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Gastroesophageal Reflux Disease: Oh dear GORD

Introduction

Gastrooesophageal reflux disease (GORD) is a chronic digestive disorder that affects the lower oesophageal sphincter (LES), the ring of muscle between the oesophagus and the stomach. The LES normally acts as a one-way valve that allows food and liquid to pass from the oesophagus into the stomach, but prevents them from flowing back into the oesophagus. However, in people with GORD, the LES is weakened or relaxes abnormally, allowing stomach acid and sometimes bile to reflux or flow back into the oesophagus. This can cause irritation, inflammation and damage to the lining of the oesophagus, as well as various symptoms and complications.

Causes and Risk Factors

The exact cause of GORD is not fully understood, but several factors may contribute to its development or worsen its symptoms. These include:

  • Hiatal hernia: a condition where the upper part of the stomach bulges through an opening in the diaphragm, which can weaken the LES and increase the pressure in the abdomen.

  • Obesity: excess weight can put pressure on the abdomen and the LES, making reflux more likely.

  • Pregnancy: hormonal changes and increased abdominal pressure can affect the function of the LES and cause reflux.

  • Connective tissue disorders: some diseases that affect the connective tissue, such as scleroderma, can cause abnormalities in the oesophagus and the LES.

  • Delayed stomach emptying: conditions that slow down or impair the movement of food from the stomach into the intestine, such as diabetes or gastroparesis, can increase the risk of reflux.

  • Smoking: tobacco use can damage the mucous membranes of the oesophagus, reduce saliva production, relax the LES and increase stomach acid production.

  • Alcohol: alcohol consumption can relax the LES, increase stomach acid production and irritate the oesophageal lining.

  • Medications: some drugs, such as aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), certain antibiotics, calcium channel blockers, nitrates and some asthma medications, can affect the function of the LES or increase stomach acid production.

  • Diet: certain foods and beverages can trigger or worsen reflux symptoms by relaxing the LES, increasing stomach acid production or irritating the oesophageal lining. These include fatty or fried foods, spicy foods, chocolate, mint, citrus fruits, tomatoes, coffee, tea and carbonated drinks.

 

Symptoms and Complications

The most common symptom of GORD is heartburn, a burning sensation in the chest or throat that usually occurs after eating or lying down. Other symptoms may include:

  • Regurgitation: a sour or bitter taste in the mouth or throat due to refluxed stomach contents.

  • Dysphagia: difficulty swallowing or a feeling of food stuck in the throat or chest.

  • Globus sensation: a feeling of a lump in the throat that is not caused by a physical obstruction.

  • Chest pain: a sharp or dull pain in the chest that may mimic a heart attack.

  • Hoarseness: a change in voice quality due to irritation of the vocal cords by refluxed acid.

  • Cough: a chronic or persistent cough that may be worse at night or when lying down.

  • Asthma: worsening of asthma symptoms or new onset of asthma due to aspiration of refluxed acid into the lungs or stimulation of nerve reflexes in the esophagus.

If GORD is left untreated or poorly controlled, it can lead to serious complications such as:

  • Oesophagitis: inflammation and ulceration of the oesophageal lining that can cause bleeding, pain and scarring.

  • Barrett’s esophagus: a precancerous condition where normal squamous cells in the lower part of the esophagus are replaced by abnormal columnar cells that are more resistant to acid damage. This increases the risk of developing esophageal adenocarcinoma, a type of cancer that affects the glandular cells of the esophagus.

  • Esophageal stricture: narrowing of the esophagus due to scar tissue formation that can interfere with swallowing and require dilation or surgery.

  • Esophageal cancer: a malignant tumour that grows in the esophagus and can cause difficulty swallowing, weight loss, bleeding, pain and other symptoms.

Diagnosis

The diagnosis of GORD is usually based on the medical history, physical examination and response to treatment. However, some tests may be performed to confirm the diagnosis, rule out other conditions, evaluate the severity of the disease or detect complications. These tests include:

  • Upper GI endoscopy: a procedure where a thin, flexible tube with a light and camera (endoscope) is inserted through the mouth into the esophagus and stomach to visualise the inner lining and take tissue samples (biopsy) if needed.

  • Ambulatory acid (pH) probe test: a test that measures the amount and duration of acid exposure in the esophagus by using a monitor that is attached to a catheter or a clip that is placed in the esophagus during an endoscopy. The monitor is connected to a small computer that is worn around the waist or over the shoulder for 24 to 48 hours.

  • X-ray of the upper digestive system: an imaging test that uses a contrast agent (barium) to coat and fill the esophagus and stomach and produce a silhouette of the structures on an X-ray film.

  • Esophageal manometry: a test that measures the pressure and movement of the esophagus by using a catheter with sensors that is inserted through the nose into the esophagus.

  • Transnasal oesophagoscopy: a procedure where a thin, flexible tube with a video camera is inserted through the nose into the esophagus to look for any damage.

Treatment

The treatment of GORD aims to relieve symptoms, heal the esophageal lining and prevent complications. The treatment options include lifestyle changes, medications and surgery.

 

Lifestyle changes are often the first line of treatment and can help reduce or prevent reflux episodes. These include:

  • Losing weight if overweight or obese.

  • Eating smaller and more frequent meals.

  • Avoiding foods and drinks that trigger or worsen reflux symptoms.

  • Not lying down within three hours after eating.

  • Elevating the head of the bed by six to eight inches or using a wedge pillow to keep the upper body at an angle.

  • Quitting smoking and limiting alcohol intake.

  • Wearing loose-fitting clothing that does not constrict the abdomen.

 

Medications are usually prescribed to reduce stomach acid production or neutralise it, as well as to protect the esophageal lining from damage. These include:

  • Antacids: over-the-counter drugs that contain aluminium, magnesium, calcium or simethicone and act by neutralising stomach acid and providing quick relief. However, they may cause side effects such as diarrhoea, constipation, gas or kidney problems if used excessively or for a long time.

  • H2 blockers: drugs such as cimetidine, ranitidine, famotidine or nizatidine that block the action of histamine, a chemical that stimulates acid secretion in the stomach. They can provide longer relief than antacids, but may lose their effectiveness over time or interact with other medications.

  • Proton pump inhibitors (PPIs): drugs such as omeprazole, lansoprazole, pantoprazole, rabeprazole, esomeprazole or dexlansoprazole that inhibit the enzyme that produces acid in the stomach. They are more effective than H2 blockers in healing esophagitis and preventing complications, but may cause side effects such as headache, diarrhoea, nausea, abdominal pain or increased risk of infections or fractures if used for a long time or at high doses.

  • Prokinetics: drugs such as metoclopramide or domperidone that enhance the movement of food from the stomach into the intestine and strengthen the LES.

Surgery is considered as a last resort for people who have severe or persistent symptoms that do not respond to medications or lifestyle changes, or who have complications such as Barrett’s esophagus or esophageal stricture. The most common surgical procedure for GORD is called fundoplication, where the upper part of the stomach is wrapped around the lower part of the esophagus to reinforce the LES and prevent reflux. This can be done through open surgery , laparoscopic or robotically (using small incisions and instruments). Another surgical option is called LINX surgery, where a ring of magnetic beads is placed around the LES to keep it closed but allow food to pass through. Both procedures have advantages and disadvantages and may require lifelong follow-up and medication use.

 

Conclusion

GORD is a common and chronic digestive disorder that can cause various symptoms and complications if left untreated. The diagnosis and treatment of GORD depend on the severity and frequency of symptoms, the presence of complications and the response to lifestyle changes and medications. Surgery may be an option for some people who do not benefit from other treatments. The goal of treatment is to improve the quality of life and prevent long-term damage to the esophagus.

Acknowledgement : https://www.mayoclinic.org/diseases-conditions/gerd/symptoms-causes/syc-20361940

Author

Dr Nikhil Nanjappa M.S., FRCS Ed., M.IPD Ed., M. FST Ed., has recently returned from the United Kingdom after serving as a Consultant Surgeon at St. James’s University Hospital, Leeds. He is a consultant surgical gastroenterologist and a colorectal surgeon in Mysore. He is known for his extensive gastrointestinal, colorectal, laparoscopic, robotic and emergency general surgery expertise.

For appointments visit www.drnikhilnanjappa.com or call 91081 27867