Gastro esophageal Reflux Disease
1. Definition & Classification
GORD (GERD) = A condition in which reflux of gastric contents causes troublesome symptoms and/or complications.
Two major phenotypes:
|
Type |
Endoscopy |
|
NERD (Non-Erosive Reflux Disease) |
Normal mucosa |
|
Erosive Reflux Disease (ERD) |
Oesophagitis present |
Other related phenotypes:
- Hypersensitive oesophagus
- Functional heartburn (Rome IV)
Most reflux patients (≈60–70%) have NERD.
2. Pathophysiology
Reflux occurs when anti-reflux mechanisms fail.
A. Lower Oesophageal Sphincter (LOS/LES) Dysfunction
- Transient LES relaxations (TLESRs) → most common cause
- Hypotensive LES (<10 mmHg)
B. Anatomical Factors
- Hiatus hernia (sliding type most common)
- Increased intra-abdominal pressure (obesity, pregnancy)
C. Impaired Clearance
- Poor oesophageal peristalsis
- Reduced salivary neutralisation
D. Delayed Gastric Emptying
- Diabetic gastroparesis
- Post-vagotomy
E. Acid Pocket
Postprandial unbuffered acid layer near gastro-oesophageal junction
3. Risk Factors
|
Cause |
Reason / Mechanism |
|
Obesity (central adiposity) |
↑ Intra-abdominal pressure → ↑ gastro-oesophageal pressure gradient → promotes reflux; also associated with ↑ transient LES relaxations (TLESRs). |
|
Pregnancy |
Progesterone → ↓ LES tone; enlarged uterus → ↑ intra-abdominal pressure → reflux. |
|
Smoking |
↓ LES pressure; ↓ salivary bicarbonate; impaired oesophageal clearance; ↑ gastric acid secretion. |
|
Alcohol |
Direct ↓ LES tone; mucosal irritation; delayed gastric emptying. |
|
Caffeine |
Relaxes LES; may ↑ gastric acid secretion (mild effect). |
|
Large meals |
Gastric distension → ↑ TLESRs; ↑ acid pocket formation post-prandially. |
|
Supine posture |
Loss of gravity-assisted oesophageal clearance → prolonged acid contact time. |
|
Calcium Channel Blockers (CCBs) |
Smooth muscle relaxation → ↓ LES tone. |
|
Nitrates |
Nitric oxide–mediated smooth muscle relaxation → ↓ LES pressure. |
|
Theophylline |
Direct ↓ LES tone; ↑ gastric acid secretion. |
|
Anticholinergics |
Impaired LES tone + delayed gastric emptying. |
|
Benzodiazepines |
Central relaxation → ↓ LES tone; reduced arousal → prolonged reflux episodes during sleep. |
4. Clinical Presentation
A. Typical Symptoms
- Heartburn (retrosternal burning)
- Acid regurgitation
- Sour taste
B. Atypical / Extra-Oesophageal
- Chronic cough
- Hoarseness
- Asthma-like symptoms
- Dental erosions
- Non-cardiac chest pain
C. Alarm Features (URGENT endoscopy)
- Dysphagia
- Odynophagia
- Weight loss
- GI bleeding
- Iron deficiency anaemia
- Persistent vomiting
- Age >55 with new symptoms (UK NICE context)
5. Endoscopic Findings
Los Angeles (LA) Classification of Oesophagitis
|
Grade |
Description |
|
A |
≤5 mm mucosal break |
|
B |
>5 mm but not between folds |
|
C |
Between ≥2 folds but <75% circumference |
|
D |
≥75% circumference |
Grade C & D = severe disease → long-term PPI
6. NERD (Non-Erosive Reflux Disease)
Defined as:
- Typical reflux symptoms
- Normal endoscopy
- Abnormal acid exposure on 24-hour pH monitoring
Subgroups:
- True NERD (abnormal acid exposure)
- Hypersensitive oesophagus (normal acid, positive symptom association)
- Functional heartburn (normal acid, no correlation)
Most NERD patients have milder disease but respond less well to PPI compared to ERD.
7. Investigations
Both National Institute for Health and Care Excellence (NICE) and British Society of Gastroenterology (BSG) recommend a symptom-based diagnosis in patients with typical features and no alarm signs.
Response to PPI supports but does NOT prove diagnosis.
1. Upper GI Endoscopy
Indications:
- Alarm symptoms
- Refractory symptoms
- Screening for Barrett’s in high-risk
2. 24-Hour pH Monitoring
Gold standard for acid reflux
- DeMeester score >14.7 = abnormal
3. Impedance-pH Monitoring
Detects:
- Acid reflux
- Weakly acidic reflux
- Non-acid reflux
4. Oesophageal Manometry
- Pre-surgery evaluation
- Exclude achalasia
9. Complications
A. Barrett’s esophagus
- Columnar metaplasia of distal oesophagus
- Risk of adenocarcinoma
- More common in:
- Males
- Obesity
- Chronic GORD >5 years
B. Stricture
- Progressive dysphagia
C. Ulcer
- Bleeding
D. Adenocarcinoma
9. Management
STEP 1: Lifestyle (All patients)
|
Intervention |
Evidence |
|
Weight loss |
Strong |
|
Head of bed elevation |
Nocturnal reflux |
|
Avoid late meals |
Yes |
|
Smoking cessation |
Recommended |
Avoid routine food elimination unless symptom-trigger identified.
STEP 2: Pharmacological Therapy
1. Proton Pump Inhibitors (PPI) – First Line
Examples:
- Omeprazole
- Esomeprazole
- Lansoprazole
- Pantoprazole
Regimen:
- Once daily 30 min before breakfast
- 4–8 weeks trial
If partial response → BD dosing
Maintenance:
- Lowest effective dose
- On-demand in NERD
PPIs heal >90% erosive oesophagitis.
2. H2 Receptor Antagonists
- Famotidine
- For mild/intermittent symptoms
3. Alginates
- Form raft barrier
- Good for postprandial symptoms
- Safe in pregnancy
4. Prokinetics (Limited Role)
- Metoclopramide (short term)
- Domperidone (QT risk)
10. Refractory GORD
Defined:
- Persistent symptoms after 8 weeks of BD PPI
Causes:
- Poor compliance
- Functional heartburn
- Weakly acidic reflux
- Bile reflux
- Eosinophilic oesophagitis
- Cardiac cause
Next steps:
- Confirm diagnosis with impedance-pH
- Consider switching PPI
- Add bedtime H2RA
- Consider surgery
11. Surgical Management
Nissen fundoplication
Indications:
- Severe reflux despite PPI
- Large hiatus hernia
- Young patient needing lifelong PPI
- Regurgitation dominant symptoms
Complications:
- Gas bloat syndrome
- Dysphagia
- Inability to vomit
12. Barrett’s Surveillance
|
Finding |
Surveillance |
|
No dysplasia |
3–5 yearly |
|
Low-grade dysplasia |
6–12 monthly or ablation |
|
High-grade dysplasia |
Endoscopic eradication therapy |
13. Special Situations
Pregnancy
- First line: lifestyle + alginates
- H2 blockers safe
- PPIs (omeprazole) considered safe
Asthma + Reflux
- Treat reflux only if symptomatic
Cardiac Chest Pain vs Reflux
- Always exclude ACS first