Gastro-oesophageal reflux disease (GORD)
Gastro-oesophageal reflux disease (GORD) is a common cause of dyspepsia - a complex of upper gastrointestinal tract symptoms, which typically last for 4 or more weeks. In the UK, approximately 25% of adults experience symptoms at some time in their lives, with 5% experience symptoms daily.
Article by Margaret Perry
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Definition
Gastro-oesophageal reflux disease (GORD) is a common cause of dyspepsia. Dyspepsia is a complex of upper gastrointestinal tract symptoms, which typically last for 4 or more weeks (National Institute for Health and Care Excellence (NICE), 2022). Prevalence rates are difficult to determine, as people with mild symptoms may self-medicate and never seek medical advice. In the UK, approximately 25% of adults experience symptoms at some time in their lives, with two to three times greater prevalence in males, and 5% experience symptoms daily (Ford and Moayyedi, 2009).
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Symptoms
GORD is associated with a variety of symptoms with multiple degrees of severity.
GORD, acid reflux and heartburn
Patients often use the terms ‘GORD’, ‘acid reflux’ and ‘heartburn’ interchangeably, and although they are related, these conditions have notable differences.
Acid reflux: the backward flow of stomach acid from the stomach to the oesophagus, causing a burning sensation in the chest (heartburn).
Heartburn: felt by patients when acid reflux has occurred. This can take place after eating a big meal, drinking coffee or alcohol, or in bed at night when lying down.
GORD: a more unpleasant form of acid reflux, when the backflow of stomach contents becomes more severe (Kinman, 2020).
Some patients experience additional symptoms, including:
- a sore, inflamed oesophagus (oesophagitis), causing bad breath
- bloating and belching
- feeling nauseous or being sick
- difficulty swallowing, which may feel like food is stuck low down in the throat
- pain when swallowing
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Aetiology
The oesophagus starts at the throat and extends to the stomach where a valve (the lower oesophageal sphincter) at the base of the oesophagus separates the two. This valve normally stays closed until there is a need to swallow, at which point it opens to allow the passage of food. The oesophagus functions as an antegrade pump (promoting forward flow of contents), the lower oesophageal sphincter functions as a valve and the stomach as a reservoir (Patti, 2021). Dysfunction of any of these systems can contribute to the onset and persistence of GORD-related symptoms.
GORD symptoms can be exacerbated by a number of lifestyle factors, including diet, smoking, alcohol consumption and obesity, outlined in more detail in the management section.
Hiatus hernia
A hiatus hernia occurs when the muscle at the base of the oesophagus protrudes into the oesophagus. People with hiatus hernias are usually asymptomatic, but some
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Diagnosis
A good history will often allow for diagnosis. Heartburn with or without regurgitation, particularly when symptoms are worse postprandially (after a meal) or when lying down, and improvement after a trial of treatment is considered diagnostic of GORD (Badillo and Francis, 2014). In this case, no further investigation is needed. If symptoms persist despite treatment, further tests will have to be conducted. The most widely used test is upper gastrointestinal endoscopy, which allows direct visualisation of the oesophageal and gastric mucosa (Clarrett, 2018).
An endoscopy can be performed to grade the degree of oesophagitis. Two grading systems are currently in use, as shown in Table 2.
| Table 2. Grading systems for oesphagitis | |
| Savary-Miller system | |
| Grade | Details |
| Grade 1 | Erosions on a single fold |
| Grade 2 | Multiple erosions affecting multiple folds which may be confluent (merging together) |
| Grade 3 | Multiple erosions |
| Grade 4 | Ulceration, stenosis (abnormal narrowing) |
| Grade 5 | Barrett’s |
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Management
GORD is a chronic disease that typically requires long-term management in the form of lifestyle modification (usually offered first), medical treatment and rarely surgery (Badillo and Francis, 2014).
Lifestyle modification
There are a number of changes that can be made to a patient’s lifestyle to improve their symptoms of GORD. Nurses should discuss these with patients, and where applicable, assist with lifestyle modification in accordance with evidence-based findings (outlined below).
Diet
Specific foods or beverages which induce symptoms can significantly vary between patients with GORD. Surgea Blaga et al (2019) suggested that a Mediterranean diet rich in fruits, vegetables, legumes, beans, fish, cereals and unsaturated fats, and lower in carbohydrates, protects against reflux.
Tobacco smoking
Nilsson et al (2004) found that people who smoked daily for more than 20 years had a 70% increased risk of GORD compared to those who smoked daily for less than a year
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Risk factors
Patients with severe long-standing inflammation caused by GORD may, in rare cases, develop a stricture with narrowing and scar tissue (Knott, 2020b).
Barrett's oesophagus
Repeated episodes of GORD cause changes to cells in the lining of the oesophagus, a condition known as Barrett’s oesophagus. An estimated one in every 10-20 people with Barrett’s oesophagus develop oesophageal cancer over a 10-20-year period (NHS Inform, 2023).
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Resources
Ali RAR, Hassan J, Egan LJ. Review of recent evidence on the management of heartburn in pregnant and breastfeeding women. BMC Gastroenterol. 2022;22(1):219. https://doi.org/10.1186/s12876-022-02287-w
Badillo R, Francis D. Diagnosis and treatment of gastroesophageal reflux disease. World J Gastrointest Pharmacol Ther. 2014;5(3):105-112. https://doi.org/10.4292/wjgpt.v5.i3.105
Clarrett DM, Hachem C. Gastroesophageal Reflux Disease (GERD). Mo Med. 2018;115(3):214-218.
Ford AC, Moayyedi P. Treatment of chronic gastro-oesophageal reflux disease. BMJ. 2009;339:b2481. https://doi.org/10.1136/bmj.b2481
Hill J. Managing gastro-oesophageal reflux disease in adults: an update. 2014. www.https://bpac.orgnz/BPJ/2014/June/gord.aspx (accessed 18 April 2023)
Kinman T. What are the differences between heartburn, acid reflux and GERD? 2020. https://www.healthline.com/health/gerd/heartburn-vs-acid-reflux (accessed 18 April 2023)
Knott L. Antacids. 2020a. https://patient.info/digestive-health/indigestion-medication/antacids (accessed 18 April 2023)
Knott L. Gastro-oesophageal reflux disease. 2020b. https://patient.info/doctor/Gastro-Oesophageal-Reflux-Disease (accessed 18 April 2023)
Mohamed ZK, Attwood S. Oesophageal dysfunction and disease in obesity. 2011;4(2):a417.
National Institute for Health and Care Excellence (NICE). Suspected cancer: recognition and referral. 2021. https://www.nice.org.uk/guidance/NG12/ (accessed 18 April 2023)
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