ClinicalClinical FeaturesGastroenterology

A Burning Issue

Theresa Lowry Lehnen talks all things GORD

What is GORD?

GORD is caused by acid leaking up from the stomach and coming into contact with the oesophagus. While the stomach is able to withstand litres of acid without pain, the gullet is not. GORD has a significant impact on quality of life and productivity, with sufferers reporting impaired sleep and interference with social activities and work.

Incidence of GORD is certainly rising as obesity rates accelerate. People are also binge drinking and eating more fatty or calorific food, which increases acidity levels and contributes to poorer digestive health.

Common Symptoms

GORD is typically a very treatable disease, but many people don’t know they have it because its symptoms are associated with numerous other conditions.

Common symptoms of GORD include:

• Chronic heartburn

• Regurgitation

• Chest pain or discomfort

• Chronic cough, sore throat, and/ or hoarseness

• Sleep disturbances and nighttime symptoms

• Belching, gas, and bloating

• Nausea

• Intolerance of certain foods

• Sour taste in the back of the mouth

It’s normal to experience reflux symptoms every now and then, especially after a large meal. Acid reflux is considered GORD if symptoms occur at least twice per week or moderate to severe symptoms occur once a week.

Other symptoms include vomiting, halitosis, anorexia, dysphagia, cough and respiratory or oropharyngeal symptoms. Theresa says, “it is estimated that between

20% and 40% of patients with heartburn will have a diagnosis of GERD (Patrick, 2011). it is estimated that between 20% and 40% of patients with heartburn will have a diagnosis of GERD (Patrick, 2011). GORD may be just an occasional symptom for some people, but for others it can be a severe, lifelong condition. Left untreated, GORD can cause considerable discomfort and a poor quality-of-life. Medical attention should be sought and symptoms investigated when GORD is severe, occurs several times a week, over the-counter medications are not helping, dysphagia or symptoms such as vomiting, haematemesis, anaemia or unexplained weight loss occur, that could suggest a more serious problem.

“Several factors may increase the risk of developing GORD. First degree relatives of patients with GORD are four times more likely to develop symptoms, raising the possibility of a strong genetic contribution to the aetiology. 11

“Medicines such as calciumchannel blockers, nitrates and non-steroidal antiinflammatory drugs (NSAIDs) can cause GORD or make the symptoms worse.” 10

Diagnosing GORD

She adds, “A presumptive diagnosis of GORD can be made based on the typical symptoms of heartburn and acid regurgitation. Tests for GORD include, endoscopy, barium swallow or meal, manometry, 24 hour pH monitoring and blood tests. A Full Blood Count should be taken to assess for anaemia, which could be a sign of internal bleeding. 8

“GORD can be classified according to the presence or absence of erosions on endoscopic examination. Absence of erosions are classified as non-erosive (NERD), whereas GORD symptoms with erosions is classified as erosive oesophagitis. 2 The primary role of endoscopy is to look for complications and to exclude other diagnoses.

“Manometry is used to assess how well muscle at the distal end of the oesophagus is functioning. A tube containing pressure sensors can measure the pressures in the oesophagus and help determine whether surgery may be necessary. 8

“A barium swallow, or barium meal, may be required to assess

swallowing ability and look for any blockages or abnormalities in the oesophagus. 8

“24 hour pH monitoring may be necessary to measure the acidity level in the oesophagus and confirm a diagnosis of GORD. It is the gold standard and most objective test to diagnose the reflux disease and allows monitoring of GORD patients in their response to medical or surgical treatment. 8

“A urea breath test is the examination of choice for patients under the age of 50 years presenting with dyspepsia. It is recommended as a non-invasive test for active H.pylori infection, but does not confirm or establish a diagnosis of GORD.” 2

Treatment and Management

The management of GORD includes pharmacotherapy, dietary and lifestyle changes and in some cases surgery,” Theresa explains. “Initial treatment is guided by the severity of symptoms and treatment is adjusted according to response. The extent of healing depends on disease severity, treatments chosen and the duration of therapy.

“Patients should be advised about lifestyle changes, avoidance of excess alcohol and consumption of aggravating foods such as fats. Other measures include smoking cessation and weight reduction if applicable, raising the head of the bed when sleeping, and the avoidance of wearing tight fitting clothing and bending down after a meal.

“Initial management for mild symptoms, may include the use of antacids and alginates which reduce reflux and protect the oesophageal mucosa. Histamine receptor antagonists such as ranitidine may be used to relieve symptoms and permit reduction in antacid consumption.

