Gastro-Oesophageal Reflux Disease
Gastro-oesophageal reflux disease (GORD) is a condition whereby gastric acid from the stomach leaks up into the oesophagus.
It is a very common problem, affecting around a quarter of the population in Western countries and represents approximately 4% of primary care appointments. It is twice as common in men compared to women.
In this article, we shall look at the risk factors, clinical features and management of gastro-oesophageal reflux disease.
The lower oesophageal sphincter controls the passage of contents from the oesophagus to the stomach.
As part of its normal function, episodic sphincter relaxation is expected, yet in GORD these episodes become more frequent and allow the reflux of gastric contents into the oesophagus.
The refluxed acidic gastric contents (or rarely alkaline bile) can cause pain and mucosal damage in the oesophagus.
The risk factors for gastro-oesophageal reflux disease include age, obesity, alcohol, smoking, caffeinated drinks, and fatty or spicy foods.
The main symptom of gastro-oesophageal reflux disease is chest pain. This is classically a burning retrosternal sensation, worse after meals, lying down, bending over, or straining. Typically, it is relieved (at least partially) by antacids.
Additional symptoms may include excessive belching, odynophagia, chronic cough or nocturnal cough, and hoarseness. Always check for red flag symptoms (dysphagia, weight loss, early satiety, malaise and loss of appetite) for any underlying malignancy (although remember that these are late symptoms of malignancy so may be absent)
Examination is typically normal.
The Los Angeles Classification of Reflux
The Los Angeles classification can be used to grade reflux oesophagitis based on severity from the endoscopic findings of mucosal breaks in the distal oesophagus:
- Grade A: breaks ≤5mm
- Grade B: breaks >5mm
- Grade C: breaks extending between the tops of ≥2 mucosal folds, but<75% of circumference
- Grade D: circumferential breaks (≥75%)
Important gastrointestinal differentials* to consider include:
- Malignancy (oesophageal or gastric)
- Peptic ulceration
- Oesophageal motility disorders
*Moreover, it is important not to miss key cardiac or biliary disease, as coronary artery disease and biliary colic can be common mimics of the episodic reflux disease
In most patients, a clinical diagnosis is reached simply from a good history and resolution of symptoms after a trial of a proton-pump inhibitor.
NICE guidance states the red-flag symptoms for a suspected upper GI malignancy requiring urgent endoscopy are:
- Patients with dysphagia
- Any patient >55yrs with weight loss and upper abdominal pain, dyspepsia, or reflux
The main role of endoscopy is to exclude malignancy and investigate for complications of reflux (oesophagitis, structuring, or Barrett’s oesophagus). It is not required in the majority of patients; indeed, around two thirds of patients with symptomatic GORD will have a normal endoscopy.
24hr pH monitoring is the gold standard in the diagnosis of reflux and is required for patients in whom medical treatment fails and surgery is being considered. It should be combined with oesophageal manometry to exclude oesophageal dysmotility (which would cause many surgeons to tailor their operative approach or avoid surgery).
pH Monitoring Studies
pH monitoring assesses 6 main criteria, which are important in assessing a patient’s suitability for surgery:
- % total time the pH is <4
- % supine time the pH is <4
- % upright time the pH is <4
- The number of reflux episodes
- The length of the longest episode
- Symptom / reflux correlation
All patients with gastro-oesophageal reflux disease should be advised to take conservative steps in its management, including avoiding known precipitants (alcohol, coffee, fatty foods), weight loss, and smoking cessation. Simple advice, such as raising the head of the bed and having evening meals at least 3 hours before bed, may also be of benefit.
Proton pump inhibitors (in addition to lifestyle changes) are the first-line treatment and are very effective for the majority of patients.
Symptoms tend to recur rapidly after ceasing to take PPIs and so many patients are likely to remain on them life-long (unless they proceed to surgery).
There are three main indications for surgery in gastro-oesophageal reflux disease:
- Failure to respond (or only a partial response) to medical therapy
- Patient preference to avoid life-long medication
- Patients with complications of GORD (in particular respiratory complications such as recurrent pneumonia or bronchiectasis)
- There is no evidence to suggest anti-reflux surgery reduces cancer risk from Barrett’s oesophagus
Surgery has been shown to be more effective than medical treatment in terms of symptom relief, quality of life improvement, and cost. However, due to associated complications and side-effects, many patients are understandably reluctant to accept it.
The main surgical intervention that can be offered for patients with GORD is a fundoplication, whereby the gastro-oesophageal junction and hiatus are dissected and the fundus wrapped around the GOJ, recreating the physiological lower oesophageal sphincter.
Several different approaches to the procedure have been described, differing in direction and completeness of the wrap (such as the posterior 360 (Nissen’s) approach or the partial anterior).
The main side-effects of anti-reflux surgery are dysphagia, bloating, and inability to vomit. The dysphagia settles after 6 weeks in most patients, as the post-operative swelling and inflammation recedes.
Several new techniques for managing GORD have recently been developed:
- Stretta®: uses radio-frequency energy delivered endoscopically to cause thickening of the lower oesophageal sphincter
- Linx®: a string of magnetic beads is inserted around the lower oesophageal sphincter laparoscopically which tightens the LOS
The main complications of GORD are aspiration pneumonia, Barrett’s oesophagus, oesophagitis and oesophageal strictures, and oesophageal cancer.
Data has shown that the 7yr risk of developing adenocarcinoma is about 0.1%, when initial endoscopy is absent of strictures, Barrett’s metaplasia, or adenocarcinoma.
- GORD will typically present with burning retrosternal chest pain, but it is important to exclude cardiac or biliary pathologies
- The main role of endoscopy is to exclude malignancy and investigate for complications of reflux, but is not required in the majority of patients with dyspepsia
- Medical management is still the mainstay of treatment, despite surgical interventions having better symptom control and quality of life effects
- Various techniques of fundoplication are used, with side effects includes dysphagia, bloating, and inability to vomit