The primary treatment goals in patients with gastro-oesophageal reflux disease (GORD) are relief of symptoms, prevention of symptom relapse, healing of erosive oesophagitis, and prevention of complications of oesophagitis.
WHAT IS GORD?
“Gastro-oesophageal reflux disease (GORD) occurs when the stomach content moves past your lower oesophageal sphincter (a set of constricting muscles that form a type of valve at the bottom end of your oesophagus or food pipe) up into your oesophagus and even all the way into your throat or mouth (reflux),” Dr Eduan Deetlefs, a gastroenterologist at Mediclinic Milnerton explains.
GORD develops when this valve is more open than it should be or if there is a hiatus hernia (where part of your stomach pushes into your chest causing a dysfunctional valve). Contributing risk factors include increased pressure in the stomach due to obesity, overeating, pregnancy, certain foods that can cause relaxation of the valve, and certain medications.
“GORD is characterised by reflux of the stomach contents into the oesophagus, oropharynx, larynx, or airway and is associated with heartburn, acid regurgitation, and dyspepsia,” said Dr Theo Scholten (University Hospital of Witten-Herdecke).
“Other less common symptoms of GORD include cough, intermittent wheezing, vocal cord inflammation, atypical chest pain, dysphagia, and hoarseness.”
TREATMENT: RELIEF & REMISSION
“The effective treatment of GORD provides symptom resolution and high rates of remission in erosive oesophagitis, lowers the incidence of GORD complications, improves health-related quality of life, and reduces the cost of this disease,” said Dr Scholten.
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 (PPIs), or surgical treatment with corrective anti-reflux surgery.
According to Sandhu and Fass, obesity is an important risk factor for the development or worsening 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.”
Other lifestyle modifications include:
- Sleeping with the head of the bed elevated.
- Elimination of factors that increase abdominal pressure.
- Avoid smoking, ingesting large quantities of fluids with meals, consuming fatty foods, coffee, chocolate, alcohol, mint, orange juice, and certain medications (such as anticholinergic drugs, calcium channel blockers, and other smooth-muscle relaxants).
If patients’ symptoms do not improve despite lifestyle modifications, medical therapy is advised.
ACID SUPPRESSION THERAPY
According to gastroenterologists Dr Charlotte Keung and Prof Geoffrey Hebbard PPIs are more potent at acid suppression than H2-receptor antagonists. They block the final common pathway of acid secretion by irreversibly binding to and inactivating the proton pump. “This results in a greater proportion of healed erosive oesophagitis compared with the use of H2-receptor antagonists,” said Dr Keung and Prof Hebbard in Australian Prescriber.
“PPIs have a short plasma half-life (mostly 1-2 hours) and are only effective when proton pumps are active (in the postprandial period). The timing of administration is therefore important, with the greatest efficacy being seen when PPI concentrations are maximal at the time of a meal. As the inactivation of the proton pump is irreversible, the biological half-life of the drug is considerably longer than its plasma half-life. Consequently, if an increase in acid suppression is required, a second dose taken later in the day (e.g. before the evening meal) is more effective than doubling the morning dose.”
- Maintenance therapy
“Patients with typical symptoms of GORD who respond to 4–8 weeks of PPI therapy can reduce their dose to ‘when required’ while continuing lifestyle measures, antacids and, when required, H2-receptor antagonists as a less potent alternative to the PPI,” Dr Keung and Prof Hebbard advise. “There may be a period of acid hypersecretion following the withdrawal of PPI, but any symptoms will reduce over a period of about a month, after which recurring symptoms are most likely to be due to underlying reflux disease. Using a PPI when required will be adequate for some patients, however 75-90% will relapse over six months. This reflects the chronic nature of the condition rather than a failure of treatment.”
According to Dr Charumathi Raghu Subramanian and gastroenterologist Dr George Triadafilopoulos anti-reflux surgery comprises a broad range of conventional and novel techniques designed to correct a mechanically defective sphincter and is recommended for patients who demonstrate partial (inadequate) response to PPI, or who cannot tolerate medical therapy.
Laparoscopic fundoplication is the most common surgical procedure.
- Recurrent vomiting
- Dysphagia or odynophagia
- Weight loss
- Evidence of gastrointestinal blood loss e.g. haematemesis, iron deficiency, or anaemia
- Duration of symptoms >5 years or <6 months
- Epigastric mass
- Age >50 years
Provided it’s treated correctly most patients will not develop serious complications from GORD. However, Mediclinic cautions some patients may be at risk of the following serious complications:
- Ulcers can form in the oesophagus from acid burn.
- The oesophagus can get scarred and narrowed, causing a stricture which can make it hard to swallow.
- If acid reflux reached your throat, it could cause irritation to the throat and vocal cords resulting in coughing, hoarseness, and breathing problems.
- Repeated damage to the lower oesophagus can cause the lining to become abnormal. Known as Barrett’s Oesophagus, this has a small risk of turning into cancer. In this case, patients should have a periodic endoscopy to look for early signs. The good news is only a small percentage of people with GORD develop Barrett’s, and an even smaller percentage develop adenocarcinoma.