“For more severe symptoms and patients with oesophagitis, oesophageal ulceration, oesophagopharyngeal reflux and Barrett’s oesophagus, treatment involves the use of Proton pump inhibitors (PPI).

“If GORD is unresponsive to diet and lifestyle changes in pregnant women, antacids or alginates can be used. If this is ineffective ranitidine a H 2 receptor antagonists may be used. Omeprazole is reserved for pregnant women with severe or complicated reflux disease.”

GORD in Infants

In most babies, reflux is nothing to worry about (as long as they are healthy and gaining weight as expected). However, in some cases (though very few) reflux can cause a lot of pain when strong acid travels up into the food pipe. When reflux becomes painful and it happens frequently, this is known as ‘gastro-oesophageal reflux disease’ (GORD).

Baby reflux symptoms include:

• constant or sudden crying when feeding

• bringing up milk during or after feeds (regularly)

• frequent ear infections

• lots of hiccups or coughing

• refusing, gagging or choking during feeds

• poor weight gain

• frequent waking at night

Theresa adds, “If necessary, suitable alginate preparations can be used instead of thickened feeds. For older children lifestyle changes may be helpful, followed if necessary by an alginate containing preparation. Infants or children who do not respond to these measures or who have complications such as oesophagitis or a respiratory disorder, need to be referred to hospital as a H 2 receptor antagonists may be required to reduce acid secretion.”

She continues, “Antacids containing aluminium or magnesium compounds can often relieve symptoms in ulcer dyspepsia and non-erosive GORD. Antacids are best given when symptoms occur or are expected, usually between meals and at bedtime. Conventional doses of liquid magnesium aluminium antacids 3-4 times daily promote ulcer healing but are not as effective as antisecretory medication. Magnesium containing antacids tend to be laxative in nature, while aluminium containing antacids can be constipating. Antacid products containing both magnesium and aluminium can reduce these colonic side effects. Sodium bicarbonate should no longer be prescribed alone for the relief of dyspepsia, but is present as an ingredient in many indigestion remedies.

“Caution must always be maintained with the use of H 2 receptor antagonists and proton pump inhibitors as they can mask the symptoms of gastric cancer. Particular care is required in patients presenting with alarm features.

“In such cases, malignancy should be out ruled before treatment commences. Side effects of H 2 receptor antagonists include diarrhoea, headache and dizziness and the H 2 receptor antagonist cimetidine should be avoided in patients stabilised on warfarin, phenytoin and theophylline. Side effects of PPIs include GI disturbances, dizzyness, headache and sleep disturbances. Patients at risk of osteoporosis on PPIs should maintain an adequate intake of calcium and vitamin D and if necessary receive other preventative therapy. Long-term use of PPIs has been linked to complications, such as vitamin and mineral malabsorption, pernicious anaemia, gastrointestinal infections, gastric cancer and dementia.” 2, 5

Theresa concludes, “Gastroesophageal reflux disease is a common disorder, and is one of the most frequent conditions encountered in primary care. Treatment and management of GORD symptoms is important and early intervention has the potential to reduce serious complications.

“The goal of treatment is to effectively control symptoms, prevent complications and improve the patient’s quality of life. The goal of antireflux treatment is to effectively control GERD symptoms, prevent complications of GERD, and improve quality of life Special attention should focus on reducing the rate of refractory GORD and complications such as Barrett’s oesophagus and adenocarcinoma. Knowledge and understanding of the safe and effective use of medications in the treatment of GORD especially PPIs, prevents inappropriate use, and addresses their adverse reactions and interactions with other medications. The clinical benefits and risk of using PPIs should be evaluated for each individual. Assessment, monitoring, audit and evaluation for disease activity, progression, and effects of the therapeutic regime on a patient with GORD is important and a continuous process. For patients requiring long term PPI therapy the clinical effects should be reviewed regularly and treatment adjusted as required. The lowest dose of a PPI that controls symptoms should be used. Implementing person centred care, monitoring and evaluating symptoms, outcomes and responses to therapy plays a pivotal role in managing the illness and improving the patient’s quality of life.”

References available on request

Theresa Lowry-Lehnen (PhD), CNS, GPN, RNP, South East Technological University’ gives HPN readers an overview of the key themes in managing and treating Gastro-oesophageal Reflux Disease (GORD).

Read the full magazine: HPN November

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