Gastro-oesophageal reflux disease (GORD)

Overview
Gastro-oesophageal reflux disease (GORD) is a chronic digestive disorder in which stomach contents, including acid, reflux into the oesophagus due to a weakened or dysfunctional lower oesophageal sphincter (LOS). While occasional reflux is common, persistent or severe reflux leading to symptoms such as heartburn, regurgitation, and oesophageal damage characterises GORD. It can significantly impact quality of life and, if untreated, may cause complications such as oesophagitis, strictures, Barrett’s oesophagus, or even oesophageal cancer.

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Causes and Risk Factors

• Lower oesophageal sphincter dysfunction (weakness, inappropriate relaxation)

• Hiatus hernia

• Delayed gastric emptying

• Obesity

• Pregnancy

• Lifestyle factors: smoking, alcohol, high-fat meals, caffeine, chocolate, spicy foods

• Medications: calcium channel blockers, nitrates, NSAIDs, bisphosphonates, certain sedatives

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Symptoms

• Typical symptoms

  • Heartburn (burning sensation behind breastbone, worse after meals or lying down)

  • Acid regurgitation (sour or bitter taste in mouth)

• Atypical symptoms

  • Chest pain mimicking angina

  • Chronic cough

  • Hoarseness or sore throat

  • Dental erosion

  • Dysphagia (difficulty swallowing)

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Diagnosis

• Clinical history is often sufficient for initial diagnosis.

• Empirical trial of proton pump inhibitors (PPIs) for 4–8 weeks can confirm diagnosis if symptoms improve.

• Endoscopy: indicated in alarm symptoms (dysphagia, bleeding, weight loss, anaemia, persistent vomiting, suspicion of cancer).

• 24-hour pH monitoring: gold standard for diagnosis in unclear cases.

• Manometry: assesses oesophageal motility disorders.

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Treatment

1. Lifestyle Modifications

• Weight reduction in overweight patients.

• Elevating head of bed by 10–20 cm.

• Avoiding meals within 3 hours of bedtime.

• Limiting alcohol, caffeine, chocolate, citrus, and fatty foods.

• Stopping smoking.

2. Pharmacological Management

• Antacids (e.g., aluminium hydroxide, magnesium hydroxide): symptomatic relief.

• Alginates (e.g., Gaviscon): form protective barrier on gastric contents.

• H2-receptor antagonists (e.g., ranitidine – though largely withdrawn, famotidine): reduce acid secretion.

• Proton Pump Inhibitors (PPIs) – mainstay of therapy:

  • Omeprazole 20–40 mg once daily

  • Lansoprazole 30 mg once daily

  • Esomeprazole 20–40 mg once daily

  • Pantoprazole 40 mg once daily

  • Rabeprazole 20 mg once daily

  • Given 30–60 minutes before meals, usually for 4–8 weeks.

• Prokinetics (e.g., metoclopramide, domperidone): sometimes used short-term to improve gastric emptying.

3. Surgical/Interventional Options (for refractory cases or complications)

• Nissen fundoplication: wrapping stomach around LOS to strengthen sphincter.

• LINX device: magnetic sphincter augmentation.

• Endoscopic therapies: less common, experimental.

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Contraindications and Precautions

• PPIs: long-term use may increase risk of fractures, kidney disease, vitamin B12 deficiency, infections (Clostridioides difficile).

• Metoclopramide: risk of extrapyramidal side effects; avoid prolonged use.

• Domperidone: risk of QT prolongation and arrhythmias.

• Caution in patients with severe liver disease or history of gastric surgery.

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Complications if Untreated

• Reflux oesophagitis

• Peptic strictures

• Barrett’s oesophagus (premalignant condition)

• Adenocarcinoma of the oesophagus

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Drug Interactions

• PPIs may reduce absorption of drugs needing acidic environment (e.g., ketoconazole, itraconazole).

• Omeprazole and esomeprazole inhibit CYP2C19, reducing activation of clopidogrel, lowering antiplatelet efficacy.

• H2 blockers and antacids may interfere with absorption of iron, digoxin, and some antivirals.

• Metoclopramide interacts with antipsychotics, increasing risk of extrapyramidal effects.

• Domperidone interacts with macrolide antibiotics and azole antifungals, raising arrhythmia risk.