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Gastro-oesophageal Reflux (GORD)

Dr Duminda Subasinghe

Dr Naveen Wijekoon

Professor Nandadeva Samarasekera

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Preface Heartburn due to gastro oesophageal reflux is a very common presentation to hospitals. It may cause significant anxiety among patients and their families since it may mimic some serious medical conditions. Even though it is a relatively benign condition, it can seriously affect the life style of these individuals. Therefore our aim in producing this booklet is to educate the reader about the important aspects of this common entity.

Dr Duminda Subasinghe MBBS(Colombo) Dr Naveen Wijekoon MBBS(Colombo)

Professor Nandadeva Samarasekera MBBS(Colombo) MS MD(East Anglia) FRCS(Eng) FRCS(Edin)

Department of Surgery Faculty of Medicine University of Colombo

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What is Gastro Oesophageal Reflux Disease (GORD)?

Gastro oesophageal reflux disease (GORD) is a common disorder related to the gastrointestinal tract. In this condition, there is movement (or reflux) of stomach contents back up into the oesophagus. When we eat, food passes down the oesophagus into the stomach. There is a ring of muscle called a “sphincter” at the junction between the oesophagus and stomach (acting as a one way valve). This relaxes to allow food down, but then normally tightens up and stops food and acid leaking back up (refluxing) into the oesophagus. If this muscular ring becomes weak, reflux can occur.

A diagram showing the upper gastrointestinal tract

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Most normal people experience acid reflux from time to time. When the frequency of acid reflux is much greater than normal or complications develop, the condition is known as gastro -oesophageal reflux disease (GORD).

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What are the symptoms? Most people have a little reflux from time to time. However, if reflux happens more often than normal, this may lead to the development of symptoms. (Please remember that having these symptoms does not necessarily mean that you have GORD).

Heartburn – A burning feeling arising from the lower chest or upper abdomen & moves up towards the neck. This is the main symptom of this condition & is worse after rich meals, citrus fruits, hot beverages or alcohol and also by bending

forward.

Regurgitation of food into the mouth -

This often leaves a bitter taste in the mouth

Chest pain

wheezing

Sore throat or dry cough due to acidic stomach contents

irritating the throat

Hoarseness or change in voice

Difficulty in swallowing

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What are the causes?

The exact cause of this condition is complex and not completely understood. The two main causes are;

1. Poor sphincter control 2. Pressure on the stomach

Poor sphincter control

There is a muscular sphincter at the junction between the stomach and the oesophagus. It relaxes and lets food into the stomach but then tightens to stop stomach acid coming up into the oesophagus. In some people, the sphincter does not work in this manner, and this causes acid reflux. There can be several reasons to have a malfunctioning sphincter.

Hiatus hernia - in this type of hernia, part of the stomach comes through the diaphragm. The muscles in the diaphragm are then stretched, and it does not allow the sphincter to close properly.

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Smoking - relaxes the sphincter muscles.

Certain foods

Some medicines – e g. - Diazepam they can make GORD worse by relaxing the sphincter.

Congenital - Some people are born with a naturally weak sphincter

Fatty food Spicy food

Types of Food contributing to

GORD

Chocolate

Citrus fruits

Coffee

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Stricture (narrowing in the

oesophagus)

Pressure on the stomach

Acid reflux can also happen when there is a lot of pressure on the stomach forcing the stomach contents up into the oesophagus.

This can occur

After a heavy meal

during pregnancy,

when you wear tight clothes

Bending forward.

What are the long term complications?

Most of patients with this condition do not develop serious complications, especially when adequate treatment is taken. However, a number of serious complications can arise in patients with severe GORD.

Ulcers - Ulcers can form in the oesophagus as a result of damage to its inner lining from acid that comes from the stomach

Stricture - Damage from acid can cause the oesophagus to narrow, causing a blockage (stricture) that causes food to get stuck.

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Lung and throat problems - Some patients have acid reflux into the throat causing a sore throat or a hoarse voice. The acid can be inhaled into the lungs and cause a type of pneumonia (aspiration pneumonia) or symptoms of asthma. Chronic acid reflux into the lungs may even cause permanent lung damage.

