In this episode of PodMD, consultant gastroenterologist and hepatologist Dr Gokul Tamilarasan will be discussing the topic of GORD, or gastro-oesophageal reflux disease, including what GORD actually is, the risks of the condition, the treatment options, the likelihood of recurrence, when a GP should refer and more.
Please note this is a machine generated transcription and may contain some errors.
*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMD studio Dr Gokul Tamilarasan
Dr Tamilarasan is a consultant gastroenterologist and hepatologist. He trained as a junior medical officer and physician trainee at Royal Prince Alