Gastro-oesophageal reflux disease (GORD) refers to the reflux of stomach contents into the oesophagus and is predominantly due to transient relaxation of the lower oesophageal sphincter (LOS).
The incidence of GORD is rising rapidly in the Western world and may relate to changes in diet and lifestyle. Around 1 in 5 people will suffer from heartburn at least once a week and treatment of GORD costs the most out of any gastrointestinal disease in many western countries.
PATHOGENESIS
The most important factor in GORD appears to be the inappropriate transient relaxation of the LOS. Although gastric acid in the esophagus is responsible for the symptoms of GORD, most patients are not gastric acid hypersecretors. Certain foods lead to relaxation of the LOS. A hiatus hernia can also disrupt the function of the LOS. Disturbance of oesophageal motility (eg Scleroderma) and poor gastric emptying (eg gastroparesis) can increase oesophageal acid exposure.
DIAGNOSIS
Heartburn and regurgitation are the classic symptoms of GORD. Response to an empirical trial of proton pump inhibitor (PPI) for 4 weeks is a useful way for diagnosing GORD.
Patient with alarm symptoms should undergo further evaluation with endoscopy:
– weight loss
– dysphagia
– odynophagia
– bleeding or anemia
– patient with long standing symptoms (to exclude Barrett’s oesophagus)
– symptoms refractory to PPI
At endoscopy the oesophageal mucosa can be visualised, and assessments can be made for underlying hiatus hernia, or complications of reflux disease such as erosive oesophagitis, peptic stricture, Barrett’s oesophagus and oesophageal adenocarcinoma.
Ambulatory 24 hour oesophageal pH monitoring is the gold standard for diagnosing GERD. Impedance monitoring can also detect nonacidic reflux.