Introduction
Gastro-oesophageal Reflux Disease (GORD or GERD) is caused by backflow of gastric and/or duodenal contents past the lower oesophageal sphincter into the oesophagus without belching or vomiting.
The disease is classified into two groups based on endoscopy findings as non-erosive gastro-oesophageal disease (non-erosive GORD) and erosive gastro-oesophageal disease (erosive GORD).
Failure to treat may result in oesophagitis, ulceration, strictures and rarely adenocarcinoma.
Causes of gastro-oesophageal reflux disease
The following are the causes of gastro-oesophageal reflux disease (GERD) otherwise known as GERD or GORD
- Obesity
- Hiatus hernia
- Increased intra-abdominal pressure e.g. in pregnancy
- Long term use of nasogastric tube
- Agents that decrease lower oesophageal sphincter pressure e.g. alcohol, cigarettes, anticholinergics (e.g. Hyoscine butylbromide, Propantheline bromide), other drugs – Morphine, Diazepam, Pethidine and Calcium channel blockers
- Children with chronic neurological disease (e.g. cerebral palsy)
Symptoms of gastro-oesophageal reflux disease
- Heartburn (worsens with vigorous exercise, bending forward, lying; relieved by antacids and sitting upright)
- Dyspepsia
- Early satiety
- Retrosternal and epigastric pain (mimics angina pectoris by radiating to neck, jaws and arms. The pain is worse on bending down e.g. sweeping)
- Pain on swallowing
- Difficulty swallowing
- Nocturnal regurgitation (wakes patients up with coughing, choking and filling of the mouth with ‘saliva’)
- Asthma-like (may be worse at night)
Symptoms in children
- Failure to thrive/refusing food
- Vomiting
- Coughing
- Forceful regurgitation which may lead to aspiration pneumonia
- Iron deficiency anaemia
- Wheezing
Signs of gastro-oesophageal reflux disease
May be none
- Epigastric tenderness occasionally
- Chest signs (e.g. wheezing)
Investigations
- Oesophago-gastro-duodenoscopy (OGD), i.e. upper gastro-intestinal tract endoscopy
- Chest X-ray to exclude other causes
- Abdominal ultrasound (to exclude other diseases)
- Barium swallow with fluoroscopy (especially useful in children)
- Oesophageal pH monitoring (in cases that are difficult to diagnose)
- Lower oesophageal sphincter manometry (in cases that are difficult to diagnose)
Treatment for gastro-oesophageal reflux disease
Objectives
- To relieve symptoms
- To prevent complications.
Non-pharmacological treatment
Lifestyle changes:
- Elevate head of bed by about 30 degrees or sleep on pillows
- Avoid sleeping within 3 hours after eating
- Avoid over-eating and heavy meals before bedtime
- Avoid foods that aggravate symptoms e.g. fatty and spicy food
- Avoid smoking and alcohol
- Avoid Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
- Encourage moderate exercise
- Weight reduction in overweight and obese individuals
- Avoid corsets, instead wear loose clothing
Surgical treatment:
Fundoplication (for severe cases, treatment failures and complications)
Pharmacological treatment
A. Non-erosive GORD
Evidence Rating: [B]
Magnesium trisilicate, oral, 15 ml 8 hourly (in between meals and at bedtime to control dyspepsia)
Or
Antacids containing Aluminum hydroxide, Magnesium hydroxide, Simethicone, Calcium alginates
Or
Omeprazole, oral,
Adults: 20 mg daily for 4-8 weeks
Children
- > 20 kg; 20 mg daily for 4-8 weeks
- 10-20 kg; 10 mg daily for 4-8 weeks
- 5-10 kg; 5 mg daily for 4-8 weeks
Or
Esomeprazole, oral,
Adults: 40 mg daily for 4 to 8 weeks
Or
Rabeprazole, oral,
Adults 20 mg daily for 4 to 8 weeks
B. Severe or Erosive GORD
Omeprazole, oral,
Adults: 20-40 mg daily for 8 weeks
Children
- > 20 kg; 20 mg daily for 4-8 weeks
- 10-20 kg; 10 mg daily for 4-8 weeks
- 5-10 kg: 5 mg daily for 4-8 weeks
Or
Esomeprazole, oral,
Adults: 40 mg daily for 8 weeks:
Or
Rabeprazole, oral,
Adults: 20-40 mg daily for 8 weeks
C. Severe or Erosive GORD (with bloating)
Use medications in Section B above for ‘Severe GORD’
And
Metoclopramide, oral: Adults 10-20 mg 6-8 hourly
Or
Domperidone, oral,
Adults: 10 mg 6-8 hourly
Referral Criteria
Refer cases not responding to the measures above to a physician or surgical specialist, as well as severe cases, treatment failures and individuals with complications.