DEFINITIONS AND SPECTRUM

Heartburn is defined as a burning sensation in the retrosternal area and regurgitation as the perception of flow of refluxed gastric content into the mouth or hypopharynx. These are the cardinal symptoms of gastro-oesophageal reflux. Reflux is a physiological event but excessive reflux exposes the patient to the risk of physical complications or symptoms that impair quality of life. Gastro-oesophageal reflux disease (GORD) is defined as a condition which develops when the reflux of stomach contents causes troublesome symptoms or complications. Thus, in the absence of physical complications the definition depends on the impact of symptoms on an individual. Frequently, significant impairment of well-being (quality of life) occurs when symptoms occur on two or more days a week. GORD can be divided into oesophageal syndromes and extra-oesophageal syndromes (Figure 3.1). The former includes symptomatic syndromes of typical reflux symptoms and reflux induced chest pain and syndromes associated with oesophageal injury including oesophagitis (erosive GORD), strictures, Barrett’s oesophagus and the small risk of oesophageal adenocarcinoma. Extra-oesophageal reflux syndromes include the established associations with cough, laryngitis and asthma as well as other putative associations.

FIGURE 3.1 The definition of GORD and its constituent syndromes.^*

^*Reproduced with permission Am J Gastroenterol 2006; 101:1900–20.

EPIDEMIOLOGY, RISK FACTORS AND NATURAL HISTORY

Reflux symptoms are common with 15%–20% of adults experiencing heartburn at least once a week. GORD prevalence is higher in Western countries but is increasing elsewhere, particularly in Asia. This is thought to be due to an increase in Western lifestyle factors that may contribute to the development of GORD.

Obesity, alcohol consumption (>7 standard drinks a week), hiatal hernia or a first-degree relative with heartburn increase the risk of having reflux symptoms.

Patients with scleroderma, chronic respiratory disease, the institutionalised or intellectually handicapped and patients nursed in a supine position for prolonged periods are at increased risk of GORD.

In most patients, GORD is a chronic disorder and may have been present regularly for years prior to presentation. In others, symptoms may wax and wane while a minority may have transient symptoms. Milder symptoms may vary in intensity and occur only on some days. With increasing severity, symptoms tend to occur more often. Many patients will require long-term management, although in a minority symptoms do not relapse or relapse infrequently after a course of treatment.

Most patients with GORD have normal oesophageal mucosa at endoscopy (Figure 3.2). Only about one-third of patients with reflux disease have reflux oesophagitis confirmed by endoscopically visible mucosal breaks (erosions or ulceration).

FIGURE 3.2 The spectrum of gastro-oesophageal reflux disease (GORD).

PATHOPHYSIOLOGY

GORD is usually associated with excessive exposure of the oesophagus to gastric contents, particularly acid and pepsin. This is largely the result of an increased frequency of reflux episodes, but impaired clearance of stomach contents from the oesophagus is also a factor. The degree of excess oesophageal acid exposure correlates with the likelihood and severity of oesophagitis. The pathophysiology of non-erosive GORD appears heterogeneous. Some patients have excess oesophageal acid exposure whereas, in others, symptoms appear to be triggered by weakly acidic reflux episodes. Functional heartburn is a term used to describe apparently typical GORD symptoms that have no definable relationship with acid exposure.

The tonic activity of the lower oesophageal sphincter (LOS) prevents reflux. When LOS function is impaired there is an inappropriate increase in transient LOS relaxations, which permit an increase in reflux episodes. In addition some reflux episodes occur because of defective basal LOS pressure.

Hiatal hernia is common in reflux disease. Hiatal hernia increases the likelihood that reflux will occur by impairing LOS function. However, the presence of a hiatal hernia does not necessarily mean that reflux disease is present.

Obesity is associated with an increased risk of GORD. It promotes reflux by a number of mechanisms including increased intra-abdominal pressure, reduced oesophageal clearance and gastric emptying, reduced LOS tone and the increased likelihood of hernia. Factors that may aggravate reflux include dietary components such as fat, chocolate, caffeine and alcohol as well as possibly smoking and some drugs.

DIAGNOSIS

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