Dr Noureen Ahmad
General Practitioner, Belgium
The oesophagus is the muscular tube in the body, which connects from the throat to the stomach. At the end of this tube, there is a closing muscle known as the lower oesophageal sphincter (LES), which opens while food passes through the oesophagus from the mouth to the stomach. The sphincter then squeezes shut in order to prevent the food and acid (which is produced by stomach for digestion) from flowing back up. A small amount of acid and stomach content can still enter the oesophagus, but this small amount usually does not cause any problems.
Gastro-oesophageal reflux disease (GORD) is a long-term condition where continuous acid reflux from the stomach to the oesophagus results in complications and symptoms due to irritation and lesions. This usually occurs due to failure of the LES.
The risk factors of GORD are partly dependent on food intake, for example, alcohol, chocolate, coffee, fatty foods, spicy foods, fizzy drinks and big heavy meals. Medications can also be a major contributor especially NSAIDs (nonsteroidal anti-inflammatory drugs) and some antidepressants.
Other risk factors include smoking and special circumstances such as pregnancy, obesity, past surgery of the stomach and hiatus hernia.
Hiatus hernia is the most common cause of GORD. This is when part of the stomach herniates protrudes abnormally in the chest and the closing muscle of the oesophagus only partially closes causing more acid reflux towards the oesophagus.
Other causes of acid reflux can be peptic ulcers and lesions in the stomach and intestines. The most common causes of these ulcers are due to a special bacterium in the stomach, called Helicobacter pylori (H pylori) and long-term use of NSAIDS. H pylori are bacteria that can reside in the stomach silently with no symptoms, but when symptoms do occur, they are mostly of gastritis and peptic ulcers. The presence of these bacteria can be diagnosed through a blood test, breath test and stool test.
Clinical symptoms of GORD in very young children can be vomiting, refusing to eat or not gaining weight, pain after eating and experiencing breathing difficulties. Older children and adolescents can showcase symptoms such as stomach pain, chest pain, heartburn, nausea, burning sensation in the mouth, frequent belching, coughing and discomfort when swallowing. Due to inadequate digestion, symptoms such as fullness, bloating and intestinal gas production can also occur.
The diagnosis of GORD is based on the clinical symptoms and further investigations are usually not needed. In cases of symptoms such as anaemia, swallowing problems, bleeding from stools and weight loss, urgent referrals and investigations are required.
The treatment for GORD lies in controlling the acid reflux symptoms.
The first step is lifestyle advice and changes. These include a healthy diet, normal weight (BMI of 18.5-24.9) and to avoid foods such as alcohol, coffee, chocolate and fatty and spicy foods. It is also advised to stop smoking and refrain from excessive use of NSAIDs. Food should be eaten in small portions frequently throughout the day and heavy meals should be avoided just before bed. Sleeping with the head side raised can also prevent acid flow towards the oesophagus due to gravity.
If there is no improvement of complaints after lifestyle changes are made, then it is advised to start with medication. There are three types of medications used in the treatment of GORD, which are antacids, H2 receptor antagonists (H2RA) and proton-pump inhibitors (PPI).
The names of the medication can vary slightly from country to country.
Antacids are used for mild symptoms management of GORD. They work by counteracting the acid in the stomach and neutralising it. They are readily available in many stores without need of a prescription. The duration of the effect is quite short, so they are not recommended for long-term treatment.
H2RA (cimetidine, ranitidine) may also reduce the acid production in the stomach. However, this medication is less effective, and is also not recommended for long-term use.
PPIs (omeprazole, pantoprazole, rabeprazole) provide more effective relief and are used as an initial management in severe cases. They work by blocking the acid production in the stomach. The starting dose of this drug depends on the severity of the symptoms. PPIs can also be used in combination of antibiotics for H pylori and also as prevention and treatments of NSAID-associated ulcers. Although PPIs can have beneficial use in some conditions as long-term treatment, care should be taken due to the risk of rebound acid hypersecretion after stopping prolonged treatment with them. If there is no improvement after a trial period of PPIs, further tests may be required such as an endoscopy.
(Always discuss with your doctor what supplements you want to take or are taking so that your health and wellbeing can be properly looked after.)