Introduction 
 


Heartburn and gastro-oesophageal reflux disease


 

Gastro-oesophageal reflux disease (GORD) is a common condition where acid from the stomach leaks out of the stomach and up into the oesophagus (gullet).

The oesophagus is a long tube of muscle that runs from the mouth to the stomach.

Common symptoms of GORD include:



heartburn – burning chest pain or discomfort that occurs after eating



acid reflux – you may havean unpleasant taste in the mouth, caused by stomach acid coming back up into your mouth



pain when swallowing (odynophagia)



difficulty swallowing (dysphagia)



GORD occurs only occasionally for some people, but if the symptoms persist it's usually regarded as a condition that needs treatment.

What causes GORD?

It's thought that GORD is caused by a combination of factors, but the most common is the failure of the lower oesophageal sphincter (LOS) – a ring of muscle towards the bottom of the oesophagus.

This acts like a valve, opening to let food fall into the stomach, then closing to prevent acid leaking out of the stomach.

In GORD, this sphincter doesn't close properly, allowing acid to leak up out of the stomach.

Known risk factors for GORD include:



being overweight or obese



being pregnant



eating a high-fat diet



 

Diagnosing GORD

Your GP should be able to diagnose and treat GORD by asking you about your symptoms.

Further testing is usually only required if you have pain or difficulty swallowing, or if your symptoms don't improve despite taking medication.

Testing usually involves using an instrument called an endoscope, which is a long, thin, flexible tube with a light and camera at one end. It will be gently lowered down your throat so that any acid damage to the oesophagus can be seen.

Endoscopy is usually used if the diagnosis of GORD is in doubt, to check for any other possible causes of your symptoms, such as functional dyspepsia (an irritable stomach or gullet) or irritable bowel syndrome (IBS).

Treating GORD

A step-by-step approach is usually used for treating GORD. This means that simple treatments, such as changing your diet, will be tried first.

If this proves ineffective in controlling your symptoms, medication – such as antacids, proton-pump inhibitors (PPIs) or H2-receptor antagonists (H2RAs) – may be recommended.

Antacids neutralise the effects of stomach acid, and PPIs and H2RAs reduce the amount of acid that the stomach produces.

Surgery may be required in cases where medication fails to control the symptoms of GORD.

Complications

A common complication of GORD is that the stomach acid can irritate and inflame the lining of the oesophagus. This is known as oesophagitis.

In severe cases of oesophagitis, ulcers (open sores) can form, which can cause pain and make swallowing difficult, particularly if the gullet becomes narrowed (stricture).

Cancer of the oesophagus, known as oesophageal cancer, is a rarer and more serious complication of GORD.

Outlook

Most people initially respond well to treatment with medication, but symptoms can often return quite quickly (within days or weeks).

People with recurring GORD may need to take medication on a long-term basis.



 




 


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How common is GORD?

GORD is a common digestive condition. About 1 in 5 people are thought to experience at least 1 episode of GORD a week, with 1 in 10 people experiencing symptoms of GORD on a daily basis.

GORD can affect people of all ages, including children. However, adults aged 40 years or over are mainly affected. The condition affects both sexes equally, although males are more likely to develop complications.Indigestion in pregnancy.How to avoid and treat heartburn in pregnancy safely.Eat right for your digestion.How to eat and drink to ensure a good digestion, including foods to avoid and which ones to fill up on.







Symptoms of gastro-oesophageal reflux disease 

The three most common symptoms of gastro-oesophageal reflux disease (GORD) are heartburn, acid reflux and difficulty swallowing (dysphagia).

Heartburn

Heartburn is a burning pain or a feeling of discomfort that develops just below your breastbone. The pain is usually worse after eating, or when bending over or lying down.

Acid reflux 

Acid reflux is where acid is regurgitated (brought back up) into your throat and mouth.

Regurgitation of acid usually causes an unpleasant, sour taste at the top of your throat or the back of your mouth.

