Have you ever heard this term, gastro- oesophageal reflux disease (GORD)? Even though you have not heard this you may have seen lot of patients complain features like heartburn and regurgitation , some use the term “ Gastritis” mistakenly for this condition.
A large number of patient attend to surgical clinics with feature of GORD. According to the available statistics both male and females equally affects from this.
As a definition GORD is a motility disorder characterised primarily by heartburn and caused by the reflux of gastric contents into the oesophagus ( food pipe).
Symptoms and Signs of GORD
Heart burn is the most common symptom which is retrosternal burning pain, with or without radiation to neck and jaw area, most commonly developed after meal and most of the times relived by antacids. But always a possibility of underlying heart attack should be considered as the typical pain developed in heart attacks are similar to this.
Regurgitation or perception of of retrograde flow of stomach contents into throat or mouth is also a common symptom. Usually these symptoms worse in lying down( supine) position, some patient awake from sleep due to regurgitation , heart burn and cough. In addition to this major symptoms excessive salivation, bad smelling from mouth(Halitosis) , feeling of a lump in the throat and belching are not uncommon.
There are few non gastrointestinal symptoms( which are not confined to the for pathway) are there. They are wheezing, cough and change in voice ( hoarseness of voice).
When the symptoms like difficulty of swallowing (disphagea), pain during swallowing, unintended weight loss, nausea and vomiting and bleeding from gastrointestinal tract( blood vomiting or dark colour stools) are called alarm symptoms because GORD pur se not causing them. They may be a symptoms of oesophageal cancer, liver disease or even stomach cancer.
Cause and Risk Factors for GORD
The major causes for GORD is the incompetent or loose (Hypotonic) lower oesophageal sphincter. This could be due permanent or transient. Protrusion of gastro-oesopageal junction or part of the stomach through the diaphragm into thoracic cavity(hiatus hernia) and some drugs like Verapamil, Nifedipine( Calcium Channel blockers) , Nitrates , Theophylline and sedatives relaxes the sphincter transiently. Some foods like chocolate, peppermint, coffee, onions and alcohol also contribute to that. Tobacco use also a contributing factor.
Complications of gastro- oesophageal reflux disease
Complications of GORD includes erosions of the oesophageal mucosa , ulceration and bleeding, changes in oesophageal mucosa- a condition called Barrett oesophagus which has a malignant potential, oesophageal strictures( narrowing), oesophageal cancers and extra-oesphageal complications like dental erosions due to acids, chronic cough and asthma due to micro aspiration.
Diagnosis of gastro- oesophageal reflux disease
The diagnosis of the GORD is clinical. The doctor will make the diagnosis clinically if the patient complains are typical for GORD and if the clinical features are uncertain a trial of drugs( Proton pump inhibitors like omeprazole ) can be tried. If the patient responds well to the drug the diagnosis is more favour of GORD. If the alarm symptoms are present( mentioned above) or not responding to the trial of treatment diagnostic studies are occupied.
The main diagnostic studies are the Upper Gastrointestinal Endoscopy( UGIE) which visualise your oesophagus , stomach and duodenum with a tube which contains a camera. Which may show changes in the mucosa of the lower oesophagus due to exposure to gastric acids. If there are significant mucosal changes, biopsy ( a small piece of tissue for testing) would be taken for pathological studies.
If endoscopy is non-diagnostic or response to therapy is incomplete, there are some tests called oesophageal manometry, wireless pH telemetry capsule studies and ambulatory 24 hour pH monitoring. These type of procedures usually occupied in gastroenterologist in Sri Lanka but not routinely practised in general surgical units as lack of resources and the relative cost.
Usually imaging/ radiological studies are not use in diagnosis of GORD but can be use for excluding other possibilities.
If the patient is having heartburn always exclusion of heart related conditions is a must, usually with an ECG.
Treatment for GORD
With regard to the treatment the goals of treatment are, symptomatic relief, prevent complications ,allowing the mucosa to heal and improve the quality of life of the patient.
Lifestyle modifications can be tried in most of the patients and will help full in relieving symptoms and complications. The lifestyle modifications include raising the head end of the bed( Not by keeping pillows, but the whole bed) , weight reduction, avoid large meals, having meals at least 2 hours before bedtime, avoid much spicy and fatty meals and smoking cessation.
Drug therapy antacids, H2 receptor blockers and proton pump inhibitors mainly.
Antacids can be adequate for patients with occasional, mild symptoms. Commonly using antacids in Sri Lanka are Aluminum Hydroxide, Magnesium Hydroxide Oral suspension and Aluminum hydroxide–magnesium carbonate.
H2 receptor blockers give symptomatic relief by reducing the gastric acid secretion. This category includes Ranitidine, Famotidine and Cimetidine.
Proton pump inhibitors are also reduce gastric acid secretion but mechanism is different from H2 receptor blockers. PPIs are more effective than H2 receptor blockers. The commonly using PPIs in Sri Lanka are Omeprazole and Pantoprazole. Initial treatment with once daily dose before the first meal of the day but depending on the response adjust unto twice daily dose. This should be continued unto 8 weeks for better response.
Baclofen is adjunct treatment of symptomatic GORD patients who do not respond to twice-daily proton pump inhibitors. It inhibits transient lower oesophageal sphincter relaxations but not very commonly practicing in Sri Lanka.
Surgical correction or Gastric Fundoplication surgery is not offered to all the patient with GORD. Indications for surgical correction are
- Patients with complicated GORD
- Patients who are young but who needs lifelong acid suppression medications.
- Symptomatic GORD who refuse/cannot afford to take lifelong medications
This surgery can be done laparoscopically or as an open surgery. Laparoscopic surgery is recommended due to less post operative compications- less hospital stay, less pain and early recovery, small scars.
If you have symptoms of GORD , you can consult a Gastroenterologist , Gastroenterological Surgeon or a General Surgeon. Self medication is not recommended and always seek medical advice before taking medication because exclusion of other serious condition is essential before treatment.