GORD

GORD is a very common condition, which is characterised by symptoms of heartburn and regurgitation.

Gastro-oesophageal reflux disease (GORD), is an extremely common condition. It is defined as reflux of stomach contents into the oesophagus, which is associated with troublesome symptoms and/or complications.

In Western European and North American populations, the estimated prevalence is as high as 10-20%.

Gastro-oesophageal reflux is a normal physiological phenomenon.

Under normal circumstances, the oesophagus propels food into the stomach by peristalsis (involuntary muscle contraction). At the gastro-oesophageal junction (where the oesophagus and stomach meet), a physiology sphincter relaxes to allow food to enter the stomach. This is known as the lower oesophageal sphincter (LOS). After entry, the sphincter contracts to prevent reflux of stomach contents.

If the LOS relaxes inappropriately, stomach content will wash back into the oesophagus. This is a normal physiological response in most people. The episodes are brief and do not causes symptoms. 

In some individuals, reflux of stomach contents causes troublesome heartburn symptoms and can cause damage to the oesophageal lining. Over time, this may lead to complications including erosions, strictures and Barrett’s oesophagus. Factors implicated in GORD include:

• Frequency of reflux episodes
• Acidity of the stomach content
• Clearance of acid from the oesophagus.

High BMI and smoking are linked to development of GORD.

Common risk factors

• High BMI
• Smoking
• Genetic association
• Pregnancy
• Hiatus hernia: part of the upper stomach pushes up through the diaphragm 
• NSAIDs, caffeine & alcohol: conflicting reports

The cardinal symptom of GORD is heartburn, which describes a burning sensation in the centre of the chest.

Heartburn classically occurs after meals and is made worse by lying down or bending forward. 

Other common features

• Regurgitation
• Dyspepsia
• Chest pain
• Dysphagia (difficulty swallowing)
• Odynophagia (painful swallowing)
• Cough
• Hoarse voice
• Nausea and/or vomiting

Collectively, the clinical manifestations of GORD can be divided into oesophageal and extra-oesophageal syndromes.

Oesophageal

• Typical reflux syndrome
• Reflux chest-pain syndrome
• Reflux oesophagitis (inflammation and damage of oesophageal mucosa)
• Reflux stricture (narrowing of oesophagus)
• Barrett’s oesophagus (premalignant condition in the oesophagus)
• Oesophageal adenocarcinoma

Extra-oesophageal

• Reflux cough syndrome
• Reflux laryngitis syndrome
• Reflux asthma syndrome
• Reflux dental erosion syndrome
• Proposed associations: idiopathic pulmonary fibrosis, sinusitis, etc

GORD is a clinical diagnosis based on characteristic symptoms.

GORD is extremely common and can be diagnosed based on characteristic symptoms. There are several red flags, which should make you concerned about an alternative diagnosis and need for upper gastrointestinal (GI) endoscopy (i.e. gastroscopy). In patients with red flag symptoms, gastroscopy is important to exclude malignancy of the upper GI tract and complications of GORD (i.e. stricture, Barrett’s). 

Red flags

• Weight loss
• Anaemia
• Dysphagia
• New onset dyspepsia (>55 years)
• Symptoms refractory to treatment

It may be difficult to distinguish reflux-associated chest pain from cardiac chest pain.

Differential diagnosis of heartburn:

• Functional heartburn
• Achalasia (failed relaxation of LOS)
• Eosinophilic oesophagitis
• Pericarditis
• Ischaemic heart disease
• Peptic ulcer disease
• Malignancy

The two key investigations in GORD are gastroscopy and pH monitoring.

pH monitoring

This may be utilised where the diagnosis is uncertain or surgery is being considered. It should be combined with gastroscopy. There are two techniques for assessing pH: 24-hour pH testing or prolonged wireless pH capsule testing.

• 24-hour pH monitoring: small tube inserted through the nose and positioned in lower oesophagus. Can be combined with high resolution manometry (assesses motor abnormalities of the oesophagus). 
• Wireless pH capsules testing: insertion of pH capsule at gastro-oesophageal junction during gastroscopy. Carry recording device to capture episodes. Will naturally fall off wall of oesophagus and pass through GI tract. 

Gastroscopy 

Gastroscopy is usually reserved for patients with red flags symptoms, suspected complications, symptoms refratory to treatment or those being considered for surgery. 

Gastroscopy is able to diagnose the presence of oesophagitis, Barrett’s oesophagus or an alternative diagnosis (i.e. oesophageal/gastric malignancy). Up to 50% of patients with GORD will have a normal gastroscopy. 

Los Angeles classification

The severity of oesophagitis can be graded into A-D using the Los Angeles classification:

• Grade A: ≥1 mucosal break, each ≤ 5mm
• Grade B: ≥1 mucosal break > 5mm. Not continuous between top of mucosal folds.
• Grade C: ≥1 mucosal break, continuous between top of mucosal folds, not circumferential
• Grade D: mucosal breaks involving more than three quarters of luminal circumference.

Reflux can be divided into four different phenotypes based on endoscopy findings and pH monitoring.

Four reflux phenotypes:

• Erosive oesophagitis: erosions seen at gastroscopy
• Non-erosive oesophageal reflux: normal gastroscopy, but pathological acid exposure on pH testing
• Acid hypersensitive oesophagus: normal gastroscopy, non-pathological acid exposure on pH testing but temporal association of reflux events with symptoms
• Functional heartburn: normal gastroscopy, non-pathological acid exposure on pH testing and no temporal association of reflux events with symptoms.

The use of proton pump inhibitors (PPIs) is the cornerstone of treatment in GORD.

The management of GORD is broadly divided into conservative measures, medical treatments and surgical intervention.

Conservative

There is variable evidence for lifestyle modifications in GORD. These include weight loss, smoking cessation and dietary modifications. Patients should be advised to avoid eating within two hours of sleep and elevation of the head of the bed may be helpful. 

Medical 

PPIs form the cornerstone of GORD treatment. PPIs prevent acid production within the stomach through inhibition of H⁺/K⁺ ATPases in parietal cells. 

Patients with typical reflux symptoms can be offered a two-week PPI trial. Response is variable (40-90%). Alternative options include ranitidine, which is a histamine receptor antagonist, and over the counter antacids that can be used in combination with medications to neutralise stomach acid.

Patients with evidence of erosions should be offered PPIs to promote healing as they have the best efficacy. 

Surgical 

The role of surgery has increased over the last decade. The main option being a Nissen fundoplication. This procedure involves wrapping the fundus of the stomach around the lower oesophagus. A good response to PPI therapy is associated with a good response to surgery, so patient selection is paramount. 

Surgery is generally reserved for patients with clear evidence of reflux or associated complications who do not want to take medications or develop side-effects preventing long-term use.

The major complications associated with gastro-oesophageal reflux include erosions, stricture and Barrett’s oesophagus.

Reflux can lead to recurrent inflammation and damage of the oesophageal mucosa. This predisposes to erosions, stricture formation due to chronic scarring and malignant transformation.

• Erosive oesophagitis: Inflammation of the oesophagus, which can lead to ulcers, bleeding and peptic stricture formation.
• Stricture: scarring and narrowing of the oesophagus due to repeated damage. Can cause dysphagia. May require dilatation or stenting.
• Barrett’s oesophagus: a premalignant condition due to columnar metaplasia (transformation of one cell type to another) of the normal squamous oesophageal mucosa. Predisposes to the development of oesophageal adenocarcinoma.