Volume 6 | Issue 7 | 2020 | Gastroenterology and Hepatology
Gastro-oesophageal reflux disease (GORD) AUTHOR: Dr Theresa Lowry Lehnen, PhD, RGN, Post Grad Coronary Care, Clinical Nurse Specialist and Associate Lecturer at Institute of Technology Carlow, Member of the Irish Student Health Association (ISHA) Gastro-oesophageal reflux disease (GORD) is a common disorder of the gastrointestinal (GI) system. A higher incidence occurs in people living in western countries, affecting up to 20 per cent of the population. GORD is defined as “symptoms or complications resulting from the reflux of gastric contents into the oesophagus or beyond, into the oral cavity (including larynx) or lung”. The most common cause is defective functioning of the lower oesophageal sphincter, leading to excessive acid exposure in the lower oesophagus. In healthy people, the ‘angle of His’ where the oesophagus enters the stomach, creates a valve that prevents bile, digestive enzymes, and stomach acid from travelling back into the oesophagus which can cause burning and inflammation of sensitive oesophageal tissue. Most patients with GORD present with the classic symptoms of heartburn and acid regurgitation, reporting a burning feeling in the retrosternal area, rising up into the chest and radiating toward the neck, throat, and occasionally the back. It is estimated that between 20 and 40 per cent of patients with heartburn will have a diagnosis of GORD (Patrick, 2011). Symptoms occur particularly after ingestion of fatty, spicy, citrus products and alcohol. The columnar epithelium lining of the oesophagus cannot withstand acid and this leads to inflammation. Other symptoms include vomiting, halitosis, anorexia, dysphagia, cough and respiratory or oropharyngeal symptoms. GORD may be just an occasional symptom for some people, but for others it can be a severe, lifelong condition. Left untreated, GORD can cause considerable discomfort and a poor quality-of-life. Medical attention should be sought and symptoms investigated when GORD is severe, occurs several times a week, over-
24
the-counter medications are not helping, dysphagia or symptoms such as vomiting, haematemesis, anaemia or unexplained weight loss occur, which could suggest a more serious problem. Several factors may increase the risk of developing GORD. First-degree relatives of patients with GORD are four times more likely to develop symptoms, raising the possibility of a strong genetic contribution to the aetiology. Medicines such as calcium-channel blockers, nitrates and non-steroidal anti-inflammatory drugs (NSAIDs) can cause GORD or make the symptoms worse. Risk factors for complications of GORD include advanced age, obesity, alcohol, and tobacco use. There is no clear association between gender and oesophageal stricture, however, men are at greater risk of developing erosive oesophagitis, Barrett’s oesophagus and oesophageal adenocarcinoma than women. The presence of a hiatus hernia increases the likelihood of GORD due to mechanical and motility factors. There is substantial overlap between symptoms of GORD and those of eosinophilic oesophagitis, functional dyspepsia, and gastroparesis, posing a challenge for patient management. Co-existent dysphagia is considered an alarm symptom, requiring investigation and evaluation. GORD may lead to Barrett’s oesophagus, which in turn is a precursor condition for oesophageal cancer. The risk of progression from Barrett’s to dysplasia is estimated at approximately 20 per cent of cases. Oesophageal cancer typically affects people aged between 60 and 80 years, with the most important risk factors being severe long-standing GORD, smoking, and heavy alcohol consumption.
of heartburn and acid regurgitation. Heartburn is described as a burning, retrosternal, rising sensation associated with meals, although this definition is often poorly understood by the general population. Practitioners need to be aware of this and clarify the nature of the symptoms being discussed when the term ‘heartburn’ is used by patients. Tests for GORD include endoscopy, barium swallow or meal, manometry, 24-hour pH monitoring and blood tests. A full blood count (FBC) should be taken to assess for anaemia, which could be a sign of internal bleeding. GORD can be classified according to the presence or absence of erosions on endoscopic examination. Absence of erosions are classified as non-erosive (NERD), whereas GORD symptoms with erosions is classified as erosive oesophagitis. The primary role of endoscopy is to look for complications and to exclude other diagnoses. Endoscopy is not generally required in the presence of typical GORD symptoms, however, it is recommended for patients who are at higher risk of Barrett’s oesophagus, a precursor for developing adenocarcinoma, which is more common in male patients over the age of 50 years. Manometry is used to assess how well muscle at the distal end of the oesophagus is functioning. A tube containing pressure sensors can measure the pressures in the oesophagus and help determine whether surgery may be necessary. A barium swallow, or barium meal, may be required to assess swallowing ability and look for any blockages or abnormalities in the oesophagus.
Diagnosis A presumptive diagnosis of GORD can be made based on the typical symptoms
24-hour pH monitoring may be necessary to measure the acidity level in the
