Introduction

Gastro-oesophageal reflux disease (GORD) is chronic reflux of acid, bile and pepsin from the stomach back into the oesophagus. It is caused by dysfunction of the lower oesophageal sphincter (LOS), and may be erosive or non-erosive. 50-85% of patients show no signs of erosion.

It is very common, affecting approximately 20-40% of people in any 12 month period. Men are more than twice as likely to be affected. Typical symptoms include heartburn and acid regurgitation which may affect a patient's quality of life.

Epidemiology

  • Incidence: 5000.00 cases per 100,000 person-years
  • Peak incidence: 50-60 years
  • Sex ratio: more common in males 2:1
Condition Relative
incidence
Gastro-oesophageal reflux disease1
Musculoskeletal chest pain0.20
Peptic ulcer disease0.02
Mallory-Weiss tear0.002
Oesophageal cancer0.002
Pharyngeal pouch0.0004
<1 1-5 6+ 16+ 30+ 40+ 50+ 60+ 70+ 80+

Aetiology

Factors which increase intra-abdominal pressure are heavily associated with GORD. Other associations include:
  • Increased intra-abdominal pressure/obesity
    • Around 22% of patients with BMI >30 suffer with GORD, compared to just 6% with a BMI <18.5
  • Smoking, alcohol and coffee
    • 18% of smokers have been shown to have GORD, compared to 15% in non-smokers
    • Smoking relaxes LOS
  • Drugs (relax LOS)
    • Tricyclics, anticholinergics, nitrates, calcium channel blockers
    • 24% of regular aspirin of NSAID users suffer with GORD, compared to 17% in non users
  • Overeating, especially fatty meals
    • Fat delays gastric emptying
  • Hiatus hernia
  • Pregnancy
  • Tight clothes
  • Surgery in achalasia

GORD has been shown to contribute to asthma. Note there is no association with H. pylori.

Pathophysiology

GORD has a multifactorial pathogenesis. The two main contributing factors are:
  • Lower oesophageal sphincter (LOS) abnormalities
  • Transient LOS relaxation
This means acid, bile, pepsin and pancreatin enzymes are able to reflux back into the oesophagus, causing mucosal injuries.

Other factors include:
  • Hiatus hernia: promotes LOS dysfunction
  • Impaired oesophageal clearance: prolonged acid exposure to the mucosa
  • Delayed gastric emptying: results in gastric distension and significantly increases the rate of transient LOS relaxations
  • Impaired mucosal defensive factors: neutralise hydrogen ions exposed to oesophageal tissue.

Clinical features

Patients often present with dyspepsia. Whilst there is no universally accepted definition, The British Society of Gastroenterology (BSG) defines dyspepsia as a group of symptoms that alert doctors to consider disease of the upper GI tract. Dyspepsia itself is not a diagnosis.

GORD is a common cause of dyspepsia, along with duodenal and gastric ulcers, oesophagitis, and oesophageal or gastric cancers; however, the cause is often unknown (functional dyspepsia). Dyspepsia accounts for between 1.2% and 4% of all consultations in primary care in the UK.

GORD can be clinically diagnosed based on the following isolated symptoms:
  • Heartburn
    • A burning retrosternal sensation worsened by stooping, straining and lying down.
    • Pain relieved by antacids.
  • Belching
  • Acid brash (acid/bile regurgitation)
  • Water brash (excessive salivation)
  • Odynophagia (painful swallowing)
    • May be due to severe oesophagitis or stricture
  • Nocturnal asthma
    • A night-time cough may be caused by slight inhalations of gastric contents.

Atypical symptoms include:
  • Chest pain
    • In up to 50% of patients with chest pain, GORD may be the cause. If the pain is due to reflux, it will normally not be linked to exercise, thereby differentiating it from angina.
  • Epigastric pain
  • Chronic aspiration may cause respiratory symptoms such as chronic cough, hoarseness (Cherry-Donner syndrome), and asthmatic symptoms. In 6-10% of patients with chronic cough, GORD is the cause.

Investigations

Whilst isolated symptoms do not require investigation, patients fitting any of the following criteria should be referred for oesophago-gastroduodenoscopy (OGD):
  • Age >55 years
  • Symptoms >4 weeks
  • Dysphagia
  • Persistent symptoms despite treatment
  • Relapsing symptoms
  • Weight loss
  • Excessive vomiting
  • GI bleeding
Note either the Savary-Miller (grades 1-5) or Los Angeles (grades A-D) grading systems may be used in endoscopy.

The LA classification may show:
GradeDescription
Grade AAt least one mucosal break, up to 5 mm, that does not extend between the tops of two mucosal folds
Grade BAt least one mucosal break, more than 5 mm long, that does not extend between the tops of two mucosal folds
Grade CAt least one mucosal break that is continuous between the tops of two or more mucosal folds but which involve less than 75% of the circumference
Grade DAt least one mucosal break which involves at least 75% of the esophageal circumference

Note that 50-85% of patients with GORD will show no erosive changes.

Other tests include:
  • A barium swallow test should be performed to rule out hiatus hernia.
  • A 24 hour oesophageal PH monitoring may be needed to distinguish GORD from other causes.
  • Patients showing systemic symptoms, or who have lesions shown on OGD, should have a FBC to rule out anaemia.

Differential diagnosis

GORD may be confused with other causes of heartburn and dyspepsia. Generally the treatment of oesophagitis will be the same, whatever the cause, however it is important to rule out causative factors which need to be removed:
  • Oesophagitis caused by infection especially in immunocompromised.
    • Similarities: heartburn.
    • Differences: oesophagitis caused by infection manifests as difficulty swallowing saliva and odynophagia. OGD shows evidence of infection. Patients will be immunocompromised, for example receiving radiation therapy or HIV-infected patients.
    • Most common causative agents are fungal and viral. Bacterial and parasitic is rare. Candida oesophagitis is most common, whilst viral may be caused by one either herpes simplex virus or cytomegalovirus.
    • Candida
  • Oesophagitis caused by corrosives, for example NSAIDs
    • Similarities: presentation will be similar. Confirmed by endoscopy. Treat with PPI.
    • Differences: increased oesophageal bleeding, perforation, or stricture on OGD. History of chemical ingestion which may have induced other symptoms.
  • Duodenal/gastric ulcer (duodenal 4x commoner than gastric)
    • Similarities: heartburn
    • Dissimilarities: pain related to hunger, eating specific foods, time of day. Epigastric tenderness, weight loss and haematemesis possible.

Management

NICE guidance states uninvestigated GORD like symptoms should be treated the same as uninvestigated dyspepsia. Typically this is managed with simple lifestyle changes and proton pump inhibitors (PPIs). Note the effect of lifestyle changes is questioned, however advice still given.

Lifestyle changes:
  • Reduce weight
  • Stop smoking
  • Decrease alcohol intake
  • Raise head at night (sleep propped up)
  • Avoid hot drinks, alcohol and eating within 3hrs of going to sleep
  • Avoid drugs which:
    • Affect oesophageal motility (nitrates, anticholinergics, tricyclic antidepressants)
    • Damage the mucosa (NSAIDs, K+ salts, alendronate)
Drugs:
  • NICE guidance states that a patient without any red flag symptoms should be given a 4 week full-does PPI therapy course.
  • If symptoms return, the dosage of PPI should be stepped down to the lowest level that still relieves symptoms.
    • Start acid suppression at a low dose for 1-2 months
    • After review, step up if still symptomatic. Step down if dosage has controlled symptoms until the lowest point it will do so.
  • Offer H2RA therapy if there is inadequate response to a PPI
  • Patients with GORD diagnosed via endoscopy may be increased to an 8 week course of PPI therapy if deemed necessary. If oesophagitis is severe, full-dose treatment can be used in the long term.

Consider referring anyone to a specialist who:
  • Has unexplained GORD symptoms not responding to treatment.
  • Is considering surgery.

Surgery

Laparoscopic fundoplication, also known as a Nissen fundoplication, is the surgical procedure of choice. It is indicated for:
  • Patients who have a confirmed GORD diagnosis via endoscopy, respond to PPI therapy, but do not wish to continue it long term.
  • Patients who have a confirmed GORD diagnosis via endoscopy, are responding to a PPI, but can not tolerate acid suppression therapy.

Complications

For most people GORD is a straightforward condition, however it may lead to complications. These can be either benign or malignant:

Benign:
  • Erosive oesophagitis - the biggest risk factor for adenocarcinoma
  • Bleeding, often leading to iron deficiency/anaemia. Remember to consider FBCs.
  • Peptic stricture
Malignant:
  • Barrett's oesophagus
    • Metaplastic change in mucosal cells from stratified squamous to simple columnar epithelium
  • Oesophageal adenocarcinoma
Managing these complications can be challenging. PPIs have been shown to significantly reduce strictures. Barrett's should be closely observed to watch for high grade dysplasia and adenocarcinoma.