Gastroesophageal reflux disease (GORD) is a chronic gastrointestinal disease that has a significant impact on patients ‘quality of life. In some patients it can lead to serious complications such as oesophageal stricture, gastrointestinal bleeding, or Barrett's oesophagus

Studies show that the typical symptoms of GORD (or GERD) including heartburn, discomfort in the upper abdomen and acid eructation are experienced daily by 4%-10%, and weekly by 10%-30% of the adult population in Western countries.

Adults between the ages of 60-70 years are most commonly affected. There is no difference in the occurrence rate in men and women.

Definition

The American Gastroenterology Association defines GORD as ‘a chronic disorder relating to the retrograde flow of gastroduodenal contents into the oesophagus and/or adjacent organs, resulting in a spectrum of symptoms, with or without tissue damage’.

Treatment

Treatment of GORD involves a stepwise approach. The goals are to control symptoms, to heal oesophagitis, and to prevent recurrent oesophagitis or other complications.

Treatment is based on:

  • Lifestyle modification.
  • Control of gastric acid secretion through medical therapy with antacids.
  • Proton pump inhibitors (PPIs).
  • Surgical treatment with corrective antireflux surgery.

Causes

GORD is believed to be caused by a combination of conditions that increase the presence of gastric content in the oesophagus. These conditions include frequent and prolonged transient lower oesophageal sphincter relaxation, decreased lower esophageal sphincter tone, impaired esophageal clearance, delayed gastric emptying, and decreased salivation.

Three main causes of GORD

Poor clearance: Most people can quickly clear reflux material from the oesophagus, however, when a patient has poor clearance, the reflux material remains in the oesophagus for an extended period, causing injury to the oesophagus. In older people, poor clearance can occur for no apparent reason. Poor clearance can occur following a stroke, or in patients with vascular disorders.

Poor gastric emptying: When the stomach does not empty as it fills up, the gastric contents ultimately spill back into the oesophagus. This can be caused by a weak lower oesophageal sphincter.

A weak gastroesophageal valve: This is the most common cause of GORD and is caused by a weak valve between the oesophagus and the stomach.

Symptoms

The most common symptom of GORD is heartburn. Besides the discomfort of heartburn, reflux may result in regurgitation. Other symptoms include odynophagia (pain on swallowing) and dysphagia (difficult swallowing). Reflux can also cause pulmonary symptoms such as coughing, wheezing, asthma, or aspiration pneumonia.

Oral symptoms include tooth enamel decay, gingivitis, halitosis, and water-brash (excessive reflex salivation), throat symptoms such as soreness, laryngitis, hoarseness, and a globus sensation. A minority of patients with diagnostic GORD symptoms will have reflux oesophagitis.

Diagnosis

Katz et al recommend the following diagnostic algorithm:

  • A presumptive diagnosis of GORD can be established in the setting of typical symptoms of heartburn and regurgitation.
  • Patients with noncardiac chest pain suspected due to GORD should have diagnostic evaluation before institution of therapy.
  • A cardiac cause should be excluded in patients with chest pain before the commencement of a gastrointestinal evaluation.
  • Barium radiographs should not be performed to diagnose GORD.
  • Upper endoscopy is not required in the presence of typical GORD symptoms.
  • Endoscopy is recommended in the presence of alarm symptoms and for screening of patients at high risk for complications. Repeat endoscopy is not indicated in patients without Barrett’s oesophagus in the absence of new symptoms.
  • Routine biopsies from the distal oesophagus are not recommended specifically to diagnose GORD.
  • Oesophageal manometry is recommended for preoperative evaluation, but has no role in the diagnosis of GORD.
  • Ambulatory oesophageal reflux monitoring is indicated before consideration of endoscopic or surgical therapy in patients with nonerosive refl ux disease, as part of the evaluation of patients refractory to PPI therapy, and in situations when the diagnosis of GORD is in question.
  • Ambulatory reflux monitoring is the only test that can assess reflux symptom association.
  • Ambulatory reflux monitoring is not required in the presence of short or long-segment Barrett’s esophagus to establish a diagnosis of GORD.
  • Screening for Helicobacter pylori infection is not recommended in GORD.
  • Eradication of H. pylori infection is not routinely required as part of antireflux therapy.
  • The diagnosis of GORD is made using some combination of symptom presentation, objective testing with endoscopy, ambulatory reflux monitoring, and response to antisecretory therapy.
  • The symptoms of heartburn and regurgitation are the most reliable for making a presumptive diagnosis based on history alone. However, these are not as sensitive as most believe. A systematic review of seven studies found the sensitivity of heartburn and regurgitation for the presence of erosive oesophagitis to be 30%-76% and the specificity from 62%-96%.
  • Empiric PPI therapy (a PPI trial) is a reasonable approach to confirm GORD when it is suspected in patients with typical symptoms. A response to therapy would ideally confirm the diagnosis.

Treatment

Lifestyle modifications can be helpful. Patients should be advised to avoid bedtime snacks, eat low fat foods, quit smoking, and reduce alcohol consumption. These strategies may have other health benefits in addition to any improvement in GORD.

Patients whose symptoms are not completely controlled by lifestyle modification may be advised to use over-the-counter medications including antacids or antisecretory agents. Response to medication should be reassessed periodically. If the patient reports troublesome symptoms that are not controlled by over-the-counter therapy and lifestyle modification, treatment may be initiated with a regular dose of a PPI once a day for four weeks. Numerous trials have shown that short-term treatment with acid suppression agents can effectively relieve the symptoms of uncomplicated GORD.

Patients whose symptoms are resolved after a course of therapy need no further investigation or therapy. Therapy may be repeated if symptoms recur. For those few patients who fail therapy with a PPI for eight weeks, a trial of twice-daily PPI for four weeks may be tried. Subsequent treatment failures may require further investigation and referral.

References available on request.