Gastro-oesophageal reflux disease (GORD)

Dyspepsia: upper abdominal discomfort/pain, often described as burning, heaviness or ache, often related to eating and may be accompanied by other symptoms such as nausea, fullness or belching.

GORD: reflux of gastric contents into the oesophagus, causing symptoms such as heartburn and acid regurgitation.

Background/Epidemiology

•  More common in men than in women
• Around 25% of adults experience heartburn and 5% have daily symptoms
  • Around a quarter of these patients will see a doctor.
• More common in patients with asthma and more common in overweight individuals

Aetiology

• Reduced lower oesophageal sphincter tone
• Increase abdominal pressure
• Smoking, alcohol, fatty foods, coffee
• Pregnancy
• Obesity
• Tight clothes/big meals
• Hiatus hernia; systemic sclerosis and post oesophageal surgery for achalasia

Presentation

• Heartburn/dyspepsia
  • Discomfort/pain may be epigastric, retrosternally or in the throat
  • Related to meals, and often made worse by lying down, stooping, straining etc
  • It may be relieved by certain drinks e.g. milk, or by antacids
• Other symptoms include
  • “Acid brash”- acid reflux causing an acidic ‘taste’ in the back of the mouth
  • “Water brash”- essentially excess salivation (response of the salivary glands in response to acid in the gullet)
  • Odynophagia (painful swallowing) or dysphagia (feeling that the food is stuck in the gullet)
  • Food or acid reflux
• Atypical features include
  • Chest pain- may be severe.  GORD can often mimic ACS, particularly in older patients
    • thought to perhaps be due to oesophageal spasm
  • Chronic hoarseness of the voice
  • recurrent chest infections
  • Chronic cough
  • Wheeze/shortness of breath
• Examination is usually normal if symptoms are not present at the time.  They may or may not have a ‘tender’ epigastric area (palpation may worsen symptoms).

Differential Diagnosis

• Peptic ulcer disease
• Drugs e.g. NSAIDs
• Infection (esp immunocompromised patients)
• Oesophageal spasm
• GI cancers

Investigations

• Bloods: FBC (?anaemia – peptic ulcer; leucopenia- infection
• NB Many patients in whom there is a high clinical suspicion of GORD won’t require endoscopy, but for those with severe/problematic disease, or with red flag symptoms e.g. weight loss, dysphagia, anaemia, etc- further investigations may be used
• Endoscopy is investigation of choice (NB can be normal)
  • NB This investigation may not show any abnormality (e.g. oesophagitis).  This DOES NOT exclude GORD as the diagnosis, it is mainly used for treatment planning (see below)
  • Patients should not have been taking any drugs that may contribute to symptoms for two weeks or more prior to endoscopy
• You can also use pH measurements to check the acidity in the oesophagus/mouth
  • 24 hour pH monitoring- where the pH is <4 for >6-7% of the study time- suggestive of GORD
• Urea breath test for H pylori infection can be used if a peptic ulcer is suspected
• Finally, if there is suspicion of a motility disorder (e.g. if the patient is complaining more of dysphagia or odynophagia with reflux), consider imaging/manometry tests

Management

• If there are underlying causes and/or contributing factors, make sure to reverse these where possible e.g.
  • Drugs e.g. NSAIDs, calcium channel blockers, nitrates, theophyllines, bisphophonates, steroids
  • H pylori infection
  • Obesity
  • Diet (fatty food, spicy food, fizzy drinks etc) and eating before bed/large meals
  • Alcohol, smoking
• Antacids/alginates e.g.
• Proton pump inhibitors
  • trial for a minimum of 4 weeks at a reasonable dose then treat at the lowest therapeutic dose thereafter (if successful)
  • If the patient doesn’t have any relief, the dose can be doubled for a further month or an H2-receptor antagonist can tried
• Other drugs that can be tried are prokinetics e.g. metoclopramide
• Surgery may be used for patients with a hiatus hernia.  Occasionally, fundoplication can be performed in other patients with refractory symptoms.  However,

Complications

• Barrett’s Oesophagus and Oesophageal adenocarcinoma
• Oesophageal ulcers and/or haemorrhage
• Oesophageal strictures
• Aspiration pneumonia
• Poor oral health (due to acid) e.g. caries/tooth decay, gingivitis, halitosis