Gastrooesophageal Reflux Disease - GORD

 

What is Gastro-Oesophageal Reflux Disease (GORD) or Acid Reflux?

GORD is the condition in which stomach contents and acid enter into the oesophagus (the gullet). Normally there is a one way valve at the junction between the oesophagus and the stomach. This valve allows food to enter the stomach and prevent it and stomach acid from going back into the oesophagus. When this valve becomes weak or leaky, fluid travels the wrong way into the oesophagus.

How common is it?

GORD is very common, affecting about 20% of adults in Australia.

What are the Symptoms of GORD?

The classic symptoms are:

•  Heartburn: This is a burning sensation at the lower end of the sternum ( breast bone) caused by inflammation of the lining of the oesophagus due to the acid.
• Regurgitation:  This is the return of fluid or food back into the mouth leading to sour or bitter taste in the mouth. This happens particularly when bending forward.

Other non-typical symptoms can occur without heartburn, these include:

• Chest pain that resembles  a heart attack
• Hoarseness of voice in the morning caused by acid reaching the vocal cords (voice box)
• Troubles with swallowing: feeling food getting stuck in the throat or gullet
• A bad breath
• Acid damage to the teeth
• Severe coughing episodes and chocking sensation at night
• Recurrent asthma attacks
• Recurrent chest infections (pneumonia)

What Causes GORD?

1. Weakness of the valve at the lower end of the gullet can occur without a cause however there are several factors that increase the risk:
2. Hiatus hernia: This occurs when part of the stomach slides into the chest through an abnormally large opening in the diaphragm.
3. Obesity
4. Pregnancy
5. Smoking and Alcohol (particularly wine)
6. Certain foods: e.g chocolate, spearmint, peppermint, fatty food, cheese, cola, tomatoes and citrus juice.
7. Certain medications: e.g. oral contraceptives,  theophillyine, calcium channel blockers, steroids,  and aspirin.
8. Bad eating habits: e.g. eating or drinking lots of fluids just before going to bed.
9. Connective tissue disorders e.g. scleroderma
10. Poor emptying of the stomach into the intestine: this can occur because of poor contraction of the stomach as in long lasting diabetes or because of blockage to the stomach by a stomach ulcer or tumour.

What happens if GORD is left untreated?

Untreated severe GORD can lead to several complications.

1. Reflux oesophagitis: this is inflammation in the lower end of the oesophagus.
2. Ulceration
3. Bleeding this can lead to anaemia
4. Stricture formation: this is scaring and narrowing in the lower end of the oesophagus from chronic ulcers. It causes difficulty in swallowing.
5. Recurrent chest infections (pneumonia)
6. Barrett's oesophagus: this is a change in the type of cells lining the oesophagus. It can lead to cancer.
7. Oesophageal cancer

Do I need any investigations for GORD prior to treatment?

The presence of heartburn or regurgitation is often enough to start treatment. However certain patients need to undergo investigations:

1. patients with non-typical symptoms or
2. patients with symptoms of complications e.g. bleeding or difficulty on swallowing
3. patients who do not improve with medical treatment
4. patients who relapse after medical treatment
5. patients whose symptoms change while on treatment

What are the tests for GORD?

·         Gastroscopy: This is a simple procedure done under sedation where a thin flexible telescope -like is inserted down the throat into the stomach.  This is done as day surgery to look for evidence of GORD and exclude its complications and conditions that resemble GORD like stomach or duodenal ulcers or cancer.

Patients who fail medical treatment are being considered for surgery may have further tests:

• 24 hour oesophageal pH study: This done with a special tube that positioned into the gullet to measure the acidity level.
• Oesophageal Manometry: This is a measurement of the pressure at different levels in the oesophagus. This is done to confirm the diagnosis and exclude medical conditions like achalasia. It may also help tailor the surgery for each patient.

How is GORD treated?

Most patients respond well to a combination of lifestyle changes and medical treatment.

Lifestyle changes

• Stop smoking
• Do not drink alcohol
• Lose weight if obese
• Eat smaller meals and avoid food that brings heartbrun
• Do not eat or drink for three hours before going to bed
• Wear loose-fitting clothes
• Raise the head of the bed with 8 inches blocks under the bedposts. Using extra pillows will not help.

Medical Treatment

There are several classes of drugs to help reflux

• Antacids, such as Mylanta, QuickEase, and Gavidcon. These can be bought without a script and are taken when needed. They work by neutralizing the acid of the stomach so when reflux occurs, it does not burn the lining of the oesophagus.
• H2 Blockers, such as Zanatac and Pepcidine. These decrease acid production by the stomach. They work for short period of time and are effective in half of the patients with GORD. Many people benefit from taking them at bedtime in combination with a proton pump inhibitors.
• Proton pump inhibitors, such as Somac, Pariet and Nexium. These are more effective than H2 blockers and work by stopping acid production by the stomach. They relieve symptoms in almost all patients with GORD.
• Prokinetics, such as Motilium and Maxalon. These may be useful in combindation with proton pump inhibitors for some patients for short term use. They work by making the stomach and  to empty faster. They are associated with side effects and drug interactions and therefore are not for long term use.

 When to consider surgery for GORD?

A combination of lifestyle changes and medical treatment is effective for most patients.  However, surgery should be considered if:

1. Failure of maximum medical treatment to control symptoms;
2. A patient decides not to take medications on a long term basis
3. Patients who develop a complication of GORD.
4. Patients who cannot take medications due to serious side effect.
5. Patients with "volume reflux", this is the continual regurgitation of food and fluid into the back of the throat. Medical treatment is effective in making the refluxing fluid not acidic but it does not stop fluid from going the wrong way into the oesophagus.
6. Patients with recurrent respiratory complications e.g. chest infections, night cough and asthma.