Gastro-oesophageal reflux
disease (GORD) is a common
condition where stomach acid leaks out of the stomach and into the oesophagus
(gullet). The oesophagus is a long tube of muscle than runs from the mouth to
the stomach.
- heartburn – burning chest pain or discomfort that occurs after eating
- an unpleasant sour taste in the mouth – caused by stomach acid coming back up into the mouth (known as regurgitation)
- dysphagia – pain and difficulty swallowing
Many people experience occasional episodes of GORD, but if people
have persistent and reoccurring symptoms it is
normally regarded as a condition that needs treatment.
Treatment
A step-by-step approach is usually recommended for
GORD. This means that relatively uncomplicated treatments, such as changing
your diet, will be tried first. If this fails to help control symptoms, then a
person can be 'stepped up' to more complex treatments such
as antacids, which help neutralise the effects of stomach acid.
In cases where medication fails to control symptoms, surgery may be required.
Causes
It is thought that GORD is caused by a combination
of factors. The most important factor is the lower oesophageal sphincter (LOS)
muscle not working properly.
The LOS acts like a valve, opening to let food fall
into the stomach and closing to prevent acid leaking out of the stomach and
into the oesophagus. In cases of GORD, the LOS does not close properly,
allowing acid to leak up, out of the stomach.
Known risk factors for GORD include:
- being overweight or obese
- being pregnant
- eating a high-fat diet
Complications
A common complication of
GORD is that the stomach acid can irritate and inflame the lining of the
oesophagus, which is known as oesophagitis. In severe cases of oesophagitis, ulcers
(open sores) can form which can cause pain and make swallowing difficult.
A rarer and more serious complication of GORD is
cancer developing inside the oesophagus (oesophageal cancer).
Who is
affected
GORD is a common digestive condition. It is
estimated that one in five people will experience at least one episode of GORD
a week, and that 1 in 10 people experience symptoms of GORD on a daily basis.
GORD can affect people of all ages, including
children. However, most cases affect adults aged 40 or over. GORD is thought to
affect both sexes equally, but males are more likely to develop complications.
Outlook
The outlook for GORD is generally good, and most
people respond well to treatment with
medication. However, relapses are common, with around half of
people experiencing a return of symptoms after a year. As a result, some people
may require a long-term course of medication to control their symptoms.
Causes of
gastro-oesophageal reflux disease
It is thought that most cases of gastro-oesophageal
reflux disease (GORD) are caused by a problem with the lower oesophageal
sphincter (LOS) muscle. The LOS is located at the bottom of the oesophagus
(gullet), the tube that runs from the back of the throat to the stomach.
The LOS works in a similar way to a valve. It opens
to let food into your stomach, and it closes to prevent acid leaking back
up into your oesophagus. However, in people with GORD, the LOS can become
weakened, which allows stomach acid to pass back into the oesophagus. This
causes symptoms of heartburn, such as a burning pain or a feeling of discomfort
in your stomach and chest.
Exactly what causes the LOS to become weakened is
not always clear, but a number of risk factors have been identified.
Risk factors
- being overweight or obese – this can place an increased pressure on your stomach, which in turn can weaken the LOS
- stress
- having a diet high in fatty foods – the stomach takes longer to dispose of stomach acids after digesting a fatty meal
- consuming tobacco, alcohol, coffee, or chocolate – it has been suggested that these four substances may relax the LOS
- being pregnant – changes in hormone levels during pregnancy can weaken the LOS and increase pressure on your stomach
- having a hiatus hernia – a hiatus hernia is where part of your stomach pushes up through your diaphragm (the sheet of muscle used for breathing)
There is also a condition
called gastroparesis, where the stomach takes longer to dispose of stomach
acid. The excess acid can push up through the LOS. Gastroparesis is common in people who have
diabetes, because high blood sugar levels can damage the nerves that
control the stomach.
There are a number of medications that can relax
the LOS, leading to the symptoms of GORD.