Dysphagia

Around a third of people with GORD have dysphagia. Acid scarring leads to the oesophagus narrowing, making it difficult to swallow.

People with GORD-associated dysphagia say it feels like a piece of food has become stuck somewhere near their breastbone.

Less common symptoms

GORD can sometimes have a number of less common symptoms associated with the irritation and damage caused by stomach acid.

Less common symptoms include:



feeling sick



persistent cough, which is often worse at night



chest pain



wheezing



tooth decay



laryngitis – inflammation of the larynx, which causes throat pain and hoarseness



If you have asthma and GORD, your asthma symptoms may get worse as a result of stomach acid irritating your airways.

When to seek medical advice

You probably don't need to see your GP if you're only experiencing symptoms such as heartburn once or twice a month.

You should be able to control your symptoms by making a number of lifestyle changes and using over-the-counter medication as and when symptoms occur.

Visit your GP if you have frequent or severe symptoms, and you're using over-the-counter medication on a daily or weekly basis. You may need prescription medication to control your symptoms and prevent complications.

Difficulty swallowing (dysphagia) is a common symptom of GORD 

 


GORD symptoms in babies and infants

Many parents don't realise that GORD can be a common condition in babies and infants under two years of age. This is because their oesophagus is shorter and narrower.

In younger children, possible signs of GORD can include:



frequently bringing up food – this can occur soon after being fed or up to two hours afterwards



frequent crying



irritability



bad breath



difficulty sleeping



arching their back during or after a feed



refusing a feed even though they're happy to suck on a dummy or similar



Many of these symptoms are common in babies and infants. However, if they occur frequently, you should contact your GP.Looking after a sick child.How to look after a sick child, including dealing with minor accidents and getting help







 

 

Causes of gastro-oesophageal reflux disease 

Most cases of gastro-oesophageal reflux disease (GORD) are thought to be caused by a problem with the lower oesophageal sphincter (LOS).

The LOS is a ring of muscle at the bottom of the oesophagus (gullet), which is the tube that runs from the back of the throat to the stomach.

The LOS works as a valve, opening to let food into your stomach to be digested by stomach acid. It then closes to stop any acid leaking back up into your oesophagus.

However, in people with GORD, this ring of muscle has become weakened, allowing stomach acid to pass back up into the oesophagus. This causes symptoms such as a burning pain in your chest (heartburn), or a feeling of discomfort in your stomach.

It's not always clear what causes the LOS to become weakened, but a number of risk factors have been identified (see below).

Risk factors

Risk factors for a weakened LOS include:



being overweight or obese – this can place increased pressure on your stomach, which in turn can weaken the LOS



eating large amounts of fatty foods – the stomach takes longer to dispose of stomach acid after digesting a fatty meal



consuming tobacco, alcohol, coffee or chocolate – it's been suggested that these four substances may relax the LOS



being pregnant – changes in hormone levels during pregnancy can weaken the LOS and increase pressure on your stomach



having a hiatus hernia – this is where part of your stomach pushes up through your diaphragm (the sheet of muscle used for breathing)



stress



There's also a condition called gastroparesis, where the stomach takes longer to dispose of stomach acid. This excess acid can push up through the LOS.

Gastroparesis is common in people who have diabetes, because high blood sugar levels can damage the nerves that control the stomach.

Medication

Certain medications can relax the LOS, leading to the symptoms of GORD. These medications include:



calcium-channel blockers – used to treat high blood pressure (hypertension)



nitrates – used to treat angina, which is chest pain caused by the blood supply to the muscles of the heart becoming restricted



There are also a number of medications that can contribute to the development of oesophagitis (where stomach acid irritates and inflames the lining of the oesophagus). These include:



non-steroidal anti-inflammatory drugs (NSAIDs) – a type of painkiller, including ibuprofen



selective serotonin reuptake inhibitors (SSRIs) – a type of antidepressant



corticosteroids (steroid medication) – which are often used to treat severe symptoms of inflammation



bisphosphonates – used to treat osteoporosis (weakening of the bones)



Diagnosing gastro-oesophageal reflux disease 

In most cases, your GP will be able to diagnose gastro-oesophageal reflux disease (GORD) by asking you about your symptoms.

