Part of the TeachMe Series

Gastro-Oesophageal Reflux Disease

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Original Author(s): Chuk Anibueze
Last updated: April 13, 2019
Revisions: 31

Original Author(s): Chuk Anibueze
Last updated: April 13, 2019
Revisions: 31

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Introduction

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.

Pathophysiology

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) result in pain and mucosal damage in the oesophagus

The Greater Curvature and Lesser Curvature of the Stomach

Figure 1 – The Greater Curvature and Lesser Curvature of the Stomach

Risk Factors

The risk factors for gastro-oesophageal reflux disease include age, obesity, male gender, alcohol, smoking, caffeinated drinks, and fatty or spicy foods.

Clinical Features

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, a chronic cough, or a nocturnal cough Always check for red flag symptoms (dysphagia, weight loss, early satiety, malaise and loss of appetite) for any underlying malignancy.

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%)

Differential Diagnosis

Important gastrointestinal differentials to consider include:

  • Malignancy (oesophageal or gastric)
  • Peptic ulceration
  • Oesophageal motility disorders
  • Oesophagitis

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

Investigations

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

Imaging

The main role of upper GI 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.

However, if the symptoms are new onset (particularly in older patients) or worsening despite PPI, patients should be referred for an endoscopy.

24hr pH monitoring is the gold standard in the diagnosis of GORD 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 studies assess various criteria such as the amount of time acid is present in the oesophagus and the correlation between the presence of acid and the patient’s symptoms.

This produces an algorithmic score called the DeMeester score and can help determine a patient’s symptom / reflux correlation

Management

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.

Medical Management

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).

Surgical Management

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)

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.

*There is no evidence to suggest anti-reflux surgery reduces cancer risk from Barrett’s oesophagus

Fundoplication

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 a 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, however these often settle after 6 weeks in most patients, as the post-operative swelling and inflammation recedes.

Fig. 2 - A Nissun fundoplication, involving a 360 posterior fundoplication using the fundus of the stomach around the oesophageal sphincter

Figure 2 – A Nissen fundoplication, involving a 360 posterior fundoplication using the fundus of the stomach around the oesophageal sphincter

New Techniques

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

Complications

The main complications of GORD are aspiration pneumoniaBarrett’s oesophagus, oesophagitis and oesophageal strictures, and oesophageal cancer.

The 7yr risk of developing adenocarcinoma is about 0.1%, in cases where initial endoscopy is absent of strictures, Barrett’s metaplasia, or adenocarcinoma.

Key Points

  • 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