GORD is one of the most common gastrointestinal ailments worldwide. About 40% of Americans report experiencing intermittent GORD symptoms, while between 10% and 20% report weekly symptoms. The exact prevalence of GORD in South Africa is uncertain.
There are a couple of major factors in GORD, one being a damaged lower oesophageal sphincter (LOS) and another is overeating. Overeating can also damage the LOS. GORD is caused by the reflux of stomach contents into the oesophagus, causing troublesome symptoms and complications. It is often referred to as acid reflux. A malfunction the LOS, located at the end of the oesophagus at the point where it joins the stomach.
Under normal circumstances, the LOS functions as a valve allowing food to pass readily into the stomach while not allowing stomach contents to backup or reflux upward into the oesophagus. When the function of the LOS is compromised, it loses its valve function and stomach contents can move the wrong direction up into the esophagus. The lining of the oesophagus is sensitive and not meant to withstand exposure stomach to juices, including acid. It is easily irritated causing many symptoms.
Typical GORD symptoms include heartburn and regurgitation. Clinical diagnosis is made on the basis of typical symptoms. Alarm symptoms include eg dysphagia, weight loss and anaemia. Atypical presentations include chest pain, laryngeal symptoms or lack of response to empiric therapy. Atypical presentations should be evaluated with an upper endoscopy.
If symptoms persist despite empiric therapy, and oesophagogastroduodenoscopy does not reveal evidence of GORD (oesophagitis, peptic oesophageal stricture, Barrett mucosa), oesophageal function tests are performed, including oesophageal manometry and ambulatory reflux monitoring.
However, wrote Savarino et al, reflux episodes can be physiological, and some findings on endoscopy (Los Angeles classification grade A or B reflux oesophagitis and manometry (hypotensive oesophagogastric junction, ineffective oesophageal manometry) can be encountered in asymptomatic individuals without GORD symptoms.
New clinical approach to GORD
- The concept of proven GORD, with prior endoscopic or physiological evidence of disease, versus unproven GORD is utilised to direct which oesophageal reflux monitoring study to use and whether it should be performed on or off acid suppressive therapy.
- Consensus definitions of thresholds for pH and pH-impedance monitoring have been made in defining physiological and pathophysiological reflux measurements, including an inconclusive ‘grey area’ that requires further evidence to confirm a diagnosis of GORD.
- Acid exposure time is physiological when <4% and pathological when >6%. Values in between are considered borderline, requiring additional clinical or physiological evidence to confirm or refute a GORD diagnosis.
- When the diagnosis is inconclusive on reflux monitoring alone, the use of additional features are suggested, including histology, new pH-impedance metrics and high-resolution manometry.
- A new classification of oesophageal contractility and oesophagogastric junction motor findings in GORD is made, incorporating data obtained by high-resolution manometry.
Indications for ambulatory reflux monitoring
- Typical symptoms (heartburn, regurgitation) persisting despite therapy
- Atypical symptoms (chest pain, cough, laryngeal symptoms), to confirm or exclude GORD
- Documentation of abnormal oesophageal reflux burden before invasive antireflux procedures and surgery
- Diagnosis of functional heartburn and reflux hypersensitivity (by exclusion of pathological acid exposure time)
- Diagnosis of supragastric belching (pH impedance) and rumination syndrome (in conjunction with manometry)
- Emerging indications
- Monitoring of reflux burden following invasive reflux procedures and surgery
- Monitoring of reflux burden following ablation of the lower oesophageal sphincter (LOS) in achalasia
Indications for manometry in GORD
- Localisation of the LOS for appropriate placement of pH and pH-impedance catheters
- Exclusion of major motor disorders, especially achalasia
- Assessment of oesophageal peristaltic performance before invasive antireflux procedures and surgery
- Diagnosis of rumination syndrome and supragastric belching (in conjunction with pH impedance)
- Evaluation of post-fundoplication dysphagia
- Diagnosis of functional oesophageal disorders by exclusion of major motor disorders.
Treatment of GORD
A stepwise approach to the treatment of GORD is recommended. This approach includes controlling the symptoms, healing the oesophagitis and preventing recurrent oesophagitis or other complications.
Treatment includes lifestyle modification, which is considered the cornerstone of therapeutic intervention, and control of gastric acid secretion through medical therapy with antacids, H2 antagonists (H2RA), proton pump inhibitors or surgical treatment with corrective antireflux surgery.
According to Sandhu and Fass, obesity is an important risk factor for the development or worsening of GORD. An American study including more than 10 000 women, found that any increase in body mass index (BMI) in individuals of normal weight, was associated with an increased risk of GORD.
Even modest weight gain can exacerbate GORD symptoms and women who reduced their BMI by 3.5 units or more reported a 40% reduction in the frequency of GORD symptoms compared with controls.
Weight loss therefore appears to be an effective lifestyle modification to improve GORD, said the authors. In addition, they wrote, lifestyle modifications associated with sleep have been shown to improve GORD related symptoms. Elevate the head of the bed and avoid eating at least three hours prior to sleep time, recommended Sandhu and Fass.
If patients’ symptoms to not improve despite lifestyle modifications, medical therapy is advised. PPIs are considered the most effective medical therapy for GORD, because of their due to their intense and consistent acid suppression. Several studies have shown that PPIs are safe to use. PPI patient satisfaction rates range between 56% to 100% as compared with other antireflux medications.
According to Sandhu and Fass, a number of notable studies have demonstrated the efficacy of PPI treatment. PPIs offer symptomatic relief for patients with nonerosive reflux disease (NERD) as well as those with eosinophilic oesophagitis (EE).
Based on the current evidence PPIs can provide symptom relief in approximately 57% to 80% of patients with EE and about 50% of the patients with NERD. In addition, healing of EE (all grades) can be obtained in greater than 85% of GERD patients undergoing treatment with a standard dose PPI.