What is gastro-oesophageal reflux disease (gord; usa gerd)
WHAT IS GASTRO-OESOPHAGEAL REFLUX DISEASE? 1. INTRODUCTION
The symptoms of gastro-oesophageal reflux (GORD) occur when stomach
acid inadvertently enters the oesophagus.
Heartburn - a rising burning sensation behind the breastbone.
Regurgitation - the sensation of acid or water flooding into the mouth.
Dysphagia or odynophagia - difficulty or pain on swallowing.
Dysphagia is usually felt behind the breastbone but may also be felt in the
Atypical symptoms of reflux disease include an unexplained hoarse voice,
nocturnal coughing, recurrent chest infections, angina-like chest pain related
to the ingestion of food, unexplained multiple dental caries, a constricting
sensation in the neck and smelly breath.
2. MECHANISMS OF REFLUX DISEASE
Keeping acid in the stomach requires an intact sphincter valve mechanism at
the point where the gullet meets the stomach. This complex sphincter relies
on specific muscle thickening at this point, pressure from the abdomen
transmitted directly onto the oesophagus and pressure on the oesophagus
from the adjacent stomach. If any of the components of this sphincter are
compromised, then acid will tend to rise from the stomach into the gullet and
give rise to the symptoms of GORD. The commonest mechanism for
compromising this sphincter is a hiatus hernia. This occurs when the lower
part of the oesophagus and the point where it joins the stomach is drawn into
There is also a tendency to reflux stomach contents into the gullet when the
stomach is full – e.g. after meals, where the pressure within the tummy cavity
is high – e.g. obesity and when the effects of gravity are eliminated – e.g.
lying down at night, bending or stooping. In addition, certain foods will tend to
slow down the emptying of the stomach and therefore allow greater
opportunity for stomach contents to reflux into the gullet. This is particularly
the case for foods containing fats and oils. Some foods may increase the
acidity in the stomach, these include citrus juices – e.g. orange and tomato
juice and some foods may be directly irritant to the oesophageal lining or
stomach – e.g. chilli and curry dishes. Finally, the actual muscle mechanism
at the lower end of the gullet is known to be affected by smoking, as
substances in cigarette smoke will cause relaxation of this sphincter. In
addition, once stomach acid enters the oesophagus and irritation of the
oesophageal lining occurs, this may also slow down the movement of
stomach contents back into the stomach and cause relaxation of the sphincter
As can be seen from this, the mechanism for ensuring stomach content does
not regurgitate into the oesophagus is complex but may be significantly
The treatment of gastro-oesophageal reflux falls into three main areas;
General measures, Medical treatment and Surgical Treatment.
a. General Measures
As gastro-oesophageal reflux can be made significantly worse by smoking,
high fat foods, large volume meals and obesity, measures should be taken to
try and tackle these particular problems. By stopping smoking reflux disease
may be abolished. Similarly by reducing the fats in the diet or by reducing
weight, reflux symptoms may significantly decrease. Meals should be
avoided after 8.00 o’clock in the evening for those who suffer from reflux
disease and large volumes of food or drink should be avoided to prevent the
volume effects of regurgitation. If reflux comes on when bending or stooping,
it is best to squat under these circumstances. Finally, reflux at night may be
controlled by elevating the head of the bed by approximately 10cm.
Traditionally by using a house brick under each bedpost (a brick with a ridged
indentation will tend to hold the bedpost more securely than a flat brick).
b. Medical Treatment
The mainstay of medical treatment is the use of antacids. There are many
formulations of these from simple tablets and lozenges to liquids. Some of
these liquids contain a substance that allows the medication to float on the
surface of the stomach fluid which then coats the lower oesophagus if reflux
occurs. (Gaviscon is the commonest example of this). These medications
can be bought over the counter at most chemists.
ii. H2 Antagonists - (Ranitidine, Cimetadine)
These drugs act by blocking the effects of histamine on the cells that generate
stomach acid in the lining of the stomach itself. They have been available for
many years and are effective in reducing stomach acid and the treatment of
reflux disease. These tables are now also available without prescription from
iii. Proton Pump Inhibitors – (e.g. Omeprazole, Esomeprazole, Lansoprazole, Pantoprazole and Rabeprazole)
These drugs are more effective at controlling stomach acid than H2
antagonists. They act by directly blocking the mechanism that allows the
transfer of acid into the lumen of the stomach from the cells that make the
acid. By reducing stomach acid when regurgitation occurs, no irritation of the
gullet lining takes place and therefore there are no symptoms.
c. Schemes for Medical Management
There are two ways in which each of these classes of drugs can be given.
