Heartburn and gastro-oesophageal reflux

The oesophagus, or gullet, is the muscular tube that connects the mouth to the stomach. The US spelling of the name of this tube is the oesophagus, hence gastroesophageal reflux disease is known throughout the world as GERD and not GORD. In Britain this type of reflux is known as GORD.

When food is swallowed, waves of muscular contractions push it down the oesophagus into the stomach. A ring of muscle known as the lower oesophageal sphincter acts as a valve to prevent it moving in reverse. GORD arises when this valve becomes weak or damaged and allows stomach contents to pass back through the sphincter and into the oesophagus.

Gastric juice is very acidic – about pH2 – and contains protein-digesting enzymes, both of which can be very damaging to the mucosa that lines the oesophagus.

The more common GORD symptoms are:

• Heartburn or a burning pain in the chest, just under the breastbone. The pain is increased by bending, stooping or lying down and tends to be worse after eating
• Difficult or painful swallowing
• Nausea after eating
• Feeling that food may be left trapped behind the breastbone
• Regurgitation of food that has ‘got stuck’

Less common symptoms include:

• Coughing or wheezing
• Difficulty swallowing
• Hiccups
• Hoarseness or change in voice
• Sore throat

In addition to pain and discomfort, GORD can bring about changes or damage to the oesophageal wall:

• Reflux oesophagitis: this follows the death of cells in the mucosa (the inner lining), which causes ulcers just above the lower oesophageal sphincter
• Oesophageal strictures: persistent narrowing of the oesophagus caused by reflux-induced inflammation
• Barrett’s oesophagus: a situation where the normal epithelial cells lining the oesophagus change from a pink, squamous, lining to a red, intestinal columnar epithelium. This stage may be a precursor to the development of cancerous changes and may need monitoring. The jury is out on whether gastroenterologists really should survey patients with Barrett’s. A large clinical trial known as BOSS is aiming to answer this question. If the GORD is brought under control, the cells usually return to their original type
• Oesophageal adenocarcinoma: this form of cancer is now the fourth most common cause of cancer death in men in the UK

A variety of conditions can lead to GORD, but the following account for the vast majority of cases:

• Obesity
• A hiatus hernia: the lower oesophageal sphincter is pushed up through the diaphragm together with some of the stomach. The hernia itself often causes no obvious lumps or discomfort and is only diagnosed following investigation for GORD

Most people with GORD who seek medical help find relief by treating the symptoms, so advanced diagnostic techniques are not always needed. Antacids are usually very effective. Further tests can be done if symptoms are severe or do not respond to treatment.

To positively identify GORD, oesophageal pH monitoring is currently the favoured technique. This is done via a catheter with a pH sensor on the end, or by a pH capsule passed into the oesophagus. GORD is diagnosed if the oesophageal pH detected is below pH 4.

In some cases, an endoscopy is used to investigate the extent of tissue damage that has resulted from GORD.