Gastro-oesophageal reflux disease

Revise the presentation and management of GORD. By GP Dr Louise Newson.

Gastroscopy can assess the severity of oesophagitis and exclude other pathology (Photo: SPL)
Gastroscopy can assess the severity of oesophagitis and exclude other pathology (Photo: SPL)

Gastro-oesophageal reflux disease (GORD) occurs when gastric contents reflux into the oesophagus and thereby cause symptoms.

1. Aetiology

Around 10-20% of the adult population has symptoms of GORD at some stage of their lives. GORD is two to three times more common in men than in women. Its prevalence increases with age.

Obesity, smoking, pregnancy, family history, hiatus hernia and various medications (for example, tricyclic antidepressants, nitrates, calcium-channel blockers) are all associated with GORD. Certain foods can relax the lower oesophageal sphincter, including chocolate, coffee, alcohol and fatty meals.

GORD can lead to oesophagitis, but it is not very common; only around 8% of patients with GORD have moderate or severe oesophagitis. Some patients have abnormalities in their lower oesophageal sphincter which leads to reflux of their gastric contents.

2. Presentation

Common symptoms include heartburn, regurgitation and dysphagia. Atypical symptoms include chest pain, cough, hoarseness and bloating. Symptoms are classically worse when lying down or leaning forward, and improve with antacids.

It is useful to assess the impact of symptoms on the patient's quality of life. It is also important to exclude alarm signs that may suggest a more serious underlying diagnosis (see box).1

Urgent referral

Indications for urgent referral for suspected GI cancer1

  • Dysphagia at any age.
  • Dyspepsia at any age combined with one or more of the following:

- Weight loss.

- Proven anaemia.

- Vomiting.

  • Dyspepsia in a patient aged ≥55 years with at least one of the following:

- Onset of dyspepsia less than one year ago.

- Continuous symptoms since onset.

  • Dyspepsia combined with at least one of the following known risk factors:

- Family history of upper GI cancer in more than two first-degree relatives.

- Barrett's oesophagitis.

- Pernicious anaemia.

- Peptic ulcer surgery more than 20 years before.

- Known dysplasia, atrophic gastritis or intestinal metaplasia.

- Jaundice.

- Upper abdominal mass.

3. Investigations

The diagnosis of GORD is usually made by the history. The most common investigation is gastroscopy, although most patients with symptoms of GORD will have a normal gastroscopy. The degree of symptoms does not usually correlate with findings on gastroscopy.

A gastroscopy may be useful to assess the severity of oesophagitis and to exclude other pathology. Among patients who have an upper endoscopy, findings range from a normal appearance, mild erythema to severe oesophagitis with stricture formation. Acid suppressant treatment should be stopped for at least two weeks before a gastroscopy.

FBC is often performed to exclude anaemia. Manometry can be performed to determine lower oesophageal sphincter pressure and identify any oesophageal motility disorders.

Oesophageal pH monitoring may be performed in some patients. This can help to confirm the diagnosis in patients in whom the history is not clear, if they have atypical symptoms, or if an endoscopy is normal.

4. Treatment

Lifestyle modification is important, including weight loss and smoking cessation (if necessary), avoidance of certain foods (for example, chocolate, citrus juice, tomato-based products), and eating smaller meals. Eating the evening meal at least three hours before going to bed is often beneficial.

The most common medications given to patients with GORD are PPIs. However, antacids are still recommended first line. They can also be used in conjunction with other medication, for example PPIs. H2 receptor antagonists, such as ranitidine, remain a useful choice for some patients.

PPIs have been shown to be more effective than H2 receptor antagonists in relieving heartburn in patients with GORD who are treated empirically and in those with normal gastroscopy findings.2

PPIs can be given at a healing dose for one to two months, which can be reduced once symptoms improve. The lowest effective dose can then be given as maintenance treatment.

Patients should have a trial without treatment once their symptoms completely improve. The dose of the PPI is gradually reduced before stopping it.

Helicobacter pylori can be initially detected using either a carbon-13 urea breath test or a stool antigen test, or laboratory-based serology where its performance has been locally validated.1 There is currently inadequate evidence to guide whether full-dose PPI for one month or H pylori test and treat should be offered first. NICE recommends that either treatment may be tried first, with the other being offered if symptoms persist or return.

Some patients do not respond to optimal medical treatment and may be offered surgery.

Successful antireflux surgery can be more effective than medical therapy in preventing both acid and bile reflux.3

Laparoscopic fundoplication can provide satisfactory outcomes and definitive relief of acid reflux.4 Indications for surgery include symptoms that are not completely controlled by PPIs, presence of Barrett's oesophagus, presence of atypical symptoms of GORD, including cough, wheezing, hoarseness, sore throat; young patients, and patients who do not want to take medication long term.

5. Complications

The risk of complications increases with longer duration and increased frequency of gastro-oesophageal symptoms. Complications of GORD include oesophagitis, gastric ulcer, anaemia, oesophageal stricture and Barrett's oesophagus.

  • Dr Newson is a GP in the West Midlands

REFERENCES

1. NICE. Managing dyspepsia in adults in primary care. CG17; August 2004.

2. Van Pinxteren B, Sigterman KE, Bonis P et al. Short-term treatment with proton pump inhibitors, H2-receptor antagonists and prokinetics for gastro-oesophageal reflux disease-like symptoms and endoscopy negative reflux disease. Cochrane Database Syst Rev 2010; (11): CD002095.

3. Marano S, Mattacchione S, Luongo B et al. Laparoscopic Nissen-Rossetti fundoplication for gastroesophageal reflux disease patients after 2-year follow-up. J Laparoendosc Adv Surg Tech 2012; 22(4): 336-42.

4. Rosemurgy AS, Donn N, Paul H et al. Gastroesophageal reflux disease. Surg Clin North Am 2011; 91(5): 1015-29.

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