Doctor, I think I have “Reflux” and its “killing” me.

This is quite a common complain I see in the gastroenterology clinics. As to what it is, well, “Reflux” or Gastro-oesophageal reflux disease (GORD) is a common condition, where more than the normal amount of stomach fluid leaks up into the food pipe (oesophagus) causing symptoms with or without tissue injury.

Typical symptoms of GORD include heartburn (usually after eating or when lying flat or bending over), regurgitation, difficulty swallowing and nausea all of which can be quite severe. Non-typical symptoms include coughing and/or wheezing (about 50% of patients who have GORD-induced asthma do not get heartburn), lung injury, hoarseness, noncardiac chest pain, earache, enamel erosion, increased salivation and sour taste in the mouth.

by Dr Prabhjot Singh Sidhu

It is important to remember that the continuous injury to the oesophagus can lead to serious complications and conditions such as reflux oesophagitis, oesophageal strictures (narrowing), Barrett’s oesophagus and oesophageal cancer.

As to how GORD happens, imagine the oesophagus as forward pump, the lower oesophageal sphincter (LES) a gate, and the stomach as a reservoir. Malfunction in any of these areas can contribute to GORD for example, poor oesophageal motility or movement decreases clearance, an inadequate LES allows the reflux of large volume of stomach fluid and a delayed stomach emptying can increase the volume and pressure in the reservoir until the gate mechanism fails. Other factors that increase the risk of GORD include obesity, hiatus hernia, smoking, certain medication, dry mouth, asthma, diabetes, connective tissue disorders, western dietary habits and tumours.

The primary investigative tool for GORD is endoscopy which will show the complications of GORD and assess the anatomy of the upper gastrointestinal tract. The next useful test and complimentary to endoscopy is the 24-hour pH probe to evaluate when and for how long the GORD occurs and if in fact it is acid that refluxes. Another useful complimentary test is oesophageal manometry where the movement and the pressures in the oesophagus (especially the LES) is measured to exclude conditions such as achalasia and dysmotily. Other helpful investigative test include the barium swallow, impedance testing and gastric emptying studies.

The management of GORD can be divided into 3 parts; lifestyle modification, medication and surgery.

The first approach, lifestyle modification, includes weight loss, avoiding tight-fitting clothing and avoiding trigger food and drinks (for example and not exclusively alcohol, chocolate, citrus juice, spicy foods, tomato-based products, fried foods, peppermint and coffee). Other lifestyle modification include eating smaller meals, waiting 3 hours after a meal before going to bed, elevating the head of your bed by 8 inches and not smoking is also worth considering.

The second management approach if lifestyle modification is ineffective is via medication. Commonly used medication include antacids (e.g. gaviscon), H2 receptor blockers (e.g. ranitidine and cimetidine), proton pump inhibitors (e.g. lansoprazole, omeprazole and esomeprazole) and/or motility agents (e.g. metoclopramide) which can be used in various regimes as directed by the gastroenterologist.

The third approach, via surgery, involves mainly one of 2 procedures which can be considered when a patient with symptoms that are not completely controlled with medication, the presence of Barrett oesophagus, in the presence of extra oesophageal manifestations (e.g. wheezing), poor patient compliance with medications, postmenopausal women with osteoporosis and in patients with cardiac conduction defects. The first procedure is the Nissen fundoplication to reinforce the LES by wrapping the top of the stomach around the oesophagus and the second is the Linx procedure to strengthen the LES with titanium beads.

It is also very important to remember that although GORD is common, there are a vast number of other conditions that could present in a similar way including coronary artery disease, functional disease (including irritable bowel disease), achalasia, gallstones, peptic ulcer disease, eosinophilic oesophagitis and malignancy.

If you are suffering from GORD, or its symptoms or even being unclear if it is GORD you are suffering from, I would suggest seeing a gastroenterologist to get it looked into if for nothing else, a little peace of mind.