Health News, Information and Advice from a British Doctor

Acid Reflux or GORD (Gastro-oesophageal reflux disease)

Acid reflux is the most commonly presenting gastrointestinal condition to GPs and Specialist Gastrointestinal clinics. It is usually characterised by a collection of symptoms that when put together, enable doctors to make a fairly firm diagnosis without having to resort to complex and invasive investigations.

The symptoms themselves include:

  • burning in the chest (pyrosis)
  • feeling sick (nausea)
  • a sensation of a  ball trapped in the pit of the stomach
  • burning pain on eating (odynyphagia)
  • burping (eructation)
  • occasional swallowing difficulties (dysphagia)
  • sensation of something lodged in the throat (globus).


 

The symptoms are predominantly caused by concentrated hydrochloric acid produced by the stomach, going ‘the wrong way’ up into the gullet (oesophagus) which isn’t very good at protecting itself against this acid ‘attack’. In reality we are all refluxing all the time without noticing it, this is because the episodes are usually brief and the gullet rapidly squirts the acid back down into the stomach by a process called peristalsis (this is the mechanism by which food and liquid is propelled through the gastrointestinal tract in a coordinated manner by a series of contractions. This also enables pranksters to drink pints of beer against gravity while standing on their heads!).

Acid is particularly likely to reflux if the valve at the bottom end of the gullet is incompetent or if there is a sliding hiatus hernia (where the top part of the stomach slips up and down into the chest).

Patients with symptoms are usually having prolonged episodes of reflux either for the above reasons or if they have hypersensitivity of the lower gullet lining, poor peristalsis, large volumes of food and fluid in the stomach (particularly in bed at night) or bile reflux (where duodenal contents are refluxing back into the stomach).

Patients who are short and overweight or long and lean seem to be particularly at risk. Pregnancy also accounts for a large number of symptomatic patients!

Investigation

Most patients (particularly under 50) do not require investigation unless the symptoms are persistent or severe. Patients with new symptoms (or longstanding symptoms) over the age of 55 do require investigation.

Endoscopy (gastroscopy) is the gold standard for investigating GORD but occasionally, (particularly if patients are extremely anxious), barium investigations are a poor second best.

In UK there is an increasing waiting list for gastroscopy so be prepared to have to wait! However if there any accompanying ‘alarm’ or ‘red flag’ symptoms your GP should be pushing for a ‘10 day wait’ appointment (no longer than 2 weeks or 10 working days).

Red flags:

  • weight loss
  • intractable pain
  • difficulty swallowing
  • passing blood
  • anaemia

Occasionally, in younger patients with persistent, severe and ‘difficult to control’ symptoms, other more complex investigations may be requested by your specialist which might include 24h pH and manometric studies. These are usually reserved for those minority of patients who are being ‘worked up’ for a surgical solution.

Management

Anti-acid drugs (eg peptac) or ‘raft’ agents (such as Gaviscon which theoretically forms a barrier on the gullet wall to protect against acid attack)

Lifestyle modifications, until the mid-1970s and the introduction of acid suppressing drugs, this is all the medical profession could really offer. Lifestyle modifications included:

  • stopping smoking
  • reducing alcohol intake
  • losing weight
  • avoiding large meals (particularly in the evening)
  • avoiding bending and stooping
  • drinking milk
  • propping the head end of the bed up on bricks!

A fairly miserable existence for those sufferers with bad symptoms!

Acid suppressing drugs

Thank goodness for these. They helped transform the lives of bad sufferers of GORD.

The first of these were the H2 receptor antagonists such as cimetidine (tagamet) and ranitidine (zantac). They worked by blocking the H1 histamine receptors in the stomach wall which controlled the amount of acid released by the stomach. They were fantastic for curing ulcers but not so good for GORD where only 40% of sufferers had any prolonged symptom relief.

Then in the 80s came along the PPIs (proton pump inhibitors) such as omeprazole (losec) and lansoprazole (zoton). They worked by blocking the acid pumps in the stomach producing almost complete standstill of acid production. They are 95% effective and are very widely used to this day.

Sometimes, GPs use a combination of ‘all of the above’ to produce effective symptom relief.

Surgery

In a minority of patients where drug therapy hasn’t helped, then keyhole surgery can be performed at the level of the oesophageal valve, by tightening up the valve and fixing the hiatus hernia. This is usually performed by specialist surgeons in this field.

Written by Dr M J Webberley, Consultant Gastroenterologist, August 2015