Gastro-esophageal reflux disease (GORD) is one of the commonest ailments seen in my practice, and with an alarmingly increasing incidence in young people. The youngest patient I have seen was 12-years old. His lesion was one of the worst the gastro-enterologist had ever seen. The condition is perfect example of how food, which is supposed to nourish our bodies, can destroy it. It is a perfect illustration of how inextricably bound health and life style are.
Reflux is so common that products like Amphogel and Gaviscon are so frequently used that they have become enshrined in the medical folklore. Gastro-oesophageal reflux has a set of typical (esophageal) symptoms, which include heartburn, regurgitation, and difficulty in swallowing. Heartburn is the classic symptom of reflux disease, and it is described as a burning retrosternal pain and extends upwards for varying distances to the throat. At times there may actual regurgitation of bitter, sourliquid into the mouth, which may cause retching.
However, a diagnosis of GORD based on the presence of typical symptoms is correct in only 70% of patients. In addition to these symptoms, atypical (extra-esophageal) symptoms such as coughing, chest pain, and wheezing, do occur. These atypical symptoms make this condition one of the most underdiagnosed in many medical practices.
Reflux is a normal physiological phenomenon that is experienced by most people, especially after a meal. GORD occurs when the amount of acid reflux is excessive leading to symptoms. A study by Richter and a Gallup Organization National Survey estimated that 25-40% of healthy adult Americans experience symptomatic GORD, most commonly manifested clinically by (heartburn), at least once a month. Furthermore, approximately 7-10% of the adult population in the United States experiences such symptoms on a daily basis.
Esophageal and stomach endoscopy help confirm the diagnosis of reflux.
- Lifestyle changes are cardinal to treatment of the condition :
- Lose weight. Excessive weight increases the intra-abdominal pressure and exaggerates the reflux of stomach contents into the oesophagus.
- Avoid rich (high fat) meals since they increase the tendency to reflux.
- Don't eat very late at night. Wait three hours after meals before lying down.
- Intake of alcohol and caffeine must be avoided since these reduce the effectiveness of the gastro-oesaphageal sphincter.
- Smoking also has the same harmful effect.
- Elevating the head of the bed when sleeping does reduce reflux.
- Antacids are still effective in controlling mild symptoms of GORD, and they help to neutralize the acid in the stomach. They include products like Aluminum Hydroxide ( amphoge l), Magnesium Carbonate and Magnesium trisilicate. These are sometimes found in combination as in Gaviscon : a combination of Aluminum Hydroxide and Magnesium Trisilicate. Antacids should be taken after each meal and at bedtime.
- H2 receptor antagonists are the first-line agents for patients with mild to moderate symptoms and grades I-II esophagitis. Options include ranitidine ( Zantac), cimetidine ( Tagamet) etc. H2 receptor antagonists are effective for healing only mild esophagitis in 70-80% of patients with GORD and for providing maintenance therapy to prevent relapse.
- Proton pump inhibitors (PPI) are the most powerful medications available for treating reflux oesophagitis. They have few adverse effects and are well tolerated for long-term use. Options include omeprazole ( Prilosec ), and esomeprazole ( Nexium) .
As in many other fields, surgical therapy for gastro-oesophageal reflux has evolved a great deal but is only rarely needed .
Indications for surgery include the following:
- Patients with symptoms that are not completely controlled by medical therapy should be considered for surgery.
- Poor patient compliance with regard to medications
- Postmenopausal women with osteoporosis