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What is gastro-oesophageal reflux disease (GORD)?
Gastro-oesophageal reflux (sometimes called acid reflux) is when material from the
stomach moves upwards into the gullet (or oesophagus). This occurs to a small extent
every day in everyone, but when it happens more than usual it can cause symptoms or
damage to the gullet, in which case it is termed gastro-oesophageal reflux disease
(GORD). Up to 20% of the population suffer from gastro-oesophageal reflux disease.
What symptoms does GORD cause?
The main symptoms of GORD are heartburn (a burning feeling behind the breastbone)
and regurgitation (an unpleasant sensation of material moving upwards behind the
Less commonly, GORD can also be responsible for a number of other symptoms, including swallowing difficulties, chest pains, abdominal burning, cough, wheeze, sore throat and hoarse voice. Occasionally there are no symptoms at all, so-called 'silent reflux'.
Why does GORD happen?
The main reason GORD happens is because of a weakening of the so-called anti-reflux barrier between the stomach and gullet. There are two main components of this barrier: the lower oesophageal sphincter muscle and the diaphragm.
The lower oesophageal sphincter is a muscle at the bottom of the gullet that opens to let food through when you swallow, and then closes to stop stomach contents refluxing back into the gullet. If this muscle is weaker, the person may be more prone to GORD.
The diaphragm is the muscle that separates your chest from your abdominal cavity. This also contracts to prevent reflux.
The lower oesophageal sphincter and diaphragm are usually positioned closely together, and work together to prevent reflux. When they become separated the barrier against reflux is less effective. The most common reason this occurs is when someone has a hiatus hernia. Here, part of the stomach moves above the diaphragm into the chest. The separation of the lower oesophageal sphincter and the diaphragm that results is the main reason GORD is more likely if you have a hiatus hernia.
What about diet and lifestyle?
There are a number of dietary and lifestyle factors that can make reflux disease more likely. Some things make the lower oesophageal sphincter weaker or more likely to relax. These include smoking, and alcoholic drinks (particularly white wine and beer).
Chocolate and caffeine can increase stomach acid production and so may also make GORD worse.
Large meal sizes can increase the pressure in the stomach, and make reflux events more likely. Something else that increases the stomach pressure and amount of reflux is increased waist size.
Is GORD dangerous?
Although GORD can cause very distressing symptoms, in most cases it is not dangerous. In a minority of cases long-standing inflammation and scarring can result in a narrowing of the gullet that can affect swallowing.
About 1 in 10 people with GORD develop something called Barrett’s oesophagus. This is when reflux damage causes cells at the bottom of the gullet to change to look more like the cells in the stomach.
Barrett’s oesophagus carries a small but important risk of developing oesophageal cancer, and so regular follow up is recommended in people with this problem.
What testing is needed?
In some people no testing is needed at all. This is particularly the case if the symptoms have not been longstanding and are easily controlled with simple medications (see below).
In other people, particularly when symptoms are severe or have been longstanding, it is important to look into the gullet with a camera (an endoscopy). This is done with local anaesthetic throat spray or with injection of a sedative. With this test the doctor is able to look for acid damage and inflammation, narrowing, or the presence of Barrett’s oesophagus. It is also the best test for ruling out oesophageal cancer.
If there is a need to clarify the diagnosis, or if an operation is to be considered (see below), further testing can be done in the form of “a 24 hour reflux study”. This involves passing a tube through the nose and into the gullet, where it sits for a day measuring acid reflux. From this test your doctor can get information about whether there is too much acid refluxing into the gullet, and whether it is causing the symptoms.
How is it treated?
Eating smaller meals, avoiding meals within the 2 hours before bedtime, and avoiding eating or drinking things that make your reflux worse (e.g. alcohol) can help.
Some people find that propping the head of the bed up at night can help nighttime symptoms, others find that lying on their left side helps.
There is evidence that stopping smoking can help reflux symptoms, as can weight loss if you are overweight.
For intermittent symptoms, over the counter medications such as antacids and Gaviscon can be helpful in offering fast relief.
Medications such as ranitidine, famotidine and cimetidine are histamine blockers that can offer longer lasting relief. It is important to note that they lose their effectiveness if taken every day for several weeks.
For more troublesome symptoms proton pump inhibitor tablets (e.g. omeprazole, lansoprazole, pantoprazole) can be needed. These usually require prescription, but are the most effective medications to block acid production in the stomach. They are generally very safe drugs (but like all medications can have side-effects) that many people are on long-term.
When taking these medications it is important to be aware that they work best when taken 30 to 60 minutes before you eat. Sometimes increasing the tablets to twice per day (before breakfast and before the evening meal) can give additional symptom relief.
For some people surgery is a very good option. It is particularly useful for people who do not want to take medications long term, or have persistence of symptoms (particularly regurgitation) when taking tablets. It usually involves a keyhole operation to fix any hiatus hernia and strengthen the anti-reflux barrier
It is very important that expert opinion is sought before having surgery for reflux disease to ensure the best chance of success. Tests will need to be done to assess the strength of the gullet contractions and to ensure there is definite evidence of GORD.