These include:
These include:
- calcium-channel blockers – a type of medication used to treat high blood pressure
- non-steroidal anti-inflammatory drugs (NSAIDs) – a type of painkiller, such as ibuprofen
- selective serotonin reuptake inhibitors (SSRIs) – a type of antidepressant
- corticosteroids (steroid medication) – which are often used to treat severe symptoms of inflammation
- bisphosphonates – used to treat osteoporosis (weakening of the bones)
- nitrates – a medication used to treat angina (a condition that causes chest pain).
Symptoms
The three most common symptoms of
gastro-oesophageal reflux disease (GORD) are:
- heartburn
- regurgitation of acid into your throat and mouth
- dysphagia (difficulty swallowing)
1. Heartburn
Heartburn is a burning pain or a feeling of
discomfort that develops just below your breastbone. The pain is usually worse
after eating, or when bending over or lying down.
2. Regurgitation
Regurgitation of acid usually causes an unpleasant,
sour taste at the top of your throat or the back of your mouth.
3. Dysphagia
Around one in three people with GORD has problems
swallowing (dysphagia). It can occur if the stomach acid causes scarring of the
oesophagus, which leads to the oesophagus narrowing, making it difficult to
swallow food. People with GORD-associated dysphagia say it feels
like a piece of food has become stuck somewhere near their breastbone.
Less
common symptoms of GORD
GORD can sometimes have a number of less common
symptoms associated with the irritation and damage caused by stomach acid.
Less common symptoms of GORD include:
- nausea (feeling sick)
- persistent cough, often worse at the night
- chest pain
- wheezing
- tooth decay
- laryngitis (inflammation of the larynx), which causes throat pain and hoarseness
If you have asthma and GORD, your asthma
symptoms may get worse as a result of stomach acid irritating your airways.
When to
seek medical advice
If you are only experiencing symptoms such as
heartburn once or twice a month, then you probably do not need to seek
treatment from your physician.
You should be able to control symptoms by making a number of lifestyle changes and using over-the-counter medication as and when symptoms occur. You should see your doctor if you are having frequent or severe symptoms and finding yourself using over-the-counter medication on a weekly or daily basis. You may require prescription medication to control symptoms and prevent complications.
You should be able to control symptoms by making a number of lifestyle changes and using over-the-counter medication as and when symptoms occur. You should see your doctor if you are having frequent or severe symptoms and finding yourself using over-the-counter medication on a weekly or daily basis. You may require prescription medication to control symptoms and prevent complications.
Diagnosing
gastro-oesophageal reflux disease
In most cases, your doctor will be able to diagnose
gastro-oesophageal reflux disease (GORD) by asking questions about your
symptoms.
Further testing for GORD is usually only required
if:
- you have dysphagia (difficulty swallowing)
- your symptoms do not improve despite taking medication
Further testing aims to confirm or disprove the
diagnosis of GORD while checking for any other possible causes of your
symptoms, such as irritiable bowel syndrome.
Endoscopy
An endoscopy is a procedure where the inside
of your body is directly examined using an endoscope. An endoscope is a long, thin flexible tube that has
a light source and video camera at one end so that images of the inside of your
body can be sent to an external monitor.
To confirm a diagnosis of GORD, the endoscope will
be inserted into your mouth and down your throat. The procedure is usually done
while you are awake, and you may be given a sedative to help you to relax.
An endoscopy is used to check whether the surface
of your oesophagus has been damaged by stomach acid. It can also rule out more
serious conditions that can also cause heartburn, such as stomach cancer.
Manometry
If an endoscopy does not find any evidence of
damage to your oesophagus, you may be referred for a further test called
manometry. Manometry is used to assess how well your lower
oesophageal sphincter (LOS) is working by measuring pressure levels inside the
sphincter muscle.
During manometry, one of your nostrils will be
numbed using a topical anaesthetic. A small tube will then be passed down your
nostril and into your oesophagus to the site of the LOS. The tube contains a
number of pressure sensors, which can detect the pressure generated by the
muscle, then send the reading to a computer.