This is known as either a step up or step down treatment regime.
i. Step Up
In this treatment regime the patient starts by taking antacids and moves up
through H2 antagonist to a proton pump inhibitor to see at what level
symptoms are controlled. Maintenance drug treatment is then continued for a
period of time before stopping it to see if these symptoms have then settled.
ii. Step Down
This regime starts with proton pump inhibitors which are then usually
maintained for 2 months decreasing the dose of the proton pump inhibitor and
if necessary moving down to the H2 antagonist and antacids to control
You should be advised by your medical practitioner as to the best regime for
4. COMPLICATIONS OF REFLUX DISEASE
Chronic exposure of the lining of the gullet to the stomach acid can lead to a
This is inflammation of the lining of the oesophagus and may give rise to
significant pain on swallowing and in consequence a reluctance to eat and
weight loss. Most patients with oesophagitis have mild symptoms and
treatment is usually completely successful using a proton pump inhibitor for 2
to 3 months. In the extreme form this condition can cause bleeding into the
gut, long term stricturing of the gullet (see below) and may predispose to
b. Barrett’s Change (Barrett’s metaplasia)
Chronic exposure of the lining of the lower gullet to acid can also lead to
changes in the cells which line this area from gullet lining cells to stomach
lining cells. Ironically as this process occurs, symptoms of reflux may appear
to decrease. The long term problem of Barrett’s oesophagus is that it may
predispose to the development of cancer in a small number of patients.
c. Stricture Formation
A stricture is by definition a narrowing in the lumen of the gullet and this may
be caused by the long term effects of oesophagitis giving rise to scarred
narrowing or may be due to the development of a malignant change within the
Barrett’s oesophagus. Symptoms of this are difficulty in swallowing. Urgent
5. INVESTIGATIONS OF GASTRO-OESOPHAGEAL REFLUX
a. Trial of Medical Treatment
Treatment with medication known to reverse the effects of gastro-
oesophageal reflux may be used as a trial to confirm the diagnosis. If
symptoms recur after stopping medication however, some other forms of
investigation are usually required, particularly in patients over the age of 45
This investigation directly visualises the lining of the gullet and stomach by
using a flexible telescope which is placed through the mouth. This procedure
is usually done as a day case under light sedation or with the patient awake
after rendering the back of the mouth anaesthetic with a local throat spray.
The advantages of this investigation is that the lining of the gullet can be
directly visualised to determine the extent of the oesophagitis and any
complications that may have occurred and biopsies can be taken of the lining
c. Barium Swallow
This investigation is usually done for those patients who are unable to tolerate
gastroscopy and involves taking an x-ray of the chest and upper abdomen
whilst swallowing barium. An hiatus hernia can be visualised using this
technique and severe oesophagitis can be recognised. However it is not as
sensitive as gastroscopy and no biopsies can be taken.
d. Oesophageal Function Studies
Probes can be inserted through the nose into the lower oesophagus to
measure the amount of acid that is regurgitating into the oesophagus and to
measure the pressures that the oesophagus generates on swallowing. Both
of these measurements give direct readings of the severity of reflux. Two
separate probes are needed for each part of the investigation. The pressure
probe is placed and withdrawn over a matter of minutes, however the pH
probe needs to stay in place for between 8 and 24 hours whilst the data on
acid in the gullet is downloaded to a portable box clipped onto a belt to which
the probe is connected. This investigation is usually reserved for those
patients with severe reflux disease who are considering surgical treatment or
as part of the investigation for atypical symptoms of reflux disease.
6. SURGICAL TREATMENT OF REFLUX DISEASE
Surgery for reflux disease is considered in those patients with complications
of reflux disease or who have classic reflux symptoms well controlled on
medication but have immediate return of symptoms on ceasing medical
treatment. It should not be considered in those patients who do not have a
definitive diagnosis of gastro-oesophageal reflux.
Treatments may be broken down into two areas. Bulking procedures on the
lower gullet performed using the gastroscope and surgery to reinforce the
a. Bulking procedures performed via the gastroscope.
