Gastro-oesophageal Reflux Disease (GERD)

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

  1. Obesity
  2. Hiatus hernia
  3. Increased intra-abdominal pressure e.g. in pregnancy
  4. Long term use of nasogastric tube
  5. 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
  6. Children with chronic neurological disease (e.g. cerebral palsy)

Symptoms of gastro-oesophageal reflux disease

  1. Heartburn (worsens with vigorous exercise, bending forward, lying; relieved by antacids and sitting upright)
  2. Dyspepsia
  3. Early satiety
  4. Retrosternal and epigastric pain (mimics angina pectoris by radiating to neck, jaws and arms. The pain is worse on bending down e.g. sweeping)
  5. Pain on swallowing
  6. Difficulty swallowing
  7. Nocturnal regurgitation (wakes patients up with coughing, choking and filling of the mouth with ‘saliva’)
  8. Asthma-like (may be worse at night)

Symptoms in children

  1.  Failure to thrive/refusing food
  2. Vomiting
  3. Coughing
  4. Forceful regurgitation which may lead to aspiration pneumonia
  5. Iron deficiency anaemia
  6. 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.