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GPs are seeing more cases of GORD than ever before ­ Dr Peter Wurm and Dr John de Caestecker outline the options available

Gastro-oesophageal reflux disease (GORD) is common: about 40 per cent of the population experience heartburn, a classic symptom of the condition, at least once a month with up to 7 per cent reporting daily symptoms.

A quarter of the adult population use OTC medication for indigestion (mostly GORD) but only a small percentage consult their GP.

There is no convincing evidence that the epidemiology of GORD is changing. However, patients present to the medical services more readily nowadays and there is an increased awareness among practitioners that GORD often presents without oesophagitis and in patients with atypical symptoms.

The pathophysiology of GORD is complex but appears to result from transient lower oesophageal sphincter relaxation (TLOSR), impaired distal oesophageal peristalsis (causing impaired clearance of refluxed acid) and 'hiatal failure' related to widening of the diaphragmatic hiatus (allowing the commonly associated hiatus hernia to occur). Thus GORD is primarily a motility disorder.

Patients presenting with classical symptoms such as heartburn and acid eructation pose little diagnostic confusion.

Atypical presentations with chest pain, cough, dental enamel erosion and hoarseness are well-recognised but difficult to diagnose.

However, for classic symptoms and chest pain, a short course of high-dose PPI, for example omeprazole 40mg bd for one to two weeks, can be prescribed as a diagnostic test .

An endoscopy is not required to make the diagnosis in young patients. Patients over 55 with new onset symptoms should be referred to a gastroenterologist for further investigation (NICE guidance).

Oesophagitis at endoscopy confirms GORD but the absence of endoscopic changes does not argue against it, as up to 50 per cent of patients with GORD have normal endoscopy. This article will refer to the Los Angeles classification for oesophagitis, in which grade C and D represent the most severe changes.

The diagnostic gold standard is 24 pH monitoring but should it be reserved for specific patients?

Initial management

The main aim of treatment is symptom control. Healing of oesophagitis is of secondary importance, except in severe oesophagitis (grades C and D) or complications such as strictures and Barrett's oesophagus.

Symptomatic control is achieved in 80-90 per cent of patients on PPIs at standard doses, for example omeprazole 20mg od. After achieving symptom control, PPI dose should be reduced to the minimum dose for symptom remission or to on-demand PPI. Esomeprazole and rabeprazole are both licensed for prn but in practice patients often use any PPI 'on demand'.

Healing of mild oesophagitis is achieved in over 90 per cent; this figure falls to about 80 per cent for severe oesophagitis.

Refractory GORD

Refractory GORD describes either inadequate symptom control or incomplete healing of oesophagitis despite medical treatment. From the data above, symptomatic treatment failure occurs in 10-20 per cent while about 20 per cent of cases with severe oesophagitis fail to heal on standard PPI doses. Furthermore 20-30 per cent of patients with Barrett's oesophagus have persistent (often asymptomatic) acid reflux on twice daily doses of a PPI.

Refractory symptoms

There are a number of reasons for this: first, acid suppressants do not address the underlying pathophysiology of GORD. Thus, some patients with 'heartburn' in fact have functional dyspepsia with no abnormal GOR on objective testing (eg by prolonged pH monitoring). Finally, as indicated above, a proportion of patients fail to suppress gastric acid production even on high doses of PPIs for reasons that are not clearly understood. There is good evidence that doubling the PPI dose and twice-daily administration is a successful measure.

Nocturnal acid breakthrough refers to a phenomenon of gastric pH <4 for="" one="" or="" more="" hours="" at="" night="" despite="" twice-daily="" ppi.="" this="" does="" not="" necessarily="" result="" in="" gor="" at="" night="" but="" may="" do="" so,="" particularly="" in="" patients="" with="" severe="" oesophagitis="" or="" barrett's="">

The addition of an H2RA to twice-daily PPI has been shown to be helpful, although loss of effect with time (tachyphylaxis) has been reported with H2RAs.

Combination therapy of prokinetics, such as cisapride, with acid suppressants has been shown to be efficacious. However, following its withdrawal from widespread use cisapride is now only available on a named-patient basis. Other prokinetics (eg domperidone and metoclopramide) have not been evaluated in this respect.

Baclofen has been shown to reduce TLOSR and is beginning to be used by some practitioners as adjunctive treatment.

Patients who do not respond to PPIs or who require long-term high doses of acid suppressants for symptom control should be referred for a specialist opinion. Endoscopic evaluation is often followed by 24 pH monitoring (off acid suppression for five days) to confirm excessive acid reflux, preferably with a close symptom-reflux association.

Manometric evaluation should be carried out at the same time to document LOS function and to exclude rare cases of achalasia, which can present with heartburn in its early stages.

Oesophageal pH monitoring might have to be repeated on high-dose acid suppressants to identify 20-30 per cent of patients who do not suppress acid on PPIs.

Severe endoscopic GORD and Barrett's oesophagus

Patients with severe oesophagitis at presentation should be endoscopically reassessed, as they often require long-term maintenance with standard or even higher PPI doses to prevent the development of complications such as strictures and Barrett's oesophagus, a premalignant condition. Likewise, all patients with Barrett's oesophagus require lifelong acid blockade with at least standard but often higher-dose PPIs.

There is some evidence, albeit soft, that long-term PPI treatment might reduce the incidence of dysplasia in these patients. The value of antireflux surgery in the latter group is controversial and recent meta-analyses have failed to show this results in a lower incidence of adenocarcinoma.

Antireflux surgery

Antireflux surgery has an established place in the management of reflux disease, particularly in patients with volume reflux.

However, patient choice such as unwillingness to take long-term acid suppression is the main indication. The patient needs to be aware of a 20-30 per cent risk of failure over five to 10 years of follow-up, the possibility of open conversion in case of laparoscopic surgery and postoperative symptoms such as persistent dysphagia or gas bloating due to the inability to belch.

The diagnosis of GORD must be confirmed prior to surgery by means of oesophageal function testing.

Endoscopic antireflux procedures

Endoscopic anti-reflux procedures have recently been developed. The 'Endocinch' system allows the plication of gastric mucosa just below the gastro-oesophageal junction in the hope of improving LOS function.

In a US multi-centre open clinical trial heartburn appeared to have improved after six months despite no reduction of oesophageal acid reflux. Recent longer-term follow-up studies show eventual failure of symptom control.

At least three further endoluminal procedures are currently being evaluated.

During the Enteryx procedure a non-biodegradable polymer is injected into the cardia.

The Gatekeeper system works on a similar principle but injects dry hydrogel cylinder-shaped prostheses into the submocosal layer of the distal oesophagus. The implants swell on contact with fluid, thus having favourable effects on LOS function.

Recent studies suggest some improvement with these procedures in reflux objectively and reduction of symptoms in the short-term.

The Stretta procedure delivers radio-frequency energy at the gastro-oesophageal junction by means of a rotatable catheter assembly. This is the only endoscopic antireflux modality to have been evaluated in a sham controlled trial, which has shown symptom relief and improvement in pH profiles after six months. NICE is currently in the process of issuing guidance on this technique.

For all modalities, long-term comparisons with standard anti-reflux procedures are currently not available to define the place of these endoscopic procedures.

None is indicated outside the clinical trial setting; all are of unproved efficacy and there have been occasional deaths reported in the US with some of the procedures.

The Los Angeles

classification of oesophagitis

Grade A One or more mucosal breaks

no longer than 5mm, not

extending between the tops of

two mucosal folds

Grade B One or more mucosal breaks

more than 5mm long, not

extending between the tops of

two mucosal folds

Grade C One or more mucosal breaks

continuous between the tops

of two or more mucosal folds

but which involves less than

75 per cent of the

oesophageal circumference

Grade D One or more mucosal breaks

involving at least 75 per cent

of oesophageal circumference

Source: Lundell et al. Endoscopic assessment of oesophagitis: clinical and functional correlates and

further validation of the Los Angeles classification.

Gut (1999) 45: 172-80

GP dilemmas

What should I say to patients who are asking about surgery when all other treatments seem to be failing? One patient has heard of new treatments in the US and is asking whether they should hold out for them

In the majority of patients symptoms can be safely controlled with acid suppressants. In case of poor response to standard treatment the diagnosis should be confirmed by an upper GI endoscopy, possibly followed by 24 pH monitoring. Increasing the dose of PPI is an effective option.

The pros and cons of a surgical antireflux procedure should be discussed at this point. Endoscopic procedures are at present of unproven efficacy and long-term outcome data is currently lacking.

At the back of my mind with refractory GORD patients is the fear that long-term acid reflux washing over their distal oesophagus could make them more prone to early cancer. Is this fear founded?

It is not yet fully understood which patients will develop cancer in Barrett's oesophagus, but the pivotal role of acid reflux is undisputed.

Patients over 55 should be offered a specialist assessment, which would include an endoscopy. If Barrett's oesophagus is detected the possibility of malignant transformation should be explained, although the absolute risk has probably been over-emphasised ­ only 5 per cent of Barrett's patients develop cancer. Long-term PPI therapy should be started and the patient should be encouraged to stop smoking. Enrolment in a surveillance programme (with endoscopic biopsies once every three years) should be offered.

Peter Wurm is consultant physician and gastroenterologist

John de Caestecker is consultant physician and gastroenterologist, Digestive Diseases Centre, University Hospitals of Leicester NHS Trust

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