Most of these procedures would still be considered experimental, however
there are a number of groups undertaking the injection of various substances
into the lower oesophagus to thicken this area to minimise reflux. In addition,
a small sewing machine can be passed gastroscopically to insert a stitch
through the lower oesophagus to plicate this. Again this would be considered
experimental. Patients wishing to consider this intervention will need to be
referred to a tertiary referral centre where the procedure is undertaken and
should consult with their medical practitioner.
b. Operations to reinforce the lower oesophageal sphincter.
The principal operation that has been available to reinforce the lower
oesophageal sphincter is the fundoplication procedure. This was first
invented by a german surgeon, Dr Nissen in 1958 and although performed
then via an open incision in the abdomen (laparotomy), is now usually
performed laparoscopically (keyhole technique). A number of other
procedures exist which can also be done either through the abdomen or by
entering the chest cavity. However Nissen fundoplication is probably the most
c. Nissen Fundoplication
During this operation the oesophagus is dissected free at the point where it
enters the abdomen through the diaphragm. The top or fundus of the
stomach is then drawn behind the oesophagus and sutured back on itself to
create an artificial sphincter wrapped around the lower gullet. If there is a
hiatus hernia, the opening in the diaphragm is usually reinforced at the same
time either with sutures or a small mesh. When performed laparoscopically
this involves a general anaesthetic and placing five incisions in the abdominal
wall, all approximately 1cm long. When performed via the open procedure it
is undertaken via a long incision in the upper abdomen between the lower
breastbone and the bellybutton. There are modifications to the Nissen
fundoplication that reduces the amount of stomach contained within the wrap.
These modifications have been devised to reduce the incidence of
postoperative dysphagia. There is currently no general consensus on
whether any of these modifications are better than a conventional Nissen
d. Complications of Nissen Fundoplication i. Operation performed for non- reflux symptoms
It is essential that this operation is only done on patients with confirmed reflux
disease. Patients with symptoms such as bloating, flatulence and generalised
upper abdominal pain will not be benefited by this operation, their symptoms
may be made worse and they will be exposed to the general risks of the
ii. Gas Bloat Syndrome
Approximately 5% of patients will experience significant bloating following the
operation associated with the inability to belch or bring up food when vomiting.
For this group of patients, these symptoms can be troublesome and a
nuisance. They tend to settle with time as the wrap loosens but this process
may take several years. It is important that gaseous drinks are avoided
following the surgery for about 3 months to minimise bloating symptoms.
iii. Difficulty Swallowing
Difficulty swallowing or dysphagia is a universal problem following
fundoplication and all patients will experience this to some extent over the first
2 to 4 months following the surgery. In a small proportion of patients the
dysphagia is persistent and may require further surgery to modify the wrap to
iv. Severe or Life-Threatening Complications
Although life-threatening complications are rare in this operation, they can
occur and consist of perforation of the gullet, bleeding from the spleen,
drawing of the fundoplication wrap into the chest with perforation of the wrap
and infection in the chest cavity (due to forcible retching post-operatively).
v. Return of Reflux Symptoms
Approximately one third of patients undergoing Nissen fundoplication will
experience some return of reflux symptoms within five years. The majority of
these patients do not consider these symptoms to be significant, although a
third may go back onto anti-reflux medication at that stage. Some patients in
this category may require re-operation if the fundoplication has come apart.
Gastro-oesophageal reflux disease is a common problem and may be
considered as a disease of affluence. For the majority, the symptoms are
mild, intermittent and require minimal intervention. For those patients that do
require intervention, simple measures such as change in lifestyle or simple
antacid medication is usually sufficient to control symptoms. Where
symptoms are persistent, proton pump inhibitors are usually the treatment of
choice. Only a small percentage of patients with gastro-oesophageal reflux
disease will need to be considered for surgery in order to control symptoms
Web Searching If you are performing an internet search on reflux disease the American
spelling of oesophagus is esophagus and therefore the GORD initials become
KC Health Coordinator for the UK Beagle Clubs The condition is seen in other breeds of dog too but Beagles along with Bernese Mountain Dogs, Duck Tolling Retrievers and Springer Spaniels seem to be over-represented in the canine population. It is primarily a disease of the younger dog, most often being seen around 6-8months of age for the first time although it has been seen as young as 10 weeks
Interviewee: Ellen Arlene Smith Interviewee: Manuel Zax Date of Interview: October 26, 2006 Location: Worcester, Massachusetts Transcriber: Manuel Zax Abstract: Ellen A. Smith was born in Worcester and has lived here almost all 92 years of her life. She attended the public schools and Salter’s, where she learned more about shorthand and typing, leading to work as a secretary for Templ