GASTRO-OESOPHAGEAL REFLUX DISEASE

Gastro-oesophageal reflux (GOR) is defined as backward flow of gastric contents into the
oesophagus. A small amount of GOR occurs in normal individuals; the term GORD (gastro-
oesophageal reflux disease) includes all the symptoms and forms of tissue damage
secondary to the reflux of gastric contents into the oesophagus. GORD is the most common
oesophageal disorder, accounting for nearly 75% of all patients with oesophageal disorders.

Clinical spectrum

Heartburn and regurgitation are considered typical symptoms and may be the only symptoms
in most cases. Other symptoms include dysphagia, chest pain, waterbrash, globus sensation
and rarely odynophagia. Over half the cases of noncardiac chest pain may be attributed to
abnormal reflux.

Major pulmonary manifestations are non-seasonal and nocturnal asthma and chronic cough.
Otolaryngological manifestations include hoarseness, postnasal drip, persistent coughing,
sore throat, choking spells, laryngospasm and posterior laryngitis.

Dysphagia is a feature of complicated reflux disease and is often a sign of peptic stricture or
oesophageal cancer. It may also be related to oesophageal motor dysfunction. Occasionally,
patients with GORD may present with acute or chronic blood loss.

Barrett’s oesophagus [columnar-lined oesophagus] is found in 8%-12% of patients with

GORD undergoing endoscopy. It is the most severe consequence of GOR. The normal
squamous lining of the oesophagus undergoes metaplasia and resembles intestinal mucosa
Barrett’s oesophagus is considered a premalignant lesion as the risk of adenocarcinoma is
30-50 times higher than in the general population.

Pathophysiology

The normal antireflux barrier at the gastro-oesophageal junction is a zone whose functional
integrity is maintained by the LOS pressure, extrinsic compression of the LOS by the crural
diaphragm, the intra-abdominal location of the LOS, integrity of the phreno-oesophageal
ligament, and maintenance of the acute angle of His.

Reflux of gastric contents occurs through a relaxed or hypotonic sphincter (Table 9.7). LOS
relaxation is usually swallow-mediated; however, during periods of gastric distension, the LOS
may relax spontaneously. A majority of reflux episodes in normal individuals and in patients
with GORD occur during brief intermittent LOS relaxation (transient LOS relaxation) rather
than because of low LOS tone. Marked basal LOS hypotension is observed in patients with
severe GORD.

Table 9.7 : Factors facilitating gastro-oesophagal reflux

1. Incompetent LOS and reduction in Diabetes mellitus, scleroderma, prolonged Ryle's

LOS pressure tube intubation, hiatus hernia, fatty foods, excess of
caffeine
2. Raised intra abdominal Obesity, ascites, pregnancy pressure
3. Impairment of oesophageal Smoking and alcohol
mucosal function
4. Impaired gastric emptying Pyloric stenosis, gastroparesis, fatty foods
5. Increased gastric contents Large meals, Zollinger-Ellison syndrome

Hiatus hernia is associated with anatomic disruption of the diaphragmatic sphincter. Its
presence in a setting of GORD is not considered very significant.
Investigations

Ambulatory oesophageal pH monitoring is the gold standard for the diagnosis of reflux.
Usually, 24-hour monitoring is preferred as it allows monitoring of the circadian pattern of
reflux and of the effects of physiological activity.

The other less specific tests include barium oesophagography, scintigraphy and the standard
acid reflux test.

Endoscopy is the most widely used method to diagnose oesophagitis, and follow up severe
GORD; it is also useful in the diagnosis and management of the complications of GORD. Only
one-third of patients with typical symptoms have endoscopic evidence of oesophagitis.

Therapy

Treatment is directed towards decreasing GOR, making the refluxate harmless to the
oesophagus and decreasing damage, and improving oesophageal clearance.

Medical therapy includes life-style modifications and drug therapy. Since the severity of reflux
diseases varies between patients, and often at different times in the same patient, a step-wise
approach is required in therapy. Phase I therapy is directed at life-style modifications and use
of antacids. Phase II therapy is useful for patients not responding to Phase I therapy and
those with grade II oesophagitis. It incorporates use of H2 receptor blockers with or without
prokinetic drugs. For patients not responding to these measures or those with severe mucosal
disease, Phase III therapy consisting of proton pump inhibitors (omeprazole, lansoprazole) or
high-dose H2 receptor blockers need to be given. In refractory cases, surgery (Phase IV
therapy) may be required. With the advent of potent acid-suppressing agents less than 10%
of patients with GORD now require anti-reflux surgery.

Life-style modifications : Since the frequency and duration of reflux episodes are increased in
the supine posture, elevation of the head end of the bed by 15-20 cm blocks is useful. The
patients should be advised to remain in an upright position, and avoid bending at the waist till
two hours after a meal. Certain foods like chocolates, carminatives, foods rich in fat, garlic,
onion, carbonated drinks with low pH, coffee, alcohol and peppermint have been shown to
relax the LOS. Smoking decreases the LOS pressure and increases acid clearance time.
Reflux-promoting foodstuffs and smoking should be avoided. Weight loss also leads to a
decrease in reflux.

Drugs like theophylline, calcium-channel blockers, nitrates, b2 agonists, anticholinergics,

antidepressants and progesterone decrease the LOS pressure. Calcium-channel blockers
and nitrates also decrease oesophageal contractility. These drugs should be avoided in GOR.

Maintenance therapy

It is important to understand that GORD is often a chronic disease; short-term therapy is not
expected to give relief to many patients. Maintenance therapy with lower doses of H2RA may
be required after healing of oesophagitis has occurred.

Surgery

Patients not responding to initial aggressive acid suppression, and those relapsing while on
maintenance therapy are candidates for surgical intervention. The most frequent surgery
done is fundoplication where the gastric fundus is wrapped around the oesophagus.