GORD

Gastro-oesophageal reflux disease (GORD)

Causes of GORD
Prevalence and statistics
Characteristic symptoms
Specific patient groups liable to GORD

• Lifestyle-influenced
• Pregnancy
• Paediatrics
• Geriatrics

Under normal, physiological conditions acid and pepsin remain in the stomach and effectively digest ingested food, and bile remains in the duodenum to emulsify fats. In certain circumstances, however, the contents of the stomach and duodenum flow back, or ‘reflux’, through the lower oesophageal sphincter (LOS) into the oesophagus (Figure 1). Reflux of acid and stomach contents occurs to some degree in everyone, but is not usually accompanied by symptoms.

GORD, however, is not generally a disease of acid hypersecretion, and there is no correlation between the amount of gastric acid secreted and the severity of oesophagitis; rather, GORD results from the inappropriate localisation of acid, pepsin and bile in the oesophagus.

Because the oesophagus lacks the mucosal protective mechanisms found in the stomach, extensive exposure of the oesophageal mucosa to acid, bile, pepsin and other digestive enzymes in the gastric juice can cause erosion and inflammation of the lower oesophagus. Because the oesophagus has many sensory nerve endings, this may cause severe pain known as heartburn, which is felt in the epigastric region of the abdomen, behind the breastbone. If reflux occurs frequently, the lining of the oesophagus may become permanently damaged. Erosion of the epithelium by gastric juice can also cause bleeding, which may be severe.

GORD is a broad term used to describe conditions ranging from episodic symptomatic reflux without oesophagitis to severe oesophageal mucosal damage, and incuding Barrett’s oesophagus. In patients who do experience symptoms of reflux, the most common presentation is heartburn,[Hansky, 1988] which occurs in approximately 86% of patients.[Jones, 1995]

The discomfort experienced by sufferers is largely due to damage to the delicate oesophageal mucosa by the combined action of hydrochloric acid (HCl), pepsin and bile. Pain is felt in the chest behind the breastbone (retrosternally) and can move to the neck or back. Heartburn and other symptoms such as waterbrash (a sudden filling of the mouth with dilute saliva) are often associated with poor posture and are usually more common when the patient is in the supine position.

Causes of GORD

LOS incompetence

The complex aetiology of GORD makes identification and isolation of the cause(s) difficult in many cases, and has precluded a medical cure for the disease. The anti-reflux barrier consists of the LOS and the crural portion of the diaphragm. Lower oesophageal sphincter incompetence is thought to be the principal anatomical reason for reflux, since a loss in muscle tone will result in a partial failure of this primary barrier to reflux and facilitate the easier passage of food from the stomach into the oesophagus. Absolute LOS pressure of <6 mm Hg is required for reflux, but this is more frequently associated with increased episodes of transient relaxation than persistently low LOS pressure. However, the roles of both a low resting tone in the LOS and an increased incidence of spontaneous LOS relaxations have been well documented in reflux.[Mittal, 1990] Although LOS incompetence is likely to be the principal cause of GORD, the disease may arise from a combination of several different factors.

Failure of the pinching effect of the diaphragm

Another physical factor that may facilitate reflux of acid and stomach contents into the oesophagus is a failure in the pinching effect of the diaphragm on the oesophagus at the hiatus (the gap in the diaphragm through which the oesophagus passes). This effect may be associated with advancing age and hormonal influences and may increase the ease with which the stomach contents can leave the stomach and enter the oesophagus.

Hiatus hernia

The presence of a hiatus hernia is common in patients with GORD, and describes a defect in the diaphragm that allows part of the stomach to leave the abdominal cavity, via the hiatus, and enter the thoracic cavity during breathing. Read more here.

Oesophageal clearance

After initial failure of the anti-reflux barrier, GORD may be caused by poor oesophageal clearance of the refluxed material or refluxate, as is evident in patients with hiatus hernia. For example, inadequate salivation, reduced peristalsis in the oesophagus, diminished bicarbonate secretion by the oesophagus and reduced effects of gravity will all combine to prolong oesophageal acid exposure and increase the likelihood of oesophageal mucosal injury.

Oesophageal mucosal resistance

Unlike the stomach, which is designed and adapted to deal with its highly acidic contents by producing large quantities of protective alkaline mucus, the oesophagus does not have such mechanisms. Although there is some local bicarbonate production and oesophageal protection afforded by alkaline saliva (pH >6), peristalsis, the combination of anatomical failures and poor oesophageal clearance mechanisms may result in mucosal damage due to low mucosal resistance to acid. Acid and pepsin can weaken intercellular junctions and facilitate increased penetration and contact with exposed nerve endings, thus resulting in the pain and discomfort of heartburn.

Delayed gastric emptying

Delayed gastric emptying and thus the resulting increased volume of gastric contents may promote reflux of the stomach contents into the oesophagus. In addition, increased gastric pressure may force the stomach contents backwards into the oesophagus.

