Gastro-oesophageal reflux disease (GORD)

Most people experience reflux of minute quantities of gastric juice into the gullet (oesophagus) – the connecting pipe between the mouth and the stomach. This is usually so little that the defense mechanism of the oesophagus is able to get rid of the little volume and it has no effect on the lining of the oesophagus. The acronym GERD or GORD depends on the spelling of oesophagus-British (GORD) or American (GERD).

What is gastro-oesophageal reflux disease (GORD)?

When the acid reflux volume exceeds the amount that can be neutralized in the oesophagus and begins to cause changes in the oesophageal lining, then the individual is said to have gastro-oesophageal reflux disease (GORD). Gastro-oesophageal reflux disease (GORD) is a condition in which gastric acid and bile flows upwards to the gullet from the stomach and small intestine, causing injury to the oesophagus with or without symptoms.

Why does reflux happen?

The lower part of the oesophagus which connects to the stomach has a band of muscles which contracts to prevent back flow of stomach contents and relaxes to allow food swallowed to enter into your stomach. This is called the lower oesophageal sphincter and it acts like a gatekeeper.

The oesophagus passes through a flat muscle that lies in between the chest and abdominal cavity, called the diaphragm, before it enters the abdomen. There’s a tight space between the outer part of the oesophagus and diaphragm. This serves as a sort of valve, to prevent back flow of food and fluid from the reservoir (stomach) back into the pipe and into the mouth.

In GORD, this space widens and allows backflow of stomach contents. This space may become wide enough for a part of the stomach to pass through. This is called hernia and coexists with GORD. Your body neutralizes acidic gastric content that gets into your gullet by producing saliva which is alkaline. When you swallow saliva, it neutralizes the acidic gastric content that gets into your gullet, thereby preventing injury to the inner linings of your gullet.

 Any food, drugs or drinks that causes the lower oesophageal sphincter to relax can cause acid reflux. In addition, any condition that may increase the pressure within the abdominal cavity -that is the space between the chest and your private part, can cause acid reflux. The pressure pushes up the stomach and as it gets higher than what the sphincter can withstand, the sphincter opens up. Thereby allowing large volumes of stomach contents including gastric acid and bile to flow into your gullet.

This large quantity cannot be neutralised by the saliva produced, hence causing injury to the oesophagus (oesophagitis), larynx (laryngitis) and even erodes the enamel of your teeth if it gets up to your mouth. Any food or drink that increases gastric acid secretion may worsen acid reflux. It is almost equally common in both men and women.

Who is at risk of having GORD?

Obesity and pregnancy increases the risk of developing this condition. Certain foods such as chocolates, coffee, fatty foods, and citrus fruits cause relaxation of the lower oesophageal sphincter, thereby increasing the risk of developing the condition. Nicotine is implicated as a risk factor for GORD as well. Drugs like beta blockers and calcium channel blockers also increase the risk of GORD.

Symptoms of GORD

The main symptoms of GORD are

• Heartburn: burning pain in the lower chest that goes up towards the mouth. It is the most common symptom of GERD. It literally feels like your chest is on fire.
• Regurgitation: This is effortless displacement of contents of the stomach into the oesophagus and in some cases up to the mouth. This may be associated with sour taste in your mouth and water brash – a condition in which there is a sudden pool of watery saliva in the mouth. Regurgitation is different from vomiting which is forceful expulsion of stomach contents. Retching may come with vomiting but never with regurgitation.
• Difficulty with swallowing (dysphagia) is another symptom of GORD. It may be described as  a feeling of a lump stuck in the throat.

Other symptoms that mimic symptoms of other organ diseases rather than the digestive system are

• Cough: Constant irritation of the larynx can cause cough and constant clearing of the throat. Regurgitation with aspiration of gastric contents into the trachea, to the lungs will cause recurrent chest infection with difficulty breathing, wheezing and cough.
• Chest pain: The pain of GORD is in the lower chest behind the collar bone. The pain may be burning and in some cases it is aching, feels like a heavy object in the chest. In this case, the chest pain mimics that of myocardial infarction. Myocardial infarction is a potentially fatal condition if not promptly identified and treated.
• Sore throat: Constant irritation of the larynx with gastric acid may cause sore throat.
• Back pain: Abdominal pain may radiate to the mid back as well.
• Nausea and vomiting: are part of the symptoms especially when complicated by a stricture.

GORD may become complicated by oesophageal strictures, weight loss, malnutrition and oesophageal cancer.

A stricture is a narrowing of a hollow organ such as oesophagus or intestine resulting from scar tissue from a healing or healed wound. Strictures may totally seal up a part of the oesophagus, such that food remains above the area of stricture as it can hardly pass through the site. The person starts to vomit food that is undigested because it couldn’t get into the stomach or didn’t stay long enough to be digested.

Oesophageal cancer may result from reflux oesophagitis which has transformed into cancer.

How is GORD diagnosed?

 GORD or acid reflux is diagnosed and treated by your gastroenterologist. Your doctor will confirm the diagnosis with an upper gastrointestinal endoscopy and oesophageal pH monitoring.

Oesophageal pH monitoring involves checking the concentration of secretions in your gullet over a few hours. If the concentration is predominantly acidic, then GORD is confirmed. Some people may have reflux without oesophagitis, hence the need for pH monitoring.

Upper GI endoscopy is a procedure in which a long tube, attached to a camera is passed through your mouth through your gullet into your stomach. With the camera being projected on a computer monitor, your doctor can view a video of the inner linings of your gastrointestinal tract. Changes in the inner linings of your oesophagus such as redness or injuries are easily identified. Your doctor might even take a little of your tissues (biopsy) to view it under the microscope. This way, cancer may be detected at the early stages.

Treatment of GERD

There are two main modalities of treatment of GORD:

Lifestyle changes namely:

• Avoid citrus fruit juices, alcoholic beverages, coffee, fatty meals , spicy meals and onions.
• Quit cigarette smoking.
• Lose weight if obese or overweight .
• Have small, frequent meals.
• Elevate the head of your bed and use a pillow. Avoid bending over.
• Avoid solid meals 3 hours before bedtime because when you lie down with a full stomach, you eliminate the effect of gravity. Therefore the food easily moves upwards.
• Drugs namely: antacids, pro kinetics, H2 receptor antagonists and proton pump inhibitors.

Surgery:

Anti reflux surgery procedure involves fixing the stomach to a point so that it’s not moving up into the chest cavity.

Summary

In summary, GORD may or may not coexist with oesophagitis. Oesophagitis is a precursor to more serious diseases such as cancer. Close monitoring while managing GORD is imperative. It can be managed by avoidance of risk factors and lifestyle changes.