During the test, you will be asked to swallow some
food and liquid to check how effectively your LOS is functioning. A manometry test takes around 20 to 30 minutes to
complete. It is not painful, but you may have minor side effects including:
- a nosebleed
- a sore throat
However, these side effects should pass quickly
once the test has been completed. Manometry can be useful for confirming a diagnosis
of GORD, or for detecting less common conditions that can disrupt the normal
workings of the LOS, such as muscle spasms or achalasia (a rare swallowing
disorder).
Barium
swallow
If you are experiencing symptoms of dysphagia then
you may be referred for a test known as a barium swallow. The barium swallow test is one of the most
effective ways of assessing your swallowing ability and finding exactly
where the problems are occurring. The test can often identify blockages or
problems with the muscles used during swallowing.
As part of the test, you will be asked to drink
some barium solution. Barium is a non-toxic chemical that is widely used in
tests because it shows up clearly on an X-ray. Once the barium moves down into
your upper digestive system, a series of X-rays will be taken to identify any
problems.
If you need to have a barium meal X-ray, you will
not be able to eat or drink anything for at least six hours before the
procedure so that your stomach and duodenum (top of the small intestine) are
empty. You may be given an injection to relax the muscles in your digestive
system.
You will then lie down on a couch and your
specialist will give you a white, chalky liquid to drink which contains barium.
As the barium fills your stomach, your specialist will be able to see your
stomach on an X-ray monitor, as well as any ulcers or abnormal growths. Your
couch may be tipped slightly during the test so that the barium fills all the
areas of your stomach.
A barium swallow usually takes about 15 minutes to
perform. Afterwards you will be able to eat and drink as normal, although you
may need to drink more water to help flush the barium out of your system. You
may feel slightly sick after a barium meal X-ray, and the barium may cause
constipation. Your stools may also be white for a few days afterwards as the
barium passes through your system.
24-hour
pH monitoring
If the manometry test cannot find problems
with your oesophageal sphincter muscles, another test known as 24-hour pH
monitoring can be used (pH is a unit of measurement used in chemistry, and describes
how acidic a solution is). The lower the pH level, the more acidic the solution
is.
The 24-hour pH monitoring test is designed to
measure pH levels around your oesophagus. You should stop taking medication
used to treat GORD for seven days before having a 24-hour pH test because the
medication could distort the test results. During the test, a small tube containing a probe
will be passed through your nose to the back of your oesophagus. This is not
painful but can feel a little uncomfortable.
The probe is connected to a portable recording
device about the size of an MP3 player, which you wear around your wrist.
Throughout the 24-hour test period, you will be asked to press a button on the
recorder every time you become aware of your symptoms. You will be asked to complete a diary sheet by
recording when you have symptoms upon eating. Eat as you normally would to
ensure an accurate assessment can be made.
After the 24-hour period is over, the probe will be
removed so measurements on the recorder can be analysed. If test results
indicate a sudden rise in your pH levels after eating, a confident diagnosis of
GORD can usually be made.
Treating
gastro-oesophageal reflux disease
A number of self-care techniques may help relieve
symptoms of gastro-oesophageal reflux disease (GORD). They are described below.
- If you are overweight, losing weight may help reduce the severity and frequency of your symptoms because it will reduce pressure on your stomach.
- If you are a smoker, consider quitting. Tobacco smoke can irritate your digestive system and may make symptoms of GORD worse.
- Eat smaller, more frequent meals, rather than three large meals a day. Make sure you have your evening meal three to four hours before you go to bed.
- Be aware of triggers that make your GORD worse. For example, alcohol, coffee, chocolate, tomatoes, or fatty or spicy food. After you identify any food that triggers your symptoms, remove them from your diet to see whether your symptoms improve.
- Raise the head of your bed by around 20cm (8 inches) by placing a piece of wood, or blocks under it. This may help reduce your symptoms of GORD. However, make sure your bed is sturdy and safe before adding the wood or blocks. Do not use extra pillows because this may increase pressure on your abdomen.