Other contributory factors

The picture is complicated further by the influence of diet, pharmacological intervention and concomitant disease, which can all decrease LOS pressure (Table 1).

TABLE 1 – Risk factors associated with decreased LOS pressure that can result in symptoms of GORD

Dietary factors	Sensitivity to certain foods (eg, fatty foods, chocolate, mints, onions, spices, caffeine, citrus fruits, tomato products) Over-eating Eating within 2–3 hours of bedtime
Drugs [Liebermann, 1990]	Anticholinergics Calcium channel blockers Nitrates Theophylline Nicotine NSAIDs Alcohol
Pregnancy [Nebel, 1976; Katz, 2000]	Increased pressure on the stomach Increased progesterone and oestrogen
Collagen vascular diseases	Scleroderma Mixed connective tissue disease Systemic lupus erythmatosus
Other risk factors	Obesity Hiatus hernia Tight clothing Poor posture Advancing age Smoking

Lifestyle modification advice for your patients »

Management of heartburn in pregnancy »

GORD prevalence and statistics

Gastro-oesophageal reflux is one of the most common GI complaints in clinical practice. Figures reflect the enormity of the problem, which is very much a Western disease, being very prevalent in Europe and developed countries worldwide.

• GORD affects around 10% of the population of the Western World.[Jones, 1990]
• As many as 60% of people in the UK have experienced symptoms of heartburn at some time. The prevalence is higher in women than in men.[Gallup Survey, 1989]
• GORD seems to become more common with increasing age, the highest incidence being in those aged 55-64.[Gallup Survey, 1989]

The cost of heartburn and reflux-associated disease

The management of upper GI disease, including reflux-associated disease, is associated with significant healthcare costs.

Figure 2 compares the number of prescription items written in the UK for four classes of drugs commonly used to manage reflux-associated diseases.

In the UK in 2006, 41.2 million prescription items were written for antacids, alginates, H2-RAs and PPIs, equating to more than 110,000 every day and corresponding to a cost of over £575 million. These figures exclude the additional thousands of over-the-counter purchases.

Characteristic symptoms of GORD

The principal symptoms of GORD are listed in Table 2.

Table 2 – Clinical signs and symptoms of GORD

Common:

A burning sensation in the chest (heartburn)

A feeling of acid backed up in the oesophagus (regurgitation)

Chest pain that feels like angina: tightness, pressure, heaviness

Trouble swallowing (dysphagia)

Chronic nausea and vomiting (less common)

Bloating

Belching

Feeling like there’s a lump in the throat (globus sensation)

Rare:

Loss of tooth enamel

Sleep apnoea: repeated but temporary stop in breathing during sleep, which can lead to restless sleep, morning headaches, and afternoon drowsiness

Iron deficiency anaemia caused by chronic blood loss from tiny ulcers in the oesophagus

In most patients, symptoms associated with GORD are mild and infrequent, and are considered as no more than an inconvenience. However, in a minority of patients the symptoms can be significant and disabling, and may seriously affect the patient’s quality of life.

A US survey into the impact of GORD on quality of life showed that although more than 60% of suspected GORD sufferers in the USA classify their symptoms as moderate or severe, 35% have not consulted a doctor. Eight percent of all adults suffer from heartburn or acid regurgitation at least twice a week and symptoms of GORD have a significant negative impact on the patient’s quality of life, with:

• 75% of sufferers finding sleeping difficult
• 51% finding work painful
• 40% finding exercise painful

Testing the acidity of the oesophagus in patients with GORD using a pH probe frequently reveals an oesophageal pH below 4, demonstrating that patients with GORD have extensive oesophageal acid exposure. This pH value is the generally accepted cut-off between physiological and pathological reflux and is much more common in patients with symptoms than in patients without. Furthermore, the frequency of symptoms is directly related to the degree of oesophageal acid exposure.[Joelsson & Johnsson, 1989]

Specific patient groups liable to GORD

Certain groups of people are more susceptible to GORD. This section outlines the reasons why these groups are at higher risk of developing the disease.

Lifestyle-influenced »
Pregnancy »
Paediatrics »
Geriatrics »

Most patients in these groups will also require special consideration when treating GORD. Click for management options in pregnancy and paediatrics.

Lifestyle-influenced

Many risk factors for GORD are associated with the patient’s lifestyle,[DeMeester, 1981] which serve to weaken or relax the LOS and increase the incidence of GORD (dietary and other lifestyle-associated risk factors are included in Table 1). Typically, therefore, some of these patients may have an over-indulgent lifestyle.

Addressing these risk factors with lifestyle modifications should help alleviate their symptoms.

Pregnancy

GORD and heartburn are reported in 45–85% of women during pregnancy,[Boussard, 1998] and up to 25% of pregnant women suffer daily symptoms of heartburn.[Nebel, 1976]

Pregnancy is associated with decreased LOS pressure, more frequent episodes of reflux and upright reflux. [Al-Amri SM, 2002] Symptoms are rarely severe, however, and subside post partum, as soon as the woman’s weight returns to normal . The symptoms can, however, cause greater distress than other potentially more serious conditions, interfering with sleep and diet, and can indirectly affect the health of the unborn child. Although endoscopic and other diagnostic tests are not usually needed, they must be used with caution in pregnant women due to potential foetal risks.

Causes of GORD in pregnancy

• Weight gain associated with pregnancy can increase the symptoms of GORD, the enlarging uterus resulting in increased intra-abdominal pressure.
• Increased serum concentrations of oestrogen and progesterone can lead to LOS dysfunction by their effects as muscle relaxants.

Management of heartburn in pregnancy »

Paediatrics

Reflux in infants

Possetting in young infants is the term used to describe the repeated, effortless regurgitation of small quantities of milk and stomach acid into the mouth after feeding, often when being winded,[Neuhauser EDB, 1947; Forshall I, 1955; Plarre FE, 1972] and can occasionally continue until the next feed.[Weldon AP, 1972] It is a common problem affecting a large proportion of infants under the age of 3 months and often continues into early childhood. Some infants are particularly susceptible to possetting, especially if they are very hungry prior to a feed or swallow more air than normal as they feed. In some babies it is merely the appropriate response to overfeeding.

Causes of possetting

In recent years, the availability of lower oesophageal pH monitoring has demonstrated that the underlying cause of possetting in most infants is GORD – namely, a weak or immature LOS.[Hillermeier AC, 1996] The LOS normally closes once the food has entered the stomach to prevent its backward movement, or reflux, into the oesophagus. However, in babies, the LOS may not always function properly, causing reflux of the stomach contents and resulting in possetting. Consequently, possetting occurs more frequently in newborn babies (approximately four in 10) than in older infants and children, and is found even more frequently in premature babies. The number of episodes of reflux decreases through the first and second years of infancy and complete recovery occurs in the majority of cases.[Hillermeier AC, 1981; Vandenplas Y, 1994]

Complications of possetting

Possetting causes no significant degree of pain or discomfort, and is no cause for concern if the baby is happy, feeds well and gains weight, and serious underlying pathology is present in only a small minority of cases. However, GORD in infants may not always be entirely straightforward and related symptoms might include excessive irritability, sleep disturbance, respiratory symptoms and failure to thrive. In a minority of infants, reflux may be sufficiently frequent to result in oesophagitis.[Vandenplas Y, 1993]

Fortunately, in the majority of infants, possetting is self-limiting, resolving spontaneously within the first year of life as the infant starts to eat solids and spends more time in an upright position. Nevertheless, it can result in obvious distress for the child and anxiety and feelings of inadequacy and guilt in the parents.

It is not only of psychological benefit to the parents to treat possetting, but it is also of significant benefit to the infant, since 1 in 10 babies left untreated may go on to develop more serious complications, such as dehydration and oesophagitis, due to the persistent exposure of the oesophagus to acid and other gastric contents. In most cases, although the condition is distressing, if the baby is developing and gaining weight as expected by the parents and health visitor, there is little cause for concern. In rare circumstances, however, infants may present with more sinister alarm symptoms that will necessitate GP referral.

Once the presence of these alarm symptoms has been ruled out, appropriate measures and treatment options can be recommended.

Managing possetting in infants

Geriatrics

The prevalence of symptomatic GORD is similar in patients >65 years as in the general population, and geriatric patients tend to report less severe or less frequent symptoms of heartburn due to an age-related decrease in pain threshold.[Collen MJ, 1995; Locke GR, 1997] However, geriatric patients (>60 years) with GORD are twice as likely to develop complications, such as erosive oesophagitis or Barrett’s oesophagus, than those under 60 years.[Collen MJ, 1995; Locke GR, 1997] Extraoesophageal manifestations of GORD, including hoarseness, noncardiac chest pain, and respiratory symptoms, are also more common in geriatric patients than in younger patients with reflux disease.

Risk factors contributing to GORD in the elderly

• Oesophageal motility can be impaired among the elderly, and acid clearance may be abnormal
• Older age is associated with an inadequate LOS response to swallowing, and a more relaxed LOS
• Saliva volume and bicarbonate concentration are lower in healthy older subjects (mean age 55 years) than in younger subjects (mean age 28 years).[Sonnenberg A, 1982] Salivary bicarbonate plays an important role in clearing refluxed acid from the oesophagus, but the elderly demonstrate a significantly decreased salivary bicarbonate response to oesophageal acid perfusion
• H. pylori infection is highly prevalent in the geriatric population and may be a factor in their impaired gastric acidity [Collen MJ, 1994; Hurwitz A, 1997]
• Elderly patients will tend to have more comorbidities than younger age groups, and will likely be taking a wide range of medicines, some of which can alter LOS pressure. These include, anticholinergics, calcium channel blockers, nitrates, and theophylline

Extra-oesophageal Reflux

Laryngopharyngeal reflux

Heartburn in Pregnancy