Understanding gastro-oesophageal reflux disease: risk factors, symptoms and treatment

Gastro-oesophageal reflux disease (GORD), often called acid reflux, is an uncomfortable but common condition where acid from your stomach moves up into your gullet (oesophagus) causing heartburn ie a burning sensation behind your breast bone. 

Although most people will experience heartburn at some point in their life, GORD refers to when these symptoms become troublesome and affect your quality of life. 

Symptoms of GORD

Heartburn isn’t the only symptom of GORD. Typical GORD symptoms include a sour, unpleasant taste at the back of your mouth, regurgitation, upper abdominal pain, nausea, vomiting, difficulty swallowing (odynophagia) and/or painful swallowing (dysphagia). 

Other symptoms include a persistent cough, sore throat, hoarseness and the feeling of having a lump in your throat despite nothing being there (globus sensation). These symptoms are often referred to as ‘silent reflux’ or laryngopharyngeal reflux (LPR) if they occur without the more typical symptoms of GORD. Around a quarter of people with GORD also have disturbed sleep.

Are you at risk of GORD?

The main risk factors for developing GORD include a poor diet, being overweight, smoking and/or pregnancy. A hiatus hernia, where part of your stomach pushes through into your chest, can also increase your risk of GORD, especially if the hernia is large. However, in some cases, GORD can develop without any obvious reason.

GORD can be made worse by certain medications (eg alpha- and beta-blockers, benzodiazepines, corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs). Lifestyle factors that can also worsen GORD include smoking, drinking alcohol, eating large meals, eating or drinking late at night, and eating foods known to trigger GORD. Trigger foods include chocolate, coffee, fizzy drinks, foods high in fat and fried foods.

If you are concerned about your symptoms you should see your GP. You should also see your GP if you’re over 55 and are newly experiencing symptoms associated with acid reflux, particularly if these symptoms are persistent and include weight loss, vomiting blood and difficulty swallowing. 

Long-term complications of GORD

In the long-term, GORD can lead to the development of Barrett's oesophagus, a condition where there are abnormal cells lining your oesophagus. Barrett’s oesophagus also increases your risk of oesophageal cancer, with 1–5% of individuals with Barrett’s oesophagus developing oesophageal cancer. 

Another complication of chronic GORD is an oesophageal stricture. This is where the oesophagus becomes narrowed and can block the passage of food into the stomach. This typically first presents as difficulty swallowing food. 

Treating GORD

Initially, GORD can be treated by making simple dietary and lifestyle changes. This includes avoiding trigger foods, eating smaller, more frequent meals and not eating or drinking too close to bedtime. It is rare that drastic or very restrictive diets are needed.

You can also find temporary relief by taking antacids or alginates. Antacids neutralise stomach acid, while alginates are liquids that form a protective layer over your stomach acid to prevent it escaping upwards into your oesophagus.

If diet and lifestyle changes aren’t enough to ease your symptoms, your doctor may prescribe acid-suppressing medication. There are two main types: proton pump inhibitors (PPIs, eg omeprazole and lansoprazole) and H2 receptor antagonists (eg famotidine). Both significantly reduce how much acid your stomach produces and consequently can reduce your symptoms. 

Although acid-suppressing medications are available over the counter, if you’re frequently struggling with acid reflux, you should see your doctor rather than continue taking more over-the-counter medication. Your doctor can investigate your symptoms and provide medical advice, which may include recommending prescription medication and having a gastroscopy. 

A gastroscopy is a diagnostic test where a tiny camera is inserted through your mouth and into your stomach. It can help determine whether there is damage to the lining of your oesophagus (oesophagitis), presence of Barrett’s oesophagus, any narrowing of the oesophagus and also the presence of a hiatus hernia.

Will you need surgery for GORD?

Surgery for GORD is rarely needed and only recommended in severe cases if diet and lifestyle changes and medication have not provided enough relief from your symptoms, or if you can’t tolerate medications due to side effects.

Before surgery is recommended, you will need to have certain diagnostic tests to check the function of your oesophagus and the extent of your acid reflux. These tests may include pH testing to check the acidity levels in your oesophagus and oesophageal manometry to measure how well the muscles in your stomach and oesophagus are working.

The two main surgical procedures used to treat GORD — laparoscopic fundoplication and LINX device implantation — both focus on mechanically preventing stomach acid leaking up into your oesophagus.

Advances in GORD diagnosis and treatment

Technology to diagnose and treat GORD continues to develop. For diagnosis, pH testing for 24 hours has long been used. This involves inserting a tiny tube via your nose and into your stomach (nasogastric tube) to measure the acid levels (pH) in both your stomach and your oesophagus. This can accurately measure the severity of GORD. However, now wireless pH testing devices allow measurements to be collected for up to four days, without the need for a nasogastric tube, which increases the chances of detecting episodes of acid reflux.

When it comes to treatment, PPIs have been around since the 1980s and until recent times there have not been many equivalent alternatives. Today, P-CABS (potassium-competitive acid blockers) are being investigated and show promise as an effective alternative to PPIs.

Advances are also being made to avoid invasive surgery for GORD. Newer, minimally invasive options to reduce symptoms include Stretta and transoral incisionless fundoplication (TIF), which are performed via a gastroscopy.