Managing Acid Reflux Disorders
This article is based on guidelines provided to UK primary care physicians (GPs).
Gastro-esophageal reflux disease (GERD) is defined as "a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications. Reflux is primarily a mechanical problem caused by transient lower esophageal sphincter relaxations (tLESRs). This leads to stomach contents splashing upwards into the esophagus. It is important to note that symptoms are caused by the reflux of bile and pepsin as well as gastric acid. Reflux is, therefore, not a problem of “too much acid” but rather stomach contents being found in the wrong place.
Other factors that can lead to reflux include increased gastric pressure (for example during pregnancy), delayed gastric emptying, hiatus hernia and impaired esophageal. Obesity, smoking history, family history and certain medications have been shown to be likely risk factors. There are many other lifestyle factors that may increase the risk of reflux, such as excess alcohol, coffee, citrus fruits and fatty foods.
GERD is more common in western countries, where it has a prevalence of 10-20%, whereas in Asia, the prevalence is reported to be less than 5%.
Frequent heartburn can lead to limitation of daily activities and to a decrease in health-related quality of life.
Diagnosis and investigations
The diagnosis of reflux, particularly in primary care, is usually based on the patient’s symptoms. The most common symptoms are heartburn and regurgitation. Many other symptoms may be associated with reflux, including chest pain, dysphagia, globus (the sensation of a lump in the throat or upper chest), bloating, belching, nausea and odynophagia (painful swallowing).
GERD is not a diagnosis normally made at endoscopy. The majority of patients will have a normal upper GI endoscopy (non-erosive reflux disease), with esophagitis found in only 25-40% of patients. As acid reflux disease is a clinical diagnosis, investigations are not essential for diagnosis. However investigations may be used to assess the severity of GERD, identify complications or assess patients who are being considered for anti-reflux surgery.
The most commonly performed investigation is upper GI endoscopy. Other investigations such as manometry, pH monitoring, gamma-scintigraphy and intra-luminal impedance testing are also used, but mainly in the tertiary setting. The role of endoscopy is to assess whether there is esophageal damage and to look for other pathology in the upper GI tract.
When assessing a patient with reflux, it is important to take a thorough history, including symptom duration and the impact of symptoms on the patient’s quality of life. Patients should be asked about current and prior use of reflux medication and their response to this treatment. They should also be asked about any medications they may be taking that can aggravate dyspepsia, such as calcium antagonists, nitrates, theophylline’s, bisphonates, corticosteroids and NSAIDs.
It is also helpful to explore any particular fears or worries a patient may have. For example, the patient may be worried about ulcers or cancer.
The most practical way for a primary care physician to assess the severity of GERD is to ask the patient about the impact of their symptoms on their day-to-day life. For example, the effect of symptoms on eating, sleeping or work.
It is also essential to look for the presence of alarm signs, which may suggest a more serious diagnosis. Alarm signs include dysphagia, chronic GI bleeding, progressive unintentional weight loss, persistent vomiting, an epigastric mass and an abnormal barium meal.
There are detailed questionnaires which can be used to assess symptoms severity. However, because of the time required, these are mainly used for research purposes.
The reflux of acid, bile and pepsin can lead to mucosal damage in the esophagus and to complications elsewhere (extra-esophageal reflux), such as in the pharynx, larynx and lungs. A panel of international experts has subdivided GERD into esophageal and extra-esophageal syndromes.
The most serious complication of acid reflux disease is esophageal adenocarcinoma. The relative risk of cancer is increased more than 40 times in patients with severe, long-standing symptoms compared with people with no history of reflux. Esophageal adenocarcinoma was once relatively rare, but the incidence is increasing in the UK. In 2008 it was found to be more common than gastric and pancreatic cancers. The incidence is more common in males than females. In the USA, the incidence of esophageal adenocarcinoma in white males increased by more than 350% between 1974-6 and 1992-4.
When and whom to refer
Patients with upper GI alarm signs should be referred under the two week referral system (in the UK) for patients with suspected cancer. Routine endoscopic investigation of patients of any age presenting with dyspepsia without alarm signs is not necessary. However, in patients aged 55 years and older with unexplained and persistent recent onset dyspepsia alone, an urgent referral for endoscopy should be made. Referral may also be appropriate in other situations, for example in patients with atypical symptoms, those who have severe or persistent symptoms and/or patients with a poor response to treatment. NICE recommend that acid suppression is stopped during the two weeks before endoscopy. Alginates and/or antacids may be used during this period to ease symptoms.
The main aims of treatment for patients who do not require further investigation are to relieve symptoms and minimise complications by healing or preventing damage to the lining of the esophagus.
Patients should initially be advised on healthy eating and to follow a GERD diet. They should also be given advice on smoking cessation and weight loss if relevant. It can help to eat little and often, take time to eat meals and avoid eating near bedtime. It is common practice to advise patients to reduce alcohol, fizzy drinks, acidic food (such as citrus fruits), spicy food, caffeinated drinks and fatty foods. Following a good acid reflux diet can cure GERD and mean that patients can reduce their need for antacids and medication. Patients are also advised to raise the head of the bed to help night-time reflux.
