Gastro-oesophageal reflux (GORD)

What is gastro-oesophageal reflux?

Gastro-oesophageal reflux, usually shortened to GORD (GERD in the USA), is a common condition where acid from your stomach leaks up into your oesophagus, the tube that carries food from your mouth to your stomach. It happens when the ring of muscle at the bottom of your oesophagus becomes weak and doesn't seal properly.

What are the symptoms of GORD?

The main symptoms are heartburn, a burning feeling behind your breastbone that can spread up to your throat, and acid reflux, where stomach acid comes back up and leaves an unpleasant, sour taste in your mouth. Both are often worse after eating, when bending over, or when lying down, and heartburn can also wake you at night.

Other symptoms could include:

• Regurgitation, where food, liquid or acid comes back up into your throat or mouth
• A sore, inflamed oesophagus (oesophagitis)
• Bloating, belching, nausea or feeling sick
• Bad breath, tooth decay or gum disease
• A persistent cough, wheezing, hoarseness or sore throat, especially at night
• Pain or difficulty swallowing.

What are the causes of GORD and who is at risk?

Gastro-oesophageal reflux happens when the ring of muscle at the bottom of your oesophagus, called the lower oesophageal sphincter, becomes weak or relaxes when it shouldn't. Normally, this muscle opens to let food into your stomach and closes to keep acid from coming back up, but it's not always clear why it stops working properly.

Your risk is higher if you're overweight, pregnant, or smoke, and eating large or fatty meals can also make reflux more likely. Alcohol, coffee and chocolate can relax the muscle further, and stress may make your symptoms worse too.

Certain conditions can also contribute, such as a hiatus hernia (where part of your stomach pushes up through the diaphragm, the sheet of muscle between your chest and tummy) or gastroparesis (where your stomach empties more slowly than normal). Some medicines, including those used for blood pressure, asthma, osteoporosis or low mood, can relax the muscle or irritate your oesophagus, so tell your doctor if you think one of your medicines might be contributing, rather than stopping it yourself.

Are there different types of gastro-oesophageal reflux?

Almost everyone has acid reflux from time to time, which is usually nothing to worry about. It's generally considered GORD when it happens more often, typically twice a week or more over several weeks, or when it starts to damage your oesophagus.

How is GORD diagnosed?

Your GP can often diagnose GORD from your symptoms alone, without any tests, especially if your heartburn is mild. They'll ask how often it happens, what makes it worse, and whether it improves with over-the-counter remedies, and they may also check for signs of a heart problem, since chest pain can feel similar to both.

You may be referred for tests if your symptoms are severe, persistent or unusual, if medicine isn't controlling them, or if you have difficulty swallowing or unexplained weight loss. The main test is an endoscopy (or gastroscopy), where a thin, flexible tube with a camera is passed through your mouth and down into your oesophagus and stomach, usually while you're awake. A numbing spray at the back of your throat helps make this process less uncomfortable, or you may be offered a sedative.

Other tests include a barium swallow (an X-ray taken after you drink a chalky liquid that shows up on the scan), manometry (a thin tube passed through your nose to measure the pressure in your oesophagus), and 24-hour pH monitoring (a sensor that measures acid levels in your oesophagus over a full day, usually connected to a small recorder worn on your waist).

How is GORD treated?

Treatment usually starts with lifestyle changes and over-the-counter medicine, moving on to prescription medicine or surgery if these don't control your symptoms.

Lifestyle changes

• eat smaller, more frequent meals rather than 3 large ones
• avoid food and drink that triggers your symptoms, such as coffee, chocolate, tomatoes, alcohol, mint, or fatty or spicy food
• wait 2–4 hours after eating before you lie down or go to bed
• raise the head of your bed by 15–20cm (6–8 inches)
• avoid tight clothing around your waist
• keep to a healthy weight, and find ways to manage stress
• stop smoking, and cut down on alcohol.

Medicines

• antacids, which neutralise stomach acid and act quickly, though the relief doesn't last long
• alginates, which form a protective coating over your stomach and oesophagus
• H2-receptor antagonists (H2 blockers), which reduce the amount of acid your stomach makes
• proton pump inhibitors (PPIs), a stronger acid-reducing medicine usually prescribed
• potassium-competitive acid blockers (PCABs), a newer type of acid-reducing medicine.

Some antacids, H2 blockers and PPIs are available over the counter, however, if you are buying and needing these regularly then you should see your GP to discuss whether you require different treatment or investigations. Side effects from any of these are usually mild, such as headaches, dizziness or an upset stomach, and your doctor will aim to prescribe the lowest dose that controls your symptoms.

Surgical options

Surgery may be an option if lifestyle changes and medicine haven't controlled your symptoms, or if you'd rather not take medicine long-term. The main procedure is a laparoscopic (keyhole) fundoplication, where your surgeon wraps the top of your stomach around the lower oesophagus and stitches it in place to tighten the muscle that's letting acid through.

This is carried out under general anaesthetic. You may need to stay in hospital for a day or two after the procedure, but this would be discussed with you prior to the surgery.

Depending on your job, you may be able to return to work within 3–6 weeks. For the first 6 weeks you'll need to stick to soft food, such as mince, mashed potato or soup, and some people notice swallowing difficulties or bloating afterwards, which tend to improve with time.

Newer keyhole techniques are also available, such as a device that creates a barrier at the base of the oesophagus (TIF -Transoral Incisionless Fundoplication), radiofrequency treatment that tightens the muscle (the Stretta procedure), or a ring of small magnets that helps keep it closed (a LINX device). These appear safe, but as these are newer procedures, less is known about long-term results at the moment.

When should I see a doctor?

See your GP if you're having symptoms several times a week, if over-the-counter medicine isn't helping, or if your symptoms are severe.

Get medical help promptly if you have:

• difficulty or pain when swallowing
• persistent vomiting, or vomiting blood
• unexplained weight loss or loss of appetite
• chest pain, especially if it's new or severe, as this can sometimes be a sign of a heart problem rather than reflux.