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GPs buried under trusts' workload dump

Gastro-oesophageal reflux disease

GP Dr Roger Henderson finds out all you need

to know about acid

reflux from consultant gastroenterologist

Dr John Gibson

Practical points

 · More than a third of the population have GORD each month

 · Treatment for Barrett's oesophagus long-term is empirical

 · No scientific basis for avoiding a list of foods

Defining reflux disease

What would be the current best definition of gastro-oesophageal reflux disease (GORD), and how common is it in the general population?

GORD is best defined as a recurrent symptoms of heartburn and acid reflux triggered by bending or lying down. It may also be associated with water brash.

It is suggested that pain associated with hot liquids and alcohol indicates the presence of oesophagitis. It is a common condition affecting 4 to 7 per cent of the population daily and 34 to 44 per cent of the population monthly. In developed countries the estimated prevalence is 7 per cent of the adult population. Anecdotally, 27 per cent of the adult population self-treat twice a month.

Does the severity of GORD symptoms necessarily equate with the degree of oesophagitis?

No. It can difficult to assess severity on symptoms although the association of pain with hot liquids and alcohol usually indicates the presence of oesophagitis.

To a certain extent this does not matter

as long as the symptoms respond to treatment.

Even dysphagia can be misleading. It is a danger symptom suggesting a stricture at least but is sometimes seen in the presence of reflux without stricture.

Problems associated with GORD

How common is Barrett's disease in GORD and how commonly does oesophageal adenocarcinoma develop from it?

Barrett's oesophagus appears to be an increasing problem and it is estimated to occur in 10-20 per cent of patients with reflux disease. As you know, there is an increased incidence of adenocarcinoma with Barrett's estimated at 0.8 per cent per annum.

Oesophageal cancer is thought to be one of the malignancies that are fastest increasing in the UK at present.

What should be the long-term management regimen of someone found to have Barrett's disease?

The honest answer is that no one is certain. So, do we screen or not? Although the facts regarding the association with malignancy are as above, our general experience is that in a screening programme you very seldom pick up an early tumour. Nonetheless many departments feel duty bound to screen Barrett's when they find it. The next question is frequency of screening.

The British Society of Gastroenterology has not yet produced a guideline on this. The general view is probably to screen patients endoscopically every two to three years with multiple biopsies. We stop screening at the age of 70 but again this is empirical.

What are the indications for prompt gastroscopy in someone with known GORD?

The answer here is danger signs, for example onset of anaemia, weight loss or anorexia. Dysphagia with a short history is very worrying and indicates carcinoma unless it is proved otherwise. The onset of dysphagia in a patient with known GORD is less worrying and probably means peptic stricture. Nevertheless, all patients with the onset of these symptoms should be endoscoped urgently.

If a patient with GORD is Helicobacter pylori positive is there any current evidence to justify eradication in the absence of peptic ulcer disease?

It has been suggested H. pylori is protective in GORD. It is now accepted that because of the association of H. pylori with oesophageal carcinoma all H. pylori patients should be treated with an eradication regimen. To coin a phrase 'A good HP is a dead HP'.

Is it acceptable for patients with GORD to remain

on PPIs indefinitely?

There is some concern expressed about the long-term use of PPIs, particularly the theoretical risk of gastric carcinoma.

I think it is now accepted there is not a risk in the absence of H. pylori and that

long-term use of PPIs is safe and indeed desirable.

The place of surgery and lifestyle advice

When should laparoscopic anti-reflux surgery be considered for GORD and what are the possible problems post-operatively and long-term?

Anti-reflux surgery can be considered in two situations. The first is if symptoms are not controlled with a full medical regimen including medication and lifestyle changes such as weight loss.

The second is if a patient does not wish to take medication long-term and is fully aware of the risks of surgery and the failure rate, and is prepared to accept these. The operative mortality of laparoscopic reflux surgery is extremely low: about 0.1 per cent.

The operation is 90-95 per cent successful with 55 remaining the same and 2-3 per cent being worse.

The main post-operative problems are gas bloat because surgery prevents burping; dysphagia because the repair is too tight; or failure of the operation because the repair isn't tight enough or fails with time.

When should tests such as 24-hour pH monitoring and oesophageal manometry be considered?

I normally use these investigations in reflux disease when patients are failing to respond symptomatically to what appears to be adequate acid suppression.

This is particularly useful when endoscopically oesophagitis has healed but the patient still has symptoms. Obviously if there are suspicions of other conditions such as achalasia then manometry is very useful as it is in a few patients with atypical symptoms that may be due to one of the rarer motility disorders. Referring back to surgical treatment, surgeons usually require pH profile proof of reflux before they will consider antireflux procedures.

Does lifestyle advice really help?

With lifestyle changes, there is now evidence-based data to show weight loss lessens reflux symptoms. Nicotine does have an effect on the lower oesophageal sphincter and therefore should be stopped.

Raising the head of the bed should help but is inconvenient to say the least and with modern drugs, I would have thought, rarely necessary. Generally I do not think spicy foods need to be avoided. My advice to patients with acid-related problems is to find the foods that upset them individually and avoid those rather than offer a list of foods to avoid that will be based on no scientific evidence. After all, the acid produced by the stomach is at a far lower pH than any food we eat.

John Gibson is a consultant gastroenterologist at Stafford General Hospital

Roger Henderson is a GP in Newport, Shropshire

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