Heartburn

Updated 24 June 2014

Gastro-Oesophageal Reflux Disease (GORD)

Sometimes, acidic juices from the stomach flow back (“reflux”) into the gullet, or oesophagus. It is called Gastro-Oesophageal Reflux Disease (GORD).

Summary

  • Sometimes, acidic juices from the stomach flow back (“reflux”) into the gullet, or oesophagus.
  • If this happens repeatedly, the acid will damage the lining of the gullet. This common condition is called Gastro-Oesophageal Reflux Disease (GORD).
  • Lifestyle changes such as giving up smoking, losing weight and modifying your diet usually prevent reflux from occurring.
  • The main symptom of reflux is a painful burning in the chest known as heartburn.
  • f you have severe reflux, your doctor might recommend an investigative procedure called a gastroscopy to rule out more serious conditions. In rare cases, surgery is an option, otherwise medication to suppress stomach acid will be used initially.

Alternative names

American spelling: Gastroesophageal Reflux Disease, or GERD.

Definition

Gastro-Oesophageal Reflux is a condition in which the lower oesophageal sphincter (the muscular ring at the lower end of the oesophagus, or gullet, near the diaphragm) is abnormally relaxed and allows the stomach's acidic contents to flow back or "reflux" into the oesophagus. Usually, the sphincter prevents the stomach contents from flowing upward, working like a one-way valve.

Some degree of reflux is normal in everyone. Sometimes, the sphincter does not close tightly enough after food has passed through it. Then stomach acid, which is essential for digesting food, flows into the oesophagus. This is called “reflux”. The reflux tendency increases when the stomach contains a lot of gastric juice or food and when there is increased pressure in or on the stomach.  Episodes of normal reflux typically occur after meals, are brief and without symptoms, and rarely occur during sleep.

If this happens often enough, the acid can damage the lining of the gullet. This condition is called Gastro-Oesophageal Reflux Disease or GORD. GORD is a very common problem, occurring in people of all ages and both sexes. 

 . . . . .       Acid reflux becomes pathological (the condition called GORD) when the person develops symptoms or when the oesophagus becomes damaged. Symptoms of GERD are an indication that potential injury to tissues has resulted from longer and more frequent acid exposure than that which occurs with normal, physiological reflux.

Cause

A weakened valve occurs in 20% of cases while in the majority, the primary cause is usually a sphincter that relaxes spontaneously more frequently than normal.

The following factors may contribute to aggravating reflux:

Food. The more the stomach is stretched by food, the higher the tendency to reflux. Eating fatty meals also increases this tendency, because fat delays the emptying of the stomach. Foods that prevent the oesophageal sphincter from working properly include chocolate and peppermint, while drinks such as coffee, fruit juices and alcohol have the same effect.

Hiatus hernia. Part of the stomach protrudes through the diaphragm (the layer separating the abdomen from the chest cavity), preventing the muscle fibres of the diaphragm from closing the lower end of the oesophagus. The oesophagus remains open, allowing stomach acid to enter it.

Overweight. When you are overweight, the fat in the abdominal cavity increases the pressure inside it. This can cause the contents of the stomach to move up into the gullet.

Pregnancy. Hormonal changes during pregnancy cause the oesophageal sphincter to relax. And because the uterus increases in size during pregnancy, it presses on the stomach, creating higher pressure inside it. Both of these factors increase the tendency to reflux.

Smoking. Tobacco prevents the oesophageal sphincter from working properly. It also increases stomach acid production and reduces the rate at which the stomach empties.

Medication. Drugs can cause reflux through sphincter relaxation e.g. in asthma and cardiac conditions.

Position of the body. The tendency to reflux increases when you are lying down. A simple way to relieve this is to use a pillow under the mattress or to raise the head of your bed by 10 cm. Bending over or bending and lifting can also cause reflux.

Who gets it and who is at risk?

Anyone can get GORD. The following groups are more likely to get reflux, however:

  • Pregnant women
  • Overweight people
  • Smokers
  • Babies: Babies do not have a fully developed lower oesophageal sphincter that normally helps prevent GORD. This explains their tendency to vomit, which should lessen during the first months, as the anti-reflux mechanisms become stronger.

Symptoms and signs

The frequency with which the symptoms occur varies. For most people, symptoms are rare, but some people experience weekly or daily episodes of reflux. Symptoms include:

  • A painful or burning sensation in the upper abdomen or chest, sometimes radiating to the back (heartburn). This usually lasts only a few minutes. Some people describe it as a “must-sit-up” feeling (regurgitation).
  • The acid reflux can reach the pharynx (throat) and mouth. It tastes sour and can burn (waterbrash).
  • A non-burning chest pain.
  • Persistant laryngitis, hoarseness and even difficulty breathing, because the refluxed fluid irritates the larynx (voice box) and respiratory tract.
  • Persistant sore throat.
    Excess burping is common.
  • Diffculty swallowing (called dysphagia), or food getting stuck.
  • Chronic cough, new onset of asthma or asthma only at night.
  • Sense of lump in throat.
  • Worsening dental disease.
  • Recurrent pneumonia.
  • Chronic sinusitis.
  • Waking up with a choking sensation.

Diagnosis

The symptoms of gastro oesophageal reflux may be so obvious that that you will not need any tests. However, if the doctor is in doubt, or if the symptoms are very troublesome, he or she might recommend a gastroscopy or upper endoscopy (commonly known as “swallowing the camera”). This is to establish whether or not you have oesophagitis, hiatus hernia, peptic ulcer and other conditions. A gastroscopy is an examination of the inside of the oesophagus, stomach and duodenum. The doctor passes a thin, flexible instrument into your mouth. This allows the doctor to see whether there is any damage to the lining of the oesophagus or stomach and whether there are any ulcers in your stomach or duodenum.

The procedure is painless and performed under a light sedative. You will need to have it done in a hospital or clinic as a day patient or in the specialist’s rooms. If you are sedated, you will not be able to drive or operate machinery for the rest of the day.

Other diagnostic procedures include a barium swallow, a 24-hour oesophageal study and an oesophageal manometry. The last teste is usually reserved for patients in whom the diagnosis is unclear or in whom surgery is being considered and will help to determine how well the sphincter is functioning.

 

Other conditions that can give you similar symptoms:

  • Gallstones: These are best diagnosed with an ultrasound scan.
  • Ulcers: These may occur in the stomach or the duodenum or oesophagus. They may give symptoms similar to GORD. Occasionally, they may rupture or bleed, leading to severe pain. They can be diagnosed by gastroscopy.
  • Heart pain: Angina is pain due to heart strain. It usually comes on while you are exercising. If angina becomes more severe, then the pain can come on at rest as well. If the pain goes down the arm then a doctor should be contacted immediately.
  •  Gastritis: Generalised inflammation of the stomach lining may be caused by an aspirin for pain or anti-inflammatory drugs.

 

Prevention

You can help prevent GORD by taking the following measures:

  • Try to lose weight if you are overweight.
  • Stop smoking.
  • Avoid large, high-fat meals, particularly in the evening.
  • Limit the amount of coffee and alcohol you drink.
  • Raise the head of your bed by about 15 cm.

Treatment

Gastro oesophageal reflux disorders are mainly treated by medication. Most people find that antacids, taken before and after meals and at bedtime, successfully control the symptoms. Antacids neutralize acids in the gastrointestinal system. They combine with hydrochloric acid in the stomach to form salt and water. Antacids differ in their reaction time, neutralizing capacity, side-effects, complications and price. Their main side-effect is that they can change bowel habits, resulting in flatulence, constipation or diarrhoea.

If simple antacids are insufficient to control the symptoms, then tablets to reduce acid secretion will usually be tried. This often starts with drugs called histamine antagonists. If these are unsuccessful, then a class of drugs called proton pump inhibitors are used. These are powerful and very effective. They work by preventing the stomach from producing any acid at all, and will also prevent the complications of gastro-oesophageal reflux. 

In only a small number of cases, you could have a type of laparoscopic (keyhole) surgery called fundoplication, in which the oesophageal sphincter is strengthened. This is indicated if there are complications or medication is too costly. However, surgery may not be successful if symptoms are not responsive to protein pump inhibitors (PPI's).

When to call the doctor

See your doctor if you experience heartburn frequently (twice a week or more), or if your symptoms are very unpleasant. Your doctor will consider whether further tests, such as a gastroscopy, should be carried out, and whether stronger medication is required. If you have any difficulty swallowing, are losing weight or feel tired (anaemic), you should see your doctor as soon as possible.

Previously reviewed by Dr Ganief Adams, Gastroenterologist, MBChB (UCT), FCP (SA)

Reviewed by Dr Jenny Edge, General Surgeon, BSc, MB BS, FRCS (Edin), M Med (Stell.)

Reviewed 2011 by Dr Maarten Prins, gastroneterologist, Panorama MediClinic, Cape Town

 

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Heartburn expert

Monique Marais is a Gastroenterologist working in Cape Town. After qualifying at the University of Pretoria, she worked in emergency rooms in South Africa and the UK before going into private practice.

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