Introduction to GORD

Gastro-oesophageal reflux disease is used to describe symptoms or mucosal damage from exposure of the distal oesophagus to refluxed gastric contents. It is however important to remember that the symptoms do not equate with the degree of mucosal damage and endoscopy negative reflux disease (ENRD) is more prevalent than reflux oesophagitis, especially in a primary care setting.

Heartburn is a common symptom in the general population and purchased medicines are often used to relieve it. While many patients with dyspepsia may have heartburn, the diagnosis of gastro-oesophageal disease (GORD) requires symptoms of heartburn to be predominant, or for oesophagitis or acid reflux to be demonstrated by endoscopy or pH monitoring respectively. GORD may be self limiting but can be a chronic disorder with serious consequences and remains undiagnosed in the majority of patients with only a minority having a confirmed diagnosis.

Public Health Implications of GORD

Dyspepsia affects 40 % of the adult UK population of whom half will have symptoms of GORD. However, only 1 in 10 will visit their GP. The national Institute of Clinical excellence (NICE) has issued its guidance on the use of Proton Pump Inhibitors (PPI’s). At present the NHS spends over £500 million every year on PPI’s in England and Wales. These acid suppressing medications should be prescribed in the long term only after establishing a diagnosis of acid reflux disease.

How do I suspect my patient has GORD (gastro-oesophageal reflux disease)

Why does Reflux Disease need long-term medication?

The condition is characteristically chronic and relapsing: in follow up studies at least two thirds of patients continue to take medication continuously or intermittently for symptoms of reflux for up to a period of 10 years. Symptoms disappear in less than a fifth of those taking no drugs. In studies with large proportions of patients having initial severe oesophagitis, relapse rates of up to 80% at six months have been reported. GORD, hence needs to be taken more seriously.

What are the Risks of inadequate management of GORD?

Inadequate management of GORD can result in serious clinical complications in some patients, in addition to an impaired quality of life as unresolved symptoms continue to disrupt patient’s lives. Long standing oesophagitis may be associated with development of Barrett’s oesophagus. This is a change in the cells lining the oesophagus that is generally considered to be a irreversible premalignant condition. It has been observed in up to 10 % of patients with reflux oesophagitis. And is associated with a 40 fold increase in the risk of developing oesophageal adenocarcinoma. Other complications are oesophageal stricture formation, leading to difficulty in swallowing. Chronic scarring can lead to shortening of the gullet.

Quality of Life Issues

Another factor underlying the importance of diagnosing and treating GORD effectively is the serious impact that the condition has on patient’s quality of live. One study warned, that patients with GORD reported lower quality of life than patients who had mild heart failure. Individuals who experienced symptoms of reflux were more anxious, more depressed and less positive about their general health and well being than those without reflux symptoms. GORD is also associated with reduced productivity and compromised well being. Nearly two-thirds of people who experienced heartburn taking part in a recent study reported frequently disturbed sleep, four out of five had avoided foods they enjoyed for fear of heartburn, and almost 20% of sufferers had at times, been unable to work as a result of their symptoms.

Investigations in GORD

Endoscopic investigation is the prime means of confirming a diagnosis of upper gastrointestinal disease in patients with dyspepsia and is safe with a complication rate less than a 0.1%. One has to however remember that only 60% of patients eventually diagnosed with GORD will have endoscopic evidence of oesophagitis. No single investigation can accurately diagnose GORD, but it is important to make sure that all those presenting with alarm symptoms like dysphagia, weight loss, anaemia and vomiting have an endoscopy.
A 24 hour oesophageal pH monitoring with observation of symptom-reflux association is the most useful test in deciding if symptoms are due to oesophageal acid exposure. However patients with typical symptoms and objective evidence of oesophagitis on endoscopy need not undergo pH testing. Patients with endoscopy negative reflux disease (ENRD), patients with non-cardiac chest pain or reflux associated pulmonary and upper respiratory symptoms stand to benefit from a pH study in establishing a diagnosis.

Medical Treatment of GORD:

Although evidence for their effectiveness has been limited general measure like cessation of smoking, weight loss, propping up the bed-head and avoiding foods like coffee, alcohol, fatty foods and NSAID’s have traditionally helped patients. H2 receptor antagonists are associated with an overall healing rate of 50% in oesophagitis falling to 20-40% in severe disease.
PPI’s achieve a 70%-90% healing rate. Endoscopic follow-up after initial treatment of patients with mild oesophagitis has shown that about half heal and have no further episodes of oesophagitis while a quarter progress to more severe disease.

Patho-physiology of Reflux and Surgical Treatment of GORD

Surgery to prevent reflux which is increasingly performed using the laparoscopic approach improves oesophagitis and can control symptoms in around 90% of people. The patho-physiology of reflux is centred on the lower oesophageal sphincter incompetence and recent evidence indicates that the diaphragmatic crural fibres surrounding the oesophageal hiatus act as an external sphincter in concert with the intrinsic lower oesophageal sphincter in avoiding reflux.
Surgical treatment would appear logical as it aims at re-enforcing this mechanism rather than decreasing acid production in the stomach.

Advantage of Surgery for Reflux disease:

The potential advantages of Nissen fundoplication include removing the need for life long medication and an excellent success rate which does not decrease significantly with time. DeMeester, reported 91% of patients had their symptoms controlled 10 years after surgery. Laparoscopic approach offers a better cosmetic result, quicker recovery, shorter hospital stay and a quicker return to work. One has to however consider these benefits along side the small but measurable risk of complications from this procedure.

Cost effectiveness related to surgery:

Several studies have looked at the cost effectiveness of surgical treatment and plotted it against time. Although the initial cost of surgery is higher, the costs become equal to medical treatment after approximately 3 years. It is however important to remember that not all patients are suitable for surgery and some with oesophageal motility disorders could be made worse with surgery.

Quality of Life after surgery for GORD

Studies looking at heartburn scores and quality of life in these patients are now emerging. It appears from these studies that laparoscopic fundoplication should be offered to patients who are dissatisfied with medical treatment.

Indications for Surgery:

Patients that should be considered for surgical treatment are:

• Those with a poor response to medical treatment where failure to suppress acid reflux is confirmed
• Persisting Volume reflux
• Regurgitation of gastric contents occurring especially at night with risks of aspiration
• Difficult benign strictures
• Patient choice especially those requiring long term maintenance treatment, including patients with Barrett’s oesophagus.

Further reading:

1. BSG, Care of patients with Gastrointestinal Disease in the United Kingdom, Strategy for the future, March 2006.
2. Donnellan C, Sharma N, Preson C, Moayyedi P Medical treatments for the maintenance therapy of reflux oesophagitis and endoscopy negative reflux disease. Cochrane Database of Sys Rev 2005; April18 (2): CD003245
3. Vakil N, et al. The Montreal Definition and Classification of Gastroesophageal Reflux Disease: a Global Evidence-based Consensus. Am J Gastroenterol 200; 101:1900-1920
4. National Institute for Health and Clinical Excellence. 2004Dyspepsia: Managing dyspepsia in adults in primary care.
5. DeMeester TR, Bonavina L, et al. evaluation of Primary repair in 100 consecutive patients. Ann Surg1986; 204:9-20
6. Dent J, Brun J et al. An evidence based appraisal of reflux disease management. Gut 1999; 44 S1-16.

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