Gastro-oesophageal reflux disease

Introduction

GORD is a common condition where gastric acid refluxes into the oesophagus, often due to weakening of the lower oesophageal sphincter (LES). This leads to irritation of the oesophageal lining and a variety of symptoms, which may be chronic and significantly affect quality of life.

Peak Incidence

• Most commonly affects individuals aged 40 years and above.

Pathophysiology

• Incompetence or transient relaxation of the lower oesophageal sphincter allows acidic stomach contents to reflux into the oesophagus.
• Contributing factors include hiatus hernia, obesity, delayed gastric emptying, and certain foods or drugs that reduce LES tone (e.g. caffeine, alcohol, anticholinergics).

Symptoms

• Heartburn – Burning sensation behind the sternum, especially after meals or when lying down.
• Acid regurgitation – Sour or bitter-tasting fluid backing up into the throat or mouth.
• Retrosternal or epigastric pain – Often described as burning or pressure-like.
• Bloating – Sensation of fullness or discomfort in the upper abdomen.
• Nocturnal cough – Due to aspiration of acid into the airways during sleep.
• Hoarseness or sore throat – Resulting from acid-related irritation of the larynx.

Signs

• Dental erosion – Enamel damage due to chronic acid exposure.
• Water brash – Excess salivation triggered by acid reflux.
• Halitosis – Bad breath associated with regurgitation.

Diagnosis

Clinical Diagnosis

• Based on characteristic symptoms (e.g. heartburn and regurgitation). No investigation needed if typical symptoms respond to empirical treatment.

Indications for Endoscopy

• Presence of alarm features such as:
  • Dysphagia
  • Unintentional weight loss
  • Gastrointestinal bleeding (e.g. melaena, haematemesis)
  • Persistent symptoms despite ≥4 weeks of acid suppression therapy
  • Anaemia

Other Investigations

• 24-hour oesophageal pH monitoring – Gold standard for confirming acid reflux, especially if endoscopy is normal.
• Oesophageal manometry – Assesses oesophageal motility and LES function; used if motility disorder (e.g. achalasia) is suspected.
• Barium swallow – Helps identify structural abnormalities such as hiatus hernia or strictures; not routinely used.

Complications

• Oesophagitis – Inflammation from chronic acid exposure.
• Oesophageal ulcers – Can cause pain and bleeding.
• Iron-deficiency anaemia – Due to occult or overt bleeding from oesophageal erosions or ulcers.
• Benign strictures – Fibrotic narrowing causing progressive dysphagia.
• Barrett’s oesophagus – Metaplasia of the lower oesophageal lining; premalignant.
• Oesophageal adenocarcinoma – Increased risk in patients with longstanding Barrett’s.
• Aspiration pneumonia – From gastric contents entering the lungs, particularly at night.

Management

Lifestyle Modifications

• Avoid large or late meals.
• Weight loss if overweight or obese.
• Elevate the head of the bed when sleeping.
• Avoid dietary triggers (e.g. caffeine, chocolate, spicy foods).
• Stop smoking and limit alcohol intake.
• Remain upright after meals for at least 30 minutes.

Pharmacological Treatment

• Proton pump inhibitors (PPIs) – e.g. omeprazole; first-line treatment to reduce acid secretion.
• H2 receptor antagonists – e.g. famotidine; alternative or adjunct if PPIs are not tolerated.
• Antacids/alginates – e.g. Gaviscon; provide symptomatic relief by neutralising acid.

Surgical Treatment

• Laparoscopic fundoplication – Involves wrapping the gastric fundus around the lower oesophagus to reinforce the LES; considered in selected cases where medical therapy fails or is not tolerated.