Further testing for GORD is usually only required if:



you have pain when swallowing (odynophagia)



you have difficulty swallowing (dysphagia)



your symptoms don't improve despite taking medication



Further testing aims to confirm or disprove the diagnosis of GORD, while checking for any other possible causes of your symptoms, such as functional dyspepsia (irritation of the stomach or gullet) or irritable bowel syndrome (IBS).

You may also have a full blood count (FBC) to exclude the possibility ofanaemia.

Endoscopy

An endoscopy is a procedure where the inside of your body is examined using an endoscope, which is a long, thin, flexible tube with a light and camera at one end.

To confirm a diagnosis of GORD, the endoscope will be gently inserted into your mouth and down your throat. The procedure is usually carried out while you're awake, and you may be given a sedative to help you relax.

The camera can then show if the surface of your oesophagus has been damaged by stomach acid. It can also rule out more serious conditions that can also cause heartburn, such as stomach cancer.

Manometry

Manometry is used to assess how well your lower oesophageal sphincter (LOS) is working, by measuring pressure levels inside the sphincter muscle.

During the procedure, one of your nostrils will be numbed using a topical anaesthetic. A small tube will be passed down your nostril, into your oesophagus, to the site of the LOS. The tube contains pressure sensors that can detect the pressure generated by the muscle and then send the reading to a computer.

You will be asked to swallow some food and liquid to check how effectively your LOS is working.

A manometry test takes around 20 to 30 minutes to complete. It's not painful, but you may experience minor side effects, including a sore throat or a nosebleed. These side effects should pass quickly once the test has been completed.

Manometry isn't essential for diagnosing GORD, but it can help exclude conditions with similar symptoms. It can also help ensure that the strength of gullet contractions are adequate if surgery is being considered.

Barium swallow

If you're experiencing symptoms of dysphagia, such as coughing or choking when eating or drinking, you may be referred for a test known as a barium swallow.

The barium swallow test is one of the most effective ways of assessing your swallowing ability and finding exactly where the problems are occurring. The test can often identify blockages or problems with the muscles used during swallowing.

As part of the test, you will be asked to drink some barium solution. Barium is a non-toxic chemical that is widely used in tests because it shows up clearly on an X-ray. Once the barium moves down into your upper digestive system, a series of X-rays will be taken to identify any problems.

If you need to have a barium meal X-ray, you won't be able to eat or drink anything for at least six hours before the procedure, so that your stomach and duodenum (top of the small intestine) are empty. You may be given an injection to relax the muscles in your digestive system.

After this, you will be asked to lie on a couch and your specialist will give you a white, chalky liquid to drink that contains barium. As the barium fills your stomach, your specialist will be able to see your stomach on an X-ray monitor, as well as any ulcers or abnormal growths. During the test, the couch may be angled slightly so that the barium fills all the areas of your stomach.

A barium swallow usually takes about 15 minutes. Afterwards, you will be able to eat and drink normally, although you may need to drink more water to help flush the barium out of your system.

You may feel slightly sick after having a barium meal X-ray, and the barium may cause constipation. Your stools may also be white for a few days afterwards as the barium passes through your system.

24-hour pH monitoring

If it's still unclear whether your symptoms are due to GORD after having an endoscopy, 24-hour pH monitoring will be recommended to help confirm the diagnosis. PH is a unit of measurement that describes how acidic a solution is; the lower the pH, the more acidic the solution.

The 24-hour pH monitoring test is designed to measure pH levels around your oesophagus. You should stop taking medication used to treat GORD for seven days before having a 24-hour pH test, as it could distort the test results.

During the test, a small tube containing a probe will be passed through your nose to the back of your oesophagus. This isn't usually painful, but it can feel a little uncomfortable.

The probe is connected to a portable recording device that is about the size of an MP3 player, which you wear around your wrist. Throughout the 24-hour test period, you will be asked to press a button on the recorder every time you become aware of your symptoms.

