Treatment

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.

Last Updated on Thursday, 07 February 2008 22:47