Gastro-oesophageal reflux disease

From Ganfyd

Gastro-oesophageal reflux is also known as GORD (and in the U.S.A. as GERD which presumably rhymes with nerd).

See Infant gastro-oesophageal reflux for babies.

We now know that treating chronic cough associated with GORD in adults by a PPI may have a number needed to treat that varies from 5 to infinity. There is a large placebo and time effect. PPIs can also induce cough as a side effect. So the evidence base for some international guidelines that recommend empirical treatment for GORD in those with chronic cough is thin

Definition

There are multiple definitions in the literature. It is reflux of gastroduodenal contents into the oesophagus, causing symptoms that are sufficient to interfere with quality of life. However there should be objective evidence of such reflux, such as oesophagitis at endoscopy or demonstration of reflux by other investigations as the symptoms of GORD are non specific.

Importance

A common cause of dyspepsia.

In European populations 20–25% have symptoms of GORD, In primary care, up to 40% of those with GORD have oesophagitis on endoscopy, but most have endoscopy-negative reflux disease.

Prolonged GORD can give rise to Barrett's oesophagus, a risk factor for oesophageal cancer.

Risk Factors

• Genetic (twin studies)
• Calcium channel blockers
• Obesity is not proved (inconsistent evidence)
• Smoking (little evidence)
• Alcohol (little evidence)
• Particular foods (little evidence but individuals may find that coffee, mints, dietary fat, onions, citrus fruits, or tomatoes, may predispose to symptoms)

Treatment

It is a chronic condition with relapse in up to 80% without medical treatment.

Lifestyle changes

• see risk factors
• raising head of bed

Drugs

• Mild disease may respond to antacids and alginates
• The main stay of treatment with severe symptoms are acid-suppression via Proton pump inhibitors. NICE recommends full dose PPI treatment for 1-2 months initially with if necessary lower dose maintenance [1].
• Histamine H2-receptor antagonists work [2].
• prokinetic drugs such a metoclopramide or domperidone may be considered
• Sucralfate may have a role
• Carbenoxolone usefulness is severely limited by its side-effects and contraindications.

Surgery

Multiple procedures but essentially fundoplication involves wrapping the part of the fundus around the area of the oesophago-gastric junction.

• Open surgery and laparoscopic surgery are no better than each other and are no better than PPIs
• Endoluminal gastroplication is regarded as investigational in England and Wales