After this, you will be asked to complete a diary sheet to record when you display symptoms. You should eat as you normally would to ensure that an accurate assessment can be made.

After the 24-hour period is over, the probe will be removed and the measurements on the recorder will be analysed. If test results indicate a sudden rise in your pH levels after eating, a confident diagnosis of GORD can usually be made.

Treating gastro-oesophageal reflux disease 

A number of treatments are available for gastro-oesophageal reflux disease (GORD), including simple, self-care measures, medication and surgery.

Self care

If you have GORD, you may find the following self-care techniques useful:



If you're overweight, losing weight may reduce your symptoms, as it will reduce pressure on your stomach.



Giving up smoking can help, as smoke irritates your digestive system and can make your symptoms worse.



Eating smaller, more frequent meals, rather than three large meals a day can help. Make sure you have your evening meal three or four hours before bedtime.



Alcohol, coffee, chocolate, tomatoes, or fatty or spicy food can trigger the symptoms of GORD. If you suspect that any of these make your symptoms worse, remove them from your diet to see whether your symptoms improve.



Raise the head of your bed by around 20cm (8 inches) by placing a piece of wood or blocks under it. This may improve your symptoms. However, make sure your bed is sturdy and safe before adding the wood or blocks. Don't use extra pillows, because it may increase pressure on your abdomen.



If you're currently taking medication for other health conditions, check with your GP to find out whether they may be contributing to your symptoms.

Alternative medicines may be available, but don't stop taking a prescribed medication without consulting your GP first.

Medication

A number of different medications can be used to treat GORD. These include:



over-the-counter medications



proton-pump inhibitors (PPIs)



H2-receptor antagonists (H2RA)



Depending on how your symptoms respond, you may need medication either on a short- or long-term basis.

Over-the-counter medications

A number of over-the-counter medicines can be used to help relieve mild to moderate symptoms of GORD.

Antacids neutralise the effects of stomach acid. However, they shouldn't be taken at the same time as other medicines, because they can stop other medicines being properly absorbed into your body. They may also damage the special coating on some types of tablets. Ask your GP or pharmacist for advice.

Alginates work differently. They produce a protective coating that shields the lining of your stomach and oesophagus from the effects of stomach acid. They work best if taken just after finishing a meal.

Proton-pump inhibitors (PPIs)

If GORD fails to respond to the self-care techniques described above, your GP may prescribe a one-month course of a PPI for you. PPIs work by reducing the amount of acid produced by your stomach.

Most people tolerate PPIs well, and side effects are uncommon. When side effects do occur, they're usually mild and may include:



headaches



diarrhoea



feeling sick



abdominal pain



constipation



dizziness



skin rashes



To minimise any side effects, your GP will prescribe the lowest possible dose of PPIs that they think will be effective in controlling your symptoms. Therefore, tell your GP if they prescribe PPIs for you that prove ineffective, because a stronger dose may be needed.

The symptoms of GORD can sometimes return after a course of PPIs has been completed. Go back to your GP if you have recurring or persistent symptoms. 

In some cases, PPIs may be needed on a long-term basis.

H2-receptor antagonists (H2RA)

If PPIs can't control your GORD symptoms, another medicine known as a H2RA may be recommended to take in combination with PPIs on a short-term basis (two weeks), or as an alternative to them.

H2RAs block the effects of the chemical histamine, which is used by your body to produce stomach acid. H2RAs therefore help reduce the amount of acid in your stomach.

Side effects of H2RAs are uncommon, but possible side effects may include:



diarrhoea



headaches



dizziness



tiredness



a rash



Some types of H2RAs are available over the counter. They're taken in lower doses than H2RAs that are available on prescription. Ask your GP or pharmacist if you're unsure whether these medicines are suitable for you.

Surgery

Surgery is usually only recommended in cases of GORD that fail to respond to the treatments discussed above.

Alternatively, you may want to consider surgery if your symptoms are troublesome and persistent, but you don't want to take medication on a long-term basis.

While surgery for GORD can help relieve your symptoms, there are some associated complications that may cause additional symptoms, such as:



difficulty swallowing (dysphagia)



flatulence



bloating



an inability to burp



You should discuss the advantages and disadvantages of surgery with your GP before making a decision about your treatment.

You could also ask your GP to refer you to a surgeon who performs the procedure you're considering. They'll be able to discuss the benefits and potential side effects in detail with you.

Surgical and endoscopic procedures used to treat GORD include:



laparoscopic nissen fundoplication (LNF)



endoscopic injection of bulking agents



endoluminal gastroplication



endoscopic augmentation with hydrogel implants



endoscopic radiofrequency ablation



laparoscopic insertion of a magnetic bead band 



These procedures are discussed below.

Laparoscopic nissen fundoplication (LNF)

Laparoscopic nissen fundoplication (LNF) is one of the most common surgical techniques used to treat GORD. It uses "keyhole surgery", avoiding the need for a large incision.

It involves the surgeon wrapping the upper section of your stomach around your oesophagus to form a collar. This helps tighten your lower oesophageal sphincter (LOS), to stop acid moving back out of your stomach.

LNF is carried out under general anaesthetic and takes 60 to 90 minutes.

After having LNF, most people can leave hospital after recovering from the effects of the general anaesthetic. This is usually within two or three days. Depending on the type of job you do, you should be able to return to work within three to six weeks.

For the first six weeks after surgery, you should only eat soft food, such as mince, mashed potatoes or soup. Avoid hard food that could get stuck at the site of the surgery, such as toast, chicken or steak.

Common side effects of LNF include:



dysphagia



belching



bloating



flatulence 



These side effects should resolve over the course of a few months. However, they can persist in about 1 in 100 cases. In such cases, further corrective surgery may be needed.

New surgical techniques

In the last decade, a number of new surgical techniques have been developed for GORD.

The National Institute for Health and Care Excellence (NICE) has looked at many of these new techniques and states that they are safe enough to be made available.

However, NICE also states that there's little scientific evidence about their effectiveness in the medium- to long-term. They therefore acknowledge that several of these techniques, particularly the endoscopic procedures, are best offered in the context of a properly designed research study.

The techniques discussed below are non-invasive (apart from LINX), which means no incisions need to be made in your body. Therefore, they can usually be carried out under local anaesthetic on a day surgery basis, so you shouldn't have to spend the night in hospital.

Endoscopic injection of bulking agents

Endoscopic injection of bulking agents involves a surgeon injecting a filler where the stomach and oesophagus meet, narrowing the junction and helping to stop acid leaking up from the stomach.

The most common side effect of this type of surgery is mild to moderate chest pain. This develops in around a half of all cases. Other side effects include:



dysphagia



feeling sick



high temperature (fever) of 38ºC (100.4ºF) or above



These side effects should resolve within a few weeks.

Endoluminal gastroplication

Endoluminal gastroplication involves the surgeon using an endoscope to sew a series of pleats (folds) into the lower oesophageal sphincter (LOS). The pleats should restrict how far the LOS can open, preventing acid leaking up from your stomach.

Side effects of this type of surgery include:



chest pain



tummy (abdominal) pain



vomiting



sore throat



These side effects should improve within a few days.

Endoscopic augmentation with hydrogel implants

This is a similar technique to the endoscopic injection of bulking agents described above, except the surgeon uses a different material – a flexible plastic gel that's very similar to living tissue.

The most common complication is that the hydrogel starts to come out of the gastro-oesophageal junction. One study found this happened in one in five cases. However, this is a relatively new technique, and success rates may improve in the future.

Endoscopic radiofrequency ablation

In endoscopic radiofrequency ablation, a tiny balloon is lowered down an endoscope to your gastro-oesophageal junction.

Once in place, the balloon is inflated and electrodes attached to the outside produce pulses of heat. The heat creates small scars, which narrow your oesophagus.

Possible complications and side effects may include:



chest pain



dysphagia



injury to the oesophagus



 

Laparoscopic insertion of a magnetic bead band (LINX)

Laparoscopic insertion of a magnetic bead band was introduced in 2011.

The procedure is carried out under general anaesthetic and uses keyhole surgery (laparoscopy) to implant magnetic beads around the lower part of the oesophagus.

The magnetic beads reinforce the LOS muscle and help keep it closed when at rest, preventing stomach acid leaking upwards. The LOS opens normally when swallowing.

This type of surgery appears to be safe and effective in the short term, but its safety and effectiveness in the long term is unknown.

The availability of LINX on is currently limited, but it's available privately. The price for private treatment is in the region of £8,000-£9,000.

 

Complications of gastro-oesophageal reflux disease

A number of possible complications can occur as a result of having long-term gastro-oesophageal reflux disease (GORD).

Oesophageal ulcers

The excess acid produced by GORD can damage the lining of your oesophagus (oesophagitis), which can lead to the formation of ulcers.

The ulcers can bleed, causing pain and making swallowing difficult. Ulcers can usually be successfully treated by controlling the underlyingsymptoms of GORD.

Medications used to treat GORD can take several weeks to become effective, so it's likely your GP will recommend additional medication to provide short-term relief from your symptoms.

Two types of medication that can be used are:



antacids – to neutralise stomach acid on a short-term basis



alginates – which produce a protective coating on the lining of your oesophagus



Both antacids and alginates are over-the-counter medications and are available from pharmacies. The pharmacist will advise you about the types of antacid and alginate that are most suitable for you.

Antacids are best taken when you have symptoms, or when symptoms are expected, such as after meals or at bedtime. Alginates are best taken after meals.

Side effects for both medications are uncommon, but can include:



diarrhoea



vomiting



flatulence



Oesophageal stricture

Repeated damage to the lining of your oesophagus can lead to the formation of scar tissue. If the scar tissue is allowed to build up, your oesophagus can become narrowed. This is known as oesophageal stricture.

An oesophageal stricture can make swallowing food painful (odynophagia) and difficult (dysphagia). Oesophageal strictures can be treated using a tiny balloon or other type of dilator, such as a bougie, to widen (dilate) the oesophagus.

This procedure is usually carried out under a local anaesthetic at the same time as an endoscopy, which is an internal examination using an endoscope.

Barrett’s oesophagus

Repeated episodes of GORD can lead to changes in the cells in the lining of your lower oesophagus. This is a condition known as Barrett’s oesophagus.

It's estimated that about 1 in 10 people with GORD will develop Barrett’s oesophagus. Most cases first develop in people who are 50 to 70 years of age. The average age at diagnosis is 62.

Barrett’s oesophagus doesn't usually cause noticeable symptoms other than those associated with GORD.

However, Barrett’s oesophagus is a pre-cancerous condition. This means that changes in the cells aren't cancerous, but there's a small risk they could become cancerous in the future. This would then trigger the onset of oesophageal cancer (see below).

Oesophageal cancer

Each year in England, it's estimated that 1 in every 200 people with Barrett’s oesophagus develop oesophageal cancer.

Risk factors that increase the risk of cells in the lining of your oesophagus turning cancerous include:



being male



having the symptoms of GORD for longer than 10 years



having three or more episodes of heartburn and related symptoms a week



smoking



obesity



If it's thought you have an increased risk of developing oesophageal cancer, it's likely you'll be referred for a regular endoscopy, to monitor the affected cells.

If oesophageal cancer is diagnosed in its initial stages, it can usually be treated and cured, first by carrying out an endoscopic resection, followed by radiofrequency ablation (RFA).

An endoscopic resection is where abnormal areas of the oesophagus lining are removed for further examination using special instruments during an endoscopy.

RFA can then be carried out, where controlled pulses of energy are used to remove the thin surface layer of tissue that contains the affected cells. It's usually carried out while the patient is conscious, but sedated.