If you are currently taking medication for other
health conditions, check with your doctor to find whether they may be
contributing to your symptoms of GORD. Alternative medicines may be available.
Do not stop taking a prescribed medication without consulting your physician
first.
Medication
A number of different medications can be used to
treat GORD. These include:
- over-the-counter medications
- proton-pump inhibitors (PPIs)
- H2-receptor antagonists
- prokinetics
Depending on how your symptoms respond, you may
only need medication for a short while or alternatively on a long-term basis.
Over-the-counter medications
A number of over-the-counter medicines can help
relieve mild to moderate symptoms of GORD. Antacids are medicines that neutralise the effects
of stomach acid. However, antacids should not be taken at the same time as
other medicines because they can stop other medicines from being properly
absorbed into your body. They may also damage the special coating on some types
of tablets. Ask your doctor or pharmacist for advice.
Alginates are an alternative type of medicine to
antacids. They work by producing a protective coating that shields the lining
of your stomach and oesophagus from the effects of stomach acid.
If GORD fails to respond to the self-care
techniques described above, your physician may prescribe a one month course of
proton-pump inhibitors (PPIs) for you. PPIs work by reducing the amount of
acid produced by your stomach.
Most people tolerate PPI well and side effects are uncommon.
Most people tolerate PPI well and side effects are uncommon.
When they do occur they are usually mild and may
include:
- headaches
- diarrhoea
- nausea (feeling sick)
- abdominal (tummy) pain
- constipation
- dizziness
- skin rashes
In order to minimise any side effects, your doctor
will prescribe the lowest possible dose of PPIs that they think will be
effective in controlling your symptoms. Therefore, inform your physician if
they prescribe PPIs for you that prove ineffective. A stronger dose may be
needed.
Sometimes, the symptoms of GORD can return after a
course of PPIs has been completed. Go back to see your doctor if you have
further or persistent symptoms.
In some cases you may need to take PPIs on a long-term
basis.
If PPIs cannot control your symptoms of GORD,
another medicine known as an H2-receptor antagonist (H2RA) may be recommended
to take in combination with PPIs on a short-term basis (two weeks), or as an
alternative to them.
H2RAs block the effects of the chemical histamine,
used by your body to produce stomach acid. H2RAs therefore help reduce the
amount of acid in your stomach. Side effects of H2RAs are uncommon. However,
possible side effects may include:
- diarrhoea
- headaches
- dizziness
- tiredness
- a rash
Some types of H2RAs are available as
over-the-counter medicines. These types of HR2As are taken in a lower dosage
than the ones available on prescription. Ask your doctor or pharmacist if you
are not sure whether these medicines are suitable for you.
If your GORD symptoms are not responding to other
forms of treatment, your physician may prescribe a short-term dose of a
prokinetic. Prokinetics speed up the emptying of your stomach,
which means there is less opportunity for acid to irritate your oesophagus.
A small number of people who take prokinetics have
what is known as ‘extrapyramidal symptoms’. Extrapyramidal symptoms are a
series of related side effects that affect your nervous system. Extrapyramidal
symptoms include:
- muscle spasms
- problems opening your mouth fully
- a tendency to stick your tongue out of your mouth
- slurred speech
- abnormal changes in body posture
If you have the above symptoms while taking
prokinetics, stop taking them and contact your doctor or out-of-hours doctor
immediately. They may recommend your dose is discontinued.
Extrapyramidal symptoms should stop within 24 hours of the medicine being withdrawn. Prokinetics are not usually recommended for people under 20 years old because of an increased risk of extrapyramidal symptoms.
Extrapyramidal symptoms should stop within 24 hours of the medicine being withdrawn. Prokinetics are not usually recommended for people under 20 years old because of an increased risk of extrapyramidal symptoms.
Surgery is usually only recommended in cases of
GORD that fail to respond to the treatments listed above. Alternatively, you may wish to consider surgery if
you have persistent and troublesome symptoms but do not want to take medication
on a long-term basis.
