Gastro-Oesophageal Reflux Disease - Health Information from Wye Surgery

Gastro-oesophageal reflux disease (GORD) is a very common complaint, affecting up to 40% of adults in its mildest form.  It is characterised by symptoms arising when stomach juices come in contact with the lining of the oesophagus or gullet.  Typical symptoms are heartburn and pain behind the breast bone related to eating, bending over or lying down.  Other symptoms include upper abdominal pain, regurgitation, difficulty swallowing and occasionally nausea and upper backache.  GORD is usually caused by the stomach acid though occasionally it may be caused by alkaline bile.
Reflux of stomach contents into the lower oesophagus is not abnormal but when it is frequent and prolonged then it causes inflammation and symptoms.  There are several natural mechanisms which should prevent reflux:
∑ the muscle at the lower end of the oesophagus should close it
∑ the part of the oesophagus below the diaphragm should act as a one-way valve when abdominal pressure goes up
∑ the diaphragm should restrict backward flow
∑ the rhythmic contractions of the oesophagus should send food towards the stomach
Patients with hiatus hernia do not have the one-way valve action but this does not mean that they invariably get symptoms, in fact they often don’t.  Only a tiny percentage of patients with reflux will have inflammation of the oesophagus (oesophagitis) when investigated by endoscopy.  Patients with the worst symptoms are found to have prolonged and frequent episodes of strong acidity in the oesophagus, when the acidity is monitored over 24hours.
Generally, the diagnosis can be made from the symptoms described.  If needed endoscopy is the investigation of choice as the extent of damage caused can be assessed and more serious problems, such as strictures and cancer, can be excluded.  X-ray monitoring of a barium meal is occasionally used to check for abnormal muscular movements and can detect strictures, ulcers and cancers. The detection and treatment of the bacteria Helicobacter pylori (responsible for stomach and duodenal ulcers) makes little difference to reflux.
By making lifestyle changes, reflux symptoms can be greatly reduced.  Fatty foods and stress delay stomach emptying; smoking relaxes the muscle at the bottom of the oesophagus; alcohol increases acid production; obesity and pregnancy disturb the natural anti-reflux mechanisms, which are also put under strain by exertion, bending over and lying down after eating.  In addition, certain drugs are associated with GORD: non-steroidal anti-inflammatories, such ibuprofen or diclofenac; oral steroids; some osteoporosis treatments; calcium-channel blockers, used to treat high blood pressure and angina, and theophyllines, including caffeine.
If lifestyle changes do not control reflux then medication is required.  Antacids may help a bit but are more effective when combined with alginates, which form a raft floating on the stomach contents, reducing reflux into the oesophagus.  Ranitidine (available over the counter as Zantac) and other drugs in this group block the histamine stimulation of acid production.  This group of drugs have relatively few side effects and are effective, though their action only lasts six to eight hours.  The group of drugs known as proton pump inhibitors (PPIs) e.g. omeprazole and lansoprazole produce a powerful reduction in acid production and provide good symptom control.  PPIs are the mainstay of treatment but they are expensive.  When you know that English GPs wrote nearly 33 million prescriptions for them in 2008, costing £208 million, it makes you realise that we pay a high price for being a dyspeptic nation!  In the past, we encouraged people to use PPIs on a regular basis but we now know that most people can manage their symptoms with a lower dose, used as required.  PPIs used to be given in the morning but as symptoms often arise overnight, it is often better to take them later in the day, remembering that they are absorbed better on an empty stomach.  Stomach emptying is delayed in as many as 40% of patients and so drugs that speed up this process can help.  A few patients, especially younger ones and those with large volume reflux, benefit from laparoscopic surgery.
Gastro-oesophageal reflux is a common problem which is well worth discussing with your GP, so that you can work out a management plan together.  It is especially important to consider further investigation by endoscopy if you have any unexplained weight loss, bleeding from the gut, persistent vomiting, iron-deficiency anaemia or  if food seems to get stuck when swallowing.
Roz Waller
Wye Surgery – March 2010

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This Winter 2010 News artile was created on 3rd March 2010

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