GORD

Acid reflux or gastro-oesophageal reflux disease GORD

Dr. Widjaja Luman
Consultant Gastroenterologist and General Physician
B Sc (St. Andrews), MB ChB (Man), MRCP (UK), M.D. (Edin),
CCST (UK), FRCP (Edin)

(Ahli penyakit pencernaan dan hepar)

What causes acid reflux?

Oesophagus (gullet) is the tube that carries food from mouth to the stomach. Acid is produced by the stomach to digest food. This acid should not reflux back into the gullet as it does not have any protective lining against corrosive effects of acid. This is made possible by a group of muscle at the bottom of the gullet which acts as a one-way valve that allows food to flow from the mouth into the stomach when it relaxes. When this group of muscle contracts, acid and gastric juice is prevented from entering the gullet. When this group of muscle becomes weak, acid and gastric juice can rise up into the gullet. This is called acid reflux. The reason why this group of muscle fails to work properly is not known.

Certain conditions will exacerbate or precipitates acid reflux:

• Pregnancy
• Smoking
• Large heavy meals, especially if this is consumed just before bed time.
• Being overweight
• Wearing tight clothing around the waist
• Bending a lot.

What are the symptoms?

As the gullet does not have any protective lining against acid, it can become inflamed and painful when it is exposed to acid. Acid reflux can cause a variety of symptoms such as heartburn, chest pain, upper abdominal bloating and throat irritation. Heartburn is a discomfort that is often described as burning in quality. It rises from the upper abdomen into the chest behind the breast bone. It tends to come on after swallowing hot fluids (soup), alcohol and hot spicy food. A similar sensation may also come on stooping or lying down. Most people suffer from heartburn at one time or another. It is important to realise that heartburn is due to acid reflux and has nothing to do with the heart. Chest pain experienced from acid reflux is often not severe and dull in nature. It is not associated with exercise. Pain from the heart is also felt in the chest and sometimes in the upper abdomen. There are two kinds of heart pain. The first, angina, is a pain in the chest due to temporary shortage of oxygen being carried in the blood to the heart muscle. Angina should be suspected if the chest pain is brought on by exercise and relieved by rest. The second is the more severe and prolonged pain of a heart attack. A heart attack should be suspected if the pain is felt intensely in the centre of the chest, spreading perhaps to one or both arms and into the lower jaw. You should consult your physician immediately if you experience pain of this nature.

What complications can occur?

Acid reflux may just lead to symptoms without any obvious inflammation in the gullet. In about half of the patients, it can lead to inflammation in the gullet (this will be known as oesophagitis by your physician). The severity of oesophagitis can range from mild to severe and determines the form of therapy you will require. The more severe form of oesophagitis, if left untreated, can then lead to scarring and narrowing at the lower end of the gullet (stricture). Difficulty in swallowing, especially solid and lumpy food may result.   The other complication is Barrett’s oesophagus; this is a condition in which the normal lining of the gullet (which is akin to the one on the skin) is replaced by a lining similar to the one in the stomach or intestine after a long period of untreated acid reflux. Some doctors may advise on regular check-ups once Barrett’s oesophagus has been found as there is a small increased risk of cancer of the gullet.

When should I consult my physician?

You should consult your physician if your symptom is frequent (more than three times per week) and has been long standing for several years. You should consult your doctor if you notice the following warning symptoms:

• Difficulty with swallowing
• Weight loss
• Vomiting of blood.
• You need to take antacids on regular basis to control your symptoms.

Your physician may decide to refer to see a specialist/gastroenterologist.

What will the specialist do when I consult him?

Depending on the severity and chronicity of your symptoms, your specialist may decide on the necessity of gastroscopy. Gastroscopy is a narrow, flexible tube containing a light source and a small camera at its tip. It is passed through the mouth and throat and on to the oesophagus. This allows the gastroenterologist to determine the severity of oesophagitis and type of therapy required. The endoscopy will also show whether there is hiatus hernia. There is a sheet of muscle (the diaphragm) that separates the chest from the abdominal cavity. The stomach should be lying in the abdominal cavity. Hiatus hernia is the part of the stomach which has slid across the opening in the diaphragm to lie in the chest cavity. Many people who suffer from frequent heartburn have a hiatus hernia. However, not everyone with a hiatus hernia suffers from heartburn.

The gastroenterologist might order barium meal instead of endoscopy. By observing the passage of a white fluid containing barium, a doctor can see on x-ray whether the gullet is ulcerated or narrowed. 24-hour pH testing enables the doctor to know the amount of acid levels in the gullet. This involves a fine tube being passed through the nose into the oesophagus for 24 hours. A special tip at the end of the tube can record down the amount of acid in the gullet. A newer method of pH monitoring is by attaching a wireless capsule at the lower oesophagus. The capsule will remain at the lower oesophagus for several days. It has a pH sensor and monitors the amount of acid reflux back into oesophagus (48 hr Bravo pH test). pH monitoring is not commonly done unless your doctors think that you have failed medical therapy and are being considered for surgical treatment.

What should I do to alleviate my symptoms?

Reflux is very common and the most helpful aspects of the treatments are those you can do for yourself. Some of the measures which you can take are:

• Stop smoking. Nicotine helps to relax the valve and if you may experience heartburn or acid reflux after heavy meal if you are a smoker.
• For many patients, weight reduction is the most effective long-term remedy.
• You may find particular foods can make your symptom worse. Some of the foods which have been reported by patients are acidic fruit drinks, fatty and spicy meals (curry or laksa), chocolate, coffee and tea. Most importantly, you should avoid large heavy meals but should take small meals at regular interval. Eating late at night should be avoided in order to ensure that the stomach is empty at bedtime. Alcohol should only be taken in moderation with meals.
• Avoid tight clothing, tight belts or under clothes as they increase pressure on the stomach.
• Avoid bending from waist or stooping just after meals. Try to bend from the knees and keep the back straight instead.
• Let your evening meal digest well before you go to bed. Night time symptoms can also be reduced by raising the head of the bed on blocks by 6 inches. Gravity helps to keep the acid in the stomach where it should be.

What will my doctor prescribe to me?

Medicines range from antacids, which helps to neutralise the acid, to stronger medication which reduce the production of acid in the stomach. Many people with acid reflux take antacids either in tablets or liquid form, which are available from the chemist. Your doctor may prescribe you stronger medications such as Proton pump inhibitors (e.g. omeprazole, pantoprazole, rabeprazole) or Potassium competitive acid blocker (e.g.Vonoprazan) which are highly effective in healing oesophagitis and in controlling symptoms.

Surgical treatment, often performed using a laparoscope (key hole surgery), can help to tighten the tissue around the valve and thereby can decrease or prevent reflux. It is not commonly performed as there are side effects from the surgery and with effective medical therapy, it is uncommon for patients to require surgery. There are also endoscopic forms of therapy (through the endoscopes) to strengthen the valve but these techniques still remain experimental.