While surgery for GORD can help relieve your
symptoms, there are some associated complications that may result in you
developing additional symptoms, such as:
- dysphagia (difficulty swallowing)
- flatulence
- bloating
- an inability to belch (burp)
Discuss the advantages and disadvantages of surgery
with your physician before making a decision about treatment.
Surgical procedures that are used to treat GORD
include:
- laparoscopic nissen fundoplication (LNF)
- endoscopic injection of bulking agents
- endoluminal gastroplication
- endoscopic augmentation with hydrogel implants
- endoscopic radiofrequency ablation
Laparoscopic nissen fundoplication (LNF) is one of
the most common surgical techniques used to treat GORD. LNF is a type of keyhole surgery that involves the
surgeon making a series of small incisions (cuts) in your abdomen (tummy).
Carbon dioxide gas is then used to inflate your abdomen to give the surgeon
room to work in.
During LNF, the surgeon will wrap the upper section
of your stomach around your oesophagus and staple it in place. This will
contract (tighten) your lower oesophageal sphincter (LOS), which should prevent
any acid moving back out of your stomach.
LNF is carried out under general anaesthetic, which
means you will not feel any pain or discomfort. The surgery takes 60 to 90
minutes to complete. After having LNF, most people can leave hospital
once they have recovered from the effects of the general anaesthetic. This is
usually within two to three days. Depending on the type of job you do, you
should be able to return to work within three to six weeks.
For the first six weeks after surgery, it is
recommended you only eat soft food, such as mince, mashed potatoes or soup.
Avoid eating hard food that could get stuck at the site of the surgery, such as
toast, chicken or steak.
Common side effects of LNF include:
- dysphagia (difficulty swallowing)
- belching
- bloating
- flatulence
These side effects should resolve over the course
of a few months. However, in about 1 in 100 cases they can be persistent. In
such circumstances, further corrective surgery may be required.
In the last decade, a number of new surgical
techniques have been introduced for the treatment of GORD. The National Institute for Health and Clinical
Excellence (NICE) has looked at a number of these surgical techniques. It has
recommended they are safe enough to be made available on the NHS.
However, NICE has also recommended that people
considering having these new techniques be aware there is little evidence
regarding their effectiveness in the medium to long-term. All techniques discussed below are non-invasive,
which means no incisions need be made into your body. Therefore, they can
usually be performed under local anaesthetic on a day surgery basis, so you
should not have to spend the night in hospital.
Endoscopic injection of bulking agents involves the
surgeon using an endoscope to find the site where stomach and oesophagus meet
(known as the gastro-oesophageal junction). A thin tube called a catheter is then passed down
the endoscope, and used to inject a combination of plastic and liquid into the
junction. This narrows the junction and helps to prevent acid leaking up from
the stomach.
The most common side effect of this type of surgery
is mild to moderate chest pain. This develops in around a half of all cases. Other side effects include:
- dysphagia
- nausea (feeling sick)
- high temperature of 38ºC (100.4ºF) or higher
These side effects should resolve within a few
weeks.
Endoluminal gastroplication involves the surgeon
using an endoscope to sow a series of pleats (folds) into the LOS. The pleats
should restrict how far the LOS can open, preventing acid leaking up from your
stomach. Side effects of this type of surgery include:
- chest pain
- abdominal (tummy) pain
- vomiting
- sore throat
These side effects should improve within a few
days.
Endoscopic augmentation with hydrogel implants is a
similar technique to an endoscopic injection, except the surgeon uses hydrogel
to narrow your gastro-oesophageal junction. Hydrogel is a type of flexible
plastic gel very similar to living tissue.
The most common complication arising from this
procedure is that the hydrogel starts to come out of the gastro-oesophageal
junction. One study found this happened in one in five cases. However, this is
a relatively new technique and success rates may well improve in future.
In endoscopic radiofrequency ablation, the surgeon
passes a balloon down an endoscope to the site of your gastro-oesophageal
junction. The balloon is then inflated. Tiny electrodes are attached to the outside of the
balloon and small pulses of heat generated. This creates small scars in the
tissue of your oesophagus, causing it to narrow and making it more difficult
for stomach acid to leak out of your stomach.
Out of all the new surgical techniques mentioned,
there is little known about the safety of endoscopic radiofrequency ablation.
Possible complications and side effects may include:
- chest pain
- dysphagia
- injury to the oesophagus
A new type of surgery introduced in 2011, not yet
considered by NICE, is the LINK Reflux Management System. This type of keyhole surgery uses magnetic beads to
reinforce the LOS muscle. The magnetic force of the beads helps keep the
LOS closed when at rest, preventing stomach acid leaking upwards. The LOS opens
normally when swallowing.
This type of surgery appears effective and safe in
the short-term but as it is a new technique, its long-term effectiveness and
safety are unclear. The availability of this type of surgery on the NHS
is currently limited, although a number of private clinics have started
offering it. The price for private treatment is in the region of £8,000 to
£9,000.
Complications
of gastro-oesophageal reflux disease
The excess acid produced by gastro-oesophageal
reflux disease (GORD) can damage the lining of your oesophagus (oesophagitis)
which can lead to the formation of ulcers. The ulcers can bleed, causing pain
and making swallowing difficult. Ulcers can usually be successfully treated by
controlling the underlying symptoms of GORD.
Medications used to treat GORD can take several
weeks to become effective, so it is likely your physician will recommend
additional medication to provide short-term relief from your symptoms. Two types of medication that can be used are:
- antacids to neutralise stomach acid on a short-term basis
- alginates, which produce a protective coating on the lining of
your oesophagus
Both antacids and alginates are over-the-counter
medications available from pharmacists. The pharmacist will advise you on the
types of antacid and alginate most suitable for you. Antacids are best taken when you have symptoms, or
when symptoms are expected, such as after meals or at bedtime. Alginates are
best taken after meals.
Side effects for both medications are uncommon but
include:
- diarrhoea
- vomiting
- flatulence
Repeated damage to the lining of your oesophagus
can lead to the formation of scar tissue. If the scar tissue is allowed to
build up, it can cause your oesophagus to become narrowed. This is known as
oesophageal stricture.
An oesophageal stricture can make swallowing food
difficult and painful. Oesophageal strictures can be treated by using a tiny
balloon to dilate (widen) the oesophagus. This procedure is usually carried out
under a local anaesthetic.
Repeated episodes of GORD can lead to changes in
the cells lining of your lower oesophagus. This is a condition known as
Barrett’s oesophagus. It is estimated that 1 in 10 people with GORD will
develop Barrett’s oesophagus. Most cases of Barrett’s oesophagus first develop
in people aged 50-70 years old. The average age at diagnosis is 62 years old.
Barrett’s oesophagus does not usually cause
noticeable symptoms other than those associated with GORD. The concern is that Barrett’s oesophagus is a
pre-cancerous condition. This means that while changes in the cells are not
cancerous, there is a small risk they could develop into ‘full blown’ cancer in
the future. This would then trigger the onset of oesophageal cancer.
Each year in England it is estimated that 1 in
every 200 people with Barrett’s oesophagus develop oesophageal cancer. Risk
factors that increase the risk of cells in the lining of your oesophagus
turning cancerous include:
- being male
- smoking
- having the symptoms of GORD for longer than 10 years
- having three or more episodes of heartburn and related symptoms a week
- obesity
If it is thought that you have an increased risk of
developing oesophageal cancer, it is likely you will be referred for regular
endoscopies to monitor the condition of the affected cells. If oesophageal cancer is diagnosed in its initial
stages, it is usually possible to cure the cancer using a treatment called
photodynamic therapy (PDT).
PDT involves injecting your oesophagus with a
medication that makes it sensitive to the effects of light. A laser
attached to an endoscope is then placed inside your oesophagus and burns away
the cancerous cells.
Source: NHS Choices.
http://healthitis.blogspot.com
Source: NHS Choices.
http://healthitis.blogspot.com