Gastro-Oesophageal Reflux Disease (GORD)
Summary
Gastro-Oesophageal Reflux Disease (GORD) is a chronic condition where gastric contents reflux into the oesophagus, causing troublesome symptoms and/or complications. It fundamentally results from a failure of the Lower Oesophageal Sphincter (LOS) barrier mechanism. While usually managed in primary care with acid suppression, untreated chronic reflux is the primary risk factor for Barrett's Oesophagus, a precursor to Oesophageal Adenocarcinoma. Diagnosis is typically clinical, but endoscopy (OGD) is crucial for Red Flags. [1,2]
Clinical Pearls
The "Heart Attack" Mimic: GORD is the most common cause of non-cardiac chest pain. It can cause severe retrosternal squeezing pain that mimics Angina. Distinguishing features: GORD pain is often post-prandial, recumbent, and relieved by antacids. Angina is exertional. (Always rule out cardiac causes first!).
Silent Reflux (LPR): Laryngopharyngeal Reflux (LPR) presents without heartburn. Patients present to ENT with chronic cough, hoarseness, throat clearing, or "globus" (lump in throat). GORD is one of the top 3 causes of chronic cough (along with Asthma and Post-nasal drip).
The H. pylori Paradox: Helicobacter pylori causes ulcers but actually protects against GORD (by causing corpus atrophy and reducing acid output). Eradicating H. pylori can paradoxically worsen pre-existing reflux symptoms.
Demographics
- Prevalence: Very common. 10-20% of Western populations experience weekly symptoms.
- Geography: more common in Western countries (Diet/Obesity).
- Gender: Equal prevalence, but complications (Barrett's/Cancer) are far more common in Men.
- Age: Prevalence increases with age (LOS laxity).
Risk Factors
- Obesity: Central adiposity increases intra-abdominal pressure.
- Hiatus Hernia: Sliding hiatus hernia displaces the LOS into the negative-pressure thorax.
- Diet: Alcohol, Caffeine, Chocolate, Fatty meals (All relax the LOS).
- Smoking: Relaxes the LOS.
- Pregnancy: Hormonal relaxation + Mechanical pressure.
- Medications: Anticholinergics, Nitrates, CCBs, Bisphosphonates.
Mechanisms of Failure
- Transient LOS Relaxations (TLOSRs): The physiological venting mechanism (burping) becomes pathological. In GORD, these relaxations are too frequent or prolonged even without swallowing.
- Hypotensive LOS: A weak sphincter (pressure less than 10mmHg) that simply yields to gastric pressure.
- Anatomical Disruption (Hiatus Hernia): The LOS is usually supported by the crura of the diaphragm (the "pinchcock" extrinsic sphincter). In a hernia, the LOS slides up into the chest, losing this support.
- Delayed Gastric Emptying: Gastroparesis keeps the stomach full, increasing the gradient for reflux.
- Acid Pocket: A pool of unbuffered acid sits on top of the food meal ("Chyme") right at the GOJ, ready to reflux.
| Condition | Distinguishing Factors |
|---|---|
| Functional Dyspepsia | Epigastric pain/bloating without acid reflux. Normal endoscopy. |
| Achalasia | Dysphagia to solids AND liquids. Regurgitation of undigested food (bland, not acidic). |
| Eosinophilic Oesophagitis | Young male with history of Atopy/Asthma. Food bolus obstruction ("Steakhouse syndrome"). |
| Peptic Ulcer Disease | Epigastric pain. DU is relieved by food; GU is worsened. |
| Angina Pectoris | Exertional. Radiation to arm/jaw. Associated with diaphoresis. |
| Oesophageal Cancer | Progressive dysphagia (solids then liquids) + Weight loss. |
Typical Symptoms ("The Classic Duo")
- Heartburn (Pyrosis): Burning retrosternal discomfort, radiating up towards the throat. Worse after meals and lying down.
- Regurgitation: Passive return of gastric contents into the mouth. Acid/Sour taste ("Acid Brash").
Atypical / Extra-Oesophageal Symptoms
"Test and Treat" Strategy
In patients less than 55-60 years with typical symptoms and NO red flags:
- Diagnosis is clinical.
- Trial of Response to PPI serves as a diagnostic test.
Endoscopy (OGD) Indications
Urgent (2 Week Wait):
- Dysphagia.
- Unexplained Weight Loss.
- Upper Abdominal Mass.
- Iron Deficiency Anaemia.
- Persistent Vomiting.
Routine:
- Refractory symptoms despite PPI.
- Surveillance for Barrett's Oesophagus (Men >50, Chronic symptoms >5 years).
Physiological Testing (Manometry & pH)
Used when diagnosis is uncertain or Pre-Surgery.
- High Resolution Manometry: Assesses oesophageal motility. Mandatory before surgery to rule out Achalasia (wrapping an achalastic gullet causes severe dysphagia).
- 24hr pH Monitoring: Gold Standard. Catheter measures Acid Exposure Time (AET > 6% is abnormal).
- Impedance: Detects non-acid reflux (Gas/Bile) which PPIs won't fix.
Management Algorithm
SYMPTOMATIC GORD
↓
LIFESTYLE ADVICE + ANTACIDS
- Weight loss (Crucial)
- Elevate bed head
- Avoid late meals
↓
FULL DOSE PPI (4-8 Weeks)
(e.g., Omeprazole 20mg OD)
(Take 30 mins BEFORE breakfast)
┌─────────┴─────────┐
RESOLVED PERSISTENT
↓ ↓
Step Down to Check Adherence
lowest effective ↓
dose / PRN Double Dose PPI
(20mg BD)
↓
H2 Antagonist?
(Add Famotidine at night)
↓
REFER OGD
↓
CONSIDER SURGERY
1. Lifestyle
- Weight Loss: The most effective non-drug intervention.
- Diet: Avoid triggers (Coffee, Chocolate, Alcohol, Tomatoes). Smaller meals.
- Timing: No food 3 hours before bed.
- Mechanical: Raise head of bed (Blocks, not just pillows).
2. Pharmacotherapy
- PPIs (Proton Pump Inhibitors): Omeprazole, Lansoprazole, Esomeprazole. Irreversibly block the H+/K+ ATPase pump.
- Note: Safe long term. Small risks (C. diff, fracture, hypomagnesaemia) are outweighed by benefit in severe GORD.
- H2 Receptor Antagonists: Famotidine. Less effective than PPIs. Tachyphylaxis (tolerance) develops quickly.
- Alginates: Gaviscon. Forms a physical "raft" of foam on top of the stomach contents. Very good for post-prandial symptoms.
3. Surgery (Anti-Reflux Surgery)
- Indications: High volume regurgitation (PPIs stop acid but can't stop the fluid coming up), Intolerance to PPIs, Patient choice (young patients avoiding life-long pills).
- Laparoscopic Nissen Fundoplication: Wrapping the gastric fundus 360 degrees around the lower oesophagus.
- Side Effects: "Gas Bloat" (inability to belch), Dysphagia (if too tight).
- LINX: Magnetic bead ring.
Oesophageal
- Oesophagitis: Mucosal breaks/erosions. (Los Angeles Classification A-D).
- Peptic Stricture: Benign scarring causing dysphagia. Needs dilation.
- Barrett's Oesophagus: Metaplasia (Squamous -> Columnar/Intestinal epithelium). Pre-malignant.
- Oesophageal Adenocarcinoma: Rising incidence in the West.
Extra-Oesophageal
- Aspiration Pneumonitis.
- Pulmonary Fibrosis.
- Severe Laryngitis.
- GORD is typically a chronic, relapsing condition.
- Quality of Life: Can be severely impaired without treatment.
- Barrett's Risk: Progression to cancer is low (~0.3-0.5% per year) but surveillance is indicated for long-segment disease.
- Surgical Outcome: >90% satisfaction at 5 years, but efficacy wanes over 10-20 years.
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| CG184 | NICE (2014) | Dyspepsia & GORD. Red flags for OGD. Step-down PPI strategy. |
| Diagnosis | Lyon Consensus (2018) | Definitive criteria for GORD on pH testing (AET >6%). |
| Barrett's | BSG Guidelines | Surveillance protocols for Barrett's. |
Landmark Evidence
1. LOTUS Trial (JAMA 2011)
- Randomized trial comparing Esomeprazole vs Laparoscopic Antireflux Surgery for chronic GORD.
- Result: At 5 years, clinical remission rates were similar. Surgery is a valid option but not superior to medical therapy for symptoms.
What is GORD?
GORD (Reflux) happens when the muscular valve at the top of your stomach becomes weak or leaky. This allows harsh stomach acid to splash back up into your gullet (oesophagus), causing burning pain (heartburn).
What makes it worse?
- Being overweight: Pushes on the stomach.
- Smoking/Alcohol: Relaxes the valve.
- Certain foods: Spicy food, coffee, chocolate.
- Eating late: Trying to sleep on a full stomach.
Is it dangerous?
Most of the time, it's just painful. However, if acid keeps burning the gullet for years, it can cause scarring (making it hard to swallow) or changes in the cells (Barrett's Oesophagus) which carries a small risk of cancer.
How do I treat it?
- Lose weight: This is the best cure.
- Medication: PPIs (like Omeprazole) turn off the acid pumps in your stomach. They don't fix the valve, but they make the liquid less harmful.
- Surgery: An operation to tighten the valve can be done for severe cases.
Primary Sources
- NICE. Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management (CG184). 2014.
- Katz PO, et al. Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol. 2013.
- Gyawali CP, et al. Modern diagnosis of GERD: the Lyon Consensus. Gut. 2018.
Common Exam Questions
- Red Flag: "56yo male, new dyspepsia + weight loss?"
- Answer: Urgent 2WW Referral for Endoscopy (Rule out Cancer).
- Pathology: "Diagnosis of Barrett's?"
- Answer: Columnar metaplasia of distal oesophagus (Salmon-pink tongues).
- Surgery: "Complication of Nissen Fundoplication?"
- Answer: Gas Bloat Syndrome (inability to burp/vomit).
- Pharmacology: "Timing of PPIs?"
- Answer: 30-60 minutes BEFORE breakfast (needs active pumps).
Viva Points
- Zollinger-Ellison Syndrome: A rare cause of severe, refractory reflux/ulcers caused by a Gastrin-secreting tumour (Gastrinoma). Suspect if multiple ulcers or diarrhoea present.
- Non-Erosive Reflux Disease (NERD): Patients have classic symptoms but a normal endoscopy. This accounts for ~60% of GORD. Diagnosis requires pH monitoring to prove acid is the cause.
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.