Reflux Disease

What is reflux?

The stomach contents escaping back into the gullet from time to time after a meal occurs in healthy people too. It is when that escape becomes frequent, causes troublesome symptoms or damages the gullet that we speak of gastro-oesophageal reflux disease (GORD).

Where the gullet meets the stomach there is a natural barrier system that prevents the stomach contents from passing upwards. Reflux is made easier when this system does not work well enough, particularly when the lower oesophageal sphincter relaxes at inappropriate moments, and in some patients when a hiatus hernia is present as well.

Reflux is a common disease and in most patients it can be brought successfully under control with suitable adjustments to daily life and with treatment.

What are the symptoms of reflux?

The two commonest symptoms are burning behind the breastbone and the stomach contents coming up towards the mouth.

Besides these there may be:

• An acid or bitter taste in the mouth,
• Burning and discomfort in the chest after meals,
• Belching,
• Symptoms that worsen on lying down or bending forward,
• Waking at night because of reflux.

Some patients also have a chronic cough, hoarseness, throat discomfort or frequent throat clearing. It should not be forgotten that these symptoms can have many different causes. In people whose complaints concern only the throat and the airways in particular, it is not correct to attribute every symptom directly to reflux.

What causes reflux?

Reflux is usually not due to a single cause.

Weakening of the natural antireflux barrier between the gullet and the stomach, relaxation of the lower oesophageal sphincter at inappropriate moments, a hiatus hernia, excess weight and certain conditions that raise the pressure inside the abdomen can all make reflux easier.

Large and fatty meals, eating close to bedtime, certain foods and drinks, smoking and personal habits may also increase symptoms in some people.

Rather than condemning every patient to the same long list of “forbidden foods”, it is a better approach for the person to identify the foods and drinks that genuinely do make their own symptoms worse.

How is reflux diagnosed?

In many patients with typical reflux symptoms and no alarm features, endoscopy is not essential at the outset for the diagnosis. Treatment can be started on the basis of the character of the symptoms, and the response to it observed.

In certain situations, however, further investigation is needed.

Endoscopy

Gastroscopy allows the gullet, the stomach and the first part of the duodenum to be assessed directly.

Inflammation of the gullet caused by reflux (oesophagitis), a stricture, a hiatus hernia or Barrett’s oesophagus can be looked for.

One point is important: a patient with reflux may have an entirely normal endoscopy. A normal endoscopy does not on its own exclude reflux disease.

Twenty-four-hour reflux monitoring

In some patients — where the diagnosis is uncertain, where symptoms persist despite treatment, or where an interventional treatment for reflux is being considered — the reflux escaping into the gullet may need to be measured objectively.

pH or pH-impedance monitoring may be used for this. These methods give detailed information about the amount of reflux and its relationship to the symptoms.

Oesophageal manometry

Manometry is not a test that shows reflux directly. It assesses the working of the muscles of the gullet and of the lower oesophageal sphincter.

It may be needed particularly when difficulty in swallowing is being investigated, when certain other diseases of the gullet are being excluded, and before reflux surgery or certain interventional treatments.

With which symptoms should endoscopy not be delayed?

If reflux symptoms are accompanied by any of the following, the patient should be assessed by a gastroenterologist:

• Difficulty swallowing,
• Pain on swallowing,
• Unintentional weight loss,
• Signs of gastrointestinal bleeding,
• Persistent or recurrent vomiting,
• Iron deficiency anaemia of unexplained cause.

These symptoms do not necessarily mean that a serious disease is present. They need investigating, however, so that other diseases are not overlooked.

How is reflux treated?

Treatment is planned individually according to the frequency and severity of the patient’s symptoms, the endoscopic findings and any accompanying conditions.

Adjustments to daily life

In people who are overweight, losing weight may reduce reflux symptoms.

In those with night-time reflux in particular:

• Not eating within about three hours of going to bed,
• Avoiding large, heavy evening meals,
• Raising the head of the bed where necessary

may help.

Giving up smoking is also advised.

If a particular food consistently triggers reflux in a person, it is sensible to cut it down. But applying the same strict diet to everyone is usually unnecessary.

Drug treatment

One of the most effective groups of drugs in reflux treatment is the proton pump inhibitors (PPIs). These reduce the production of stomach acid, bringing symptoms under control and allowing reflux oesophagitis to heal.

The dose and duration of treatment should be decided for each patient.

In some patients the dose can be reduced or the drug stopped after a defined period of treatment. In others the nature of the disease means that long-term treatment is needed.

There is therefore no single length of time for taking reflux medication that holds for everyone.

Is long-term use of reflux medication harmful?

There is a great deal of alarming material about PPI drugs on the internet. Some of it is not based on studies that establish cause and effect.

Current scientific evidence indicates that PPI treatment is generally safe when used for the right reason and at a suitable dose.

Taking medication unnecessarily is not right either. In patients on long-term treatment, whether the drug is genuinely needed, the dose being used and the need to continue should be reviewed by the doctor from time to time.

Is endoscopic or surgical treatment possible?

Yes. But these methods are not necessary or suitable for every patient with reflux.

Antireflux procedures may be considered in patients whose significant symptoms persist despite drug treatment, who do not wish to take medication long-term, or who are anatomically suitable.

Laparoscopic fundoplication is one of the surgical treatments in use for many years. In suitable patients it aims to strengthen the antireflux mechanism where the stomach and gullet join.

Antireflux methods carried out endoscopically through the mouth, such as TIF (transoral incisionless fundoplication), can now also be applied in selected patients. In patients with a large hiatus hernia, surgical or combined approaches that include repair of the hernia may be needed.

Before these treatments are considered it is important that reflux is objectively shown to be present and that the function of the gullet is properly assessed.

What is Barrett’s oesophagus?

In some patients long-standing reflux may change the structure of the cells lining the lower part of the gullet. This is called Barrett’s oesophagus.

Barrett’s oesophagus is not cancer. But because it increases the risk of a particular cancer of the gullet developing, follow-up at suitable intervals may be needed once it is found.

Not every patient with reflux develops Barrett’s oesophagus, and not every patient with reflux needs an endoscopy solely to look for it. The decision is made by weighing the risk factors together.

What is the course and outlook?

Reflux is generally a benign and controllable disease.

In some people changes to daily life and a short course of medication are enough; in others symptoms recur from time to time and longer treatment is needed.

Untreated or severe reflux may in some patients lead to oesophagitis, a stricture of the gullet or Barrett’s oesophagus. These complications do not arise in every patient with reflux.

With the right diagnosis, avoidance of unnecessary treatment and the right treatment chosen for the person who genuinely has reflux disease, symptoms can be brought successfully under control in the great majority of patients.

This section is for general information. It does not take the place of personal diagnosis or treatment advice. A doctor should be consulted for the assessment of reflux symptoms and the choice of suitable treatment.