Barrett's oesophagus- In this condition the cells that line the lower oesophagus is replaced by a different type of cells. The changed cells are more prone than usual to become cancerous. As a result, patients with Barrett's oesophagus are advised to have a periodic endoscopy to monitor for early warning signs of cancer.

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Endoscopic view of Barrett’s oesophagus (arrows indicate the abnormal lining due to acid reflux)

Cancer – In longstanding GORD the risk of

developing cancer of the oesophagus is slightly increased

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Oesophageal cancer (Endoscopic view)

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How is it diagnosed? Gastro-oesophageal reflux disease is usually diagnosed based upon symptoms and the response to treatment. Specific testing is only required, if symptoms are severe, symptoms do not improve with treatment or are not typical of GORD. These tests include;

upper gastrointestinal endoscopy- Endoscopy is the commonest test performed. A thin, flexible telescope with a camera is passed down the oesophagus into the stomach. This allows a doctor to look inside. Damage to the lining of these structures can be evaluated and samples of tissue (biopsies) can be taken to determine the extent of tissue damage.

In a few patients two additional tests may be required.

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Oesophageal manometry This involves swallowing a tube that measures the muscle contractions of the oesophagus to determine whether the lower esophageal sphincter is functioning properly.

24-hour oesophageal pH study

This is the most sensitive test for the diagnosis of GORD. This measures the frequency and duration of stomach acid that is refluxed into the oesophagus during a 24-hour period. It is usually reserved for patients whose diagnosis is unclear after endoscopy or a trial of treatment. It is also useful for patients who continue to have symptoms despite treatment.

The test involves swallowing a thin tube, which is left in the oesophagus for 24 hours. During this time the patient has to keep a diary of symptoms. The tube is attached to a small device that measures how much stomach acid is reaching the oesophagus.

What are the treatment methods of GORD?

There are 3 main aspects of managing a patient with GORD.

1. Life style changes 2. Drug therapy 3. Surgery

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Life style changes

Stop smoking.

Stop taking Alcohol

Avoid foods like- tomatoes, chocolate, spicy foods, hot drinks, coffee

Avoid eating just before going to sleep

Avoid medicines like - Ibuprofen or aspirin

Avoid wearing tight clothes

Lose weight

Raise the head of the bed by 4 to 8 inches

Drug therapy

If symptoms persist after these life style changes, drug therapy may be required.

Antacids

They are alkali liquids or tablets that neutralize the acid in the stomach. These usually give quick relief.

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Acid-suppressing medicines

Two groups of medicines are used –

1. Proton pump inhibitors (PPIs)- Omeprazole, Lansoprazole, Pantoprazole, Rabeprazole, Esomeprazole

2. Histamine receptor blockers (H2 antagonists) Cimetidine, Famotidine, Nizatidine, and Ranitidine.

They work in different ways but both reduce (suppress) the amount of acid that the stomach makes.

Prokinetic medicines

These are medicines that speed up the passage of food through the stomach. They include Domperidone and Metoclopramide.

They are not commonly used. Surgery

Those patients who do not respond well to lifestyle changes or medications, or those who continually require medications to control their symptoms may have to undergo surgery. During the operation the lower oesophageal valve is strengthened thereby preventing reflux of acid into the

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oesophagus. During this surgery, upper part of the stomach is wrapped around the lower oesophagus and the opening through which the oesophagus enters the abdominal cavity is narrowed.This is called fundoplication.This can be done as a laparascopic surgery (keyhole surgery).

Steps of fundoplication surgery

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IMPORTANT THINGS TO REMEMBER!

• Heart burn, regurgitation of the food, bitter taste in the throat are the common symptoms

• Having these symptoms occasionally does not mean that you are having the disease

• GORD symptoms can be controlled by life style changes

• Stop smoking /alcohol, spicy foods, tomatoes etc.

• Number of serious complication can arise in patients with severe GORD ( e.g.-cancer of the oesophagus)

• You have to undergo specific tests, if you are having severe symptoms

• In those, who not respond to life style changes, drugs can be used to control the disease

• Final option of treatment is Surgery