What is GORD?
1 in 4 people in the UK have heartburn. GORD happens when acid and other stomach content persistently leak up from the stomach back into the food pipe (oesophagus) causing symptoms such as heartburn and regurgitation. The body has a natural anti-reflux mechanism consisting of a ring of muscles at the junction of the oesophagus and stomach which acts as a one-way system. When this valve is weakened, the one-way system fails resulting in backflow of stomach acid and content into the oesophagus.
Some reflux is normal, but persistent excessive reflux is not and requires medical attention. Whilst the stomach can resist acid, the oesophagus cannot and acid in the oesophagus causes pain. If left untreated, GORD can cause damage to the lining of the oesophagus known as oesophagitis, and in some cases, can lead to precancerous changes in the cells of the oesophagus known as Barrett’s oesophagus which can lead to cancer (https://heartburncanceruk.org).
What causes GORD?
There are lifestyle factors which interfere with our natural anti-reflux valve including excess alcohol, smoking, excess body weight. Certain foods contain chemicals which cause the muscles in the valve to relax, such as chocolate, peppermint, coffee. During pregnancy, many women experience heartburn because of the pressure the growing womb exerts on the stomach. It most often settles after delivery.
A hiatus hernia is when part of the stomach slides up into the chest through the natural gap (hiatus) in the muscle separating the chest from the abdomen (diaphragm). Most hiatus hernias are asymptomatic and can be left alone, but they do increase the risk of developing heartburn. Extremely large hiatus hernias are different, and the recommendation is to speak to a specialist even if they are not causing symptoms.
Symptoms of GORD – Typical symptoms:
Heartburn – a burning pain starting at the lowest end of the breastbone and travels up to the centre of the chest, sometimes even into the throat.
Regurgitation – effortless backflow of food or liquid from the stomach back into the oesophagus, the throat sometimes even the mouth, usually on bending down or lying flat after a meal. It occurs without retching or feeling sick.
Pain in the centre of the chest behind the breastbone on swallowing – especially hot drinks.
Atypical symptoms which may not be due to GORD:
A persistent cough.
Sore throat.
Hoarse voice.
Sensation of a lump in the throat.
How is GORD diagnosed?
If your doctor suspects you have GORD, they may start you on acid-suppressant medications. If your symptoms resolve whilst on these tablets you likely have GORD. If you require long-term medication to control GORD your doctor will refer you for further tests.
Gastroscopy – camera into the stomach – to look directly at the inner lining of the oesophagus and the inside of your stomach to look for inflammation, ulcers and hiatus hernias.
Barium swallow – X ray video taken whilst you swallow a liquid called Barium, it helps assess how well the oesophagus muscles work and if there is a hiatus hernia.
Oesophageal Physiology – these tests help determine if you have abnormal amounts of acid in your oesophagus (GORD) and more importantly if your symptoms are due to GORD. Invasive anti-reflux treatment is only successful when the symptoms you describe correlate with acid reflux. They are only performed after you see a specialist and if your symptoms do not improve with non-invasive treatment or if surgery is considered to treat GORD. They are done at Heatherwood Hospital.
Treatment – most GORD improves with lifestyle changes.
Diet – Avoiding trigger foods such as coffee, tea, chocolate, fizzy drinks, spicy foods, fatty foods and acidic foods such as citrus and tomatoes can help.
Smoking – You can get information about help with smoking cessation through your GP.
Alcohol – Reducing alcohol intake will help with GORD.
Excess Weight – being overweight put excess pressure on the stomach and therefore stress on the anti-reflux valve. Losing weight improves reflux symptoms in over half of patients. You can speak to your GP about available services to help you through your weight loss journey, including if you qualify for a referral for weight loss drugs or weight loss surgery.
Acid-suppressant medications – These are split into 2 groups:
Histamine H2-receptor antagonists (H2 blockers). These include, Cimetidine, Famotidine and Nizatidine. These can be taken prior to bedtime.
Proton pump inhibitors (PPIs). These include Omeprazole, lansoprazole, Pantoprazole, Rabeprazole and Esomeprazole. These are best taken 30 minutes prior to breakfast or evening meal.
If your symptoms do not resolve with lifestyle changes, the acid suppressant medications are no longer working, causing side effects or you simply do not wish to remain on tablets or if you have troublesome regurgitation then your doctor can refer you to an Upper GI specialist surgeon to assess your symptoms and discuss possible treatment options including surgery if this is right for you.
Upper GI surgeons, myself included, are trained to assess whether symptoms are likely to improve with surgery. We can talk you through what options are available to you as well as the pros and cons.
NICE recommends the following surgeries to treat reflux:
Laparoscopic fundoplication – is the gold standard for anti-reflux surgery and involves wrapping the top part of the stomach (called the fundus) around the lower oesophagus (food pipe) to create a new valve. If there is a hiatus hernia this will be repaired too. This is a keyhole procedure and can be a day-case.
Magnetic Sphincter Augmentation (MSA) or LINX procedure – a bracelet of magnetic titanium beads is placed around the lower end of the oesophagus via keyhole surgery to strengthen the anti-reflux valve. If there is a hiatus hernia this will be repaired too. This is a keyhole day-case procedure.
If your BMI is greater than 40, weight loss surgery is recommended over anti-reflux surgery to treat reflux.
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