Antacids work predominantly by raising the pH in the esophagus (rather than in the stomach). They are useful as a first-line treatment and as an OTC (over-the-counter) treatment.
Alginate reflux suppressants
Alginate reflux suppressants work by forming a protective raft on the surface of the stomach contents. This barrier suppresses reflux. They can be used on their own for intermittent symptoms, either on prescription or OTC. Examples of alginates are Gaviscon, Gaviscon Advance and Peptac
H2 receptor antagonists (H2RAs)
H2RAs, such as cimetidine and ranitidine, work by reducing gastric acid production by parietal cells in the stomach. They are less effective than PPIs but may suit individual patients. Prokinetics Prokinetics such as domperidone and metoclopramide work by increasing peristalsis, lower esophageal sphincter pressure and gastric emptying. They are moderately effective at treating symptoms of reflux but less effective at healing esophagitis. Prokinetics can be prescribed on their own but are usually used as an adjuvant to acid suppressing drugs.
Proton Pump Inhibitors (PPIs)
PPIs reduce acid production in the stomach by inhibiting the proton pump in the parietal cells, thereby raising the pH (and making the environment less acidic) of the stomach contents. PPIs are effective at relieving symptoms of acid reflux and at healing esophagitis. PPIs do not stop reflux but make the refluxate less acidic. Proton pump inhibitors should be used at the lowest effective dose for the shortest period possible and the need for long-term treatment should be reviewed periodically.
Various endoscopic procedures have been developed. These procedures usually involve suturing, stapling or injecting the gastro-esophageal junction. None of these procedures are yet in common use.
Anti-reflux surgery may be used, for example, for patients in whom regurgitation has not been helped by medication, or when patients do not wish to take long-term medication. NICE guidance suggests that surgery may be an option in patients whose quality of life is significantly affected by their symptoms.
Updates on clinical guidance
Rebound acid hypersecretion
After prolonged treatment with PPIs, patients may experience recurrent heartburn soon after stopping treatment. Patients usually assume this means that the reflux has recurred. However, evidence now suggests that this may be due to increased acid production as a result of stopping prolonged treatment with a PPI. This is called rebound acid hypersecretion. It is thought that long-term elevated gastric pH (alkalinity) caused by PPIs stimulates gastrin release and that this raised gastrin results in hypersecretion of gastric acid once the PPI is stopped. PPIs may therefore be causing the same symptoms as those of the condition they are used to treat. If rebound hypersecretion is not well understood, patients may be started on PPIs empirically and then receive long-term treatment to counteract the rebound symptoms, or they may be unnecessarily referred for endoscopy to investigate the recurrent symptoms. It is important to explain this to patients and to suggest strategies to manage it. Stepping-down treatment is likely to help and options include a slow reduction in PPI dose and/or alginates.
However, some patients may still require long-term PPIs if these strategies are ineffective.
Antacid and/or alginate therapy prescribed or bought OTC, may be appropriate for rapid symptom relief for many patients. Additional therapy should be considered when symptoms are significantly affecting quality of life. PPIs should be used at the lowest effective dose for the shortest period possible. They may also be used on an as required basis and this should be discussed with patients. Patients should be reviewed annually and encouraged to step-down and stop treatment if possible. Self-treatment with antacids and/or alginates may be appropriate. Acid suppression should be stopped for at least two weeks prior to endoscopy. Antacids and/or alginates can be used to manage breakthrough symptoms during this period. Patients should be provided with access to educational materials and to continue with a GERD diet along with and to support the care they receive.
Management of breakthrough symptoms
Many patients experience breakthrough symptoms whilst taking PPIs. These commonly occur at night and can have a significant effect on quality of life. About 50% of patients with breakthrough symptoms take OTC medication in addition to their PPI, often without informing their doctor. When patients have breakthrough symptoms whilst taking a PPI, options include increasing the PPI dose to a twice daily regimen and adjuvant therapies, such as alginates. A reflux suppressant containing sodium alginate and potassium bicarbonate does not interact with PPIs and they can be used concomitantly. Its mechanism of action is complementary to that of PPIs, which suppress acid production but not the reflux per se.
Reflux is primarily a mechanical problem caused by tLESR, leading to the contents of the stomach (acid, enzymes and bile) splashing upwards into the esophagus. GERD is defined as reflux causing troublesome symptoms and/or complications. GERD is a common problem in western countries and can have a significant effect on quality of life of those with the condition. The majority of patients will have a normal endoscopy, with esophagitis found in only a minority of cases.
Complications can develop, including esophagitis, bleeding, stricture formation, Barrett’s esophagus and esophageal adenocarcinoma.
Useful tips to remember when managing patients with reflux disorders include:
- Medical treatment should involve a step-up and step-down approach
- PPIs are effective at treating symptoms and healing esophagitis
- Some alginates (for example Gaviscon) can be useful for breakthrough symptoms and can be used with PPIs.
- Long-term treatment with PPIs should be avoided where possible, as they can cause rebound acid hypersecretion and protracted dyspepsia.
- Management usually involves lifestyle advice (including a GERD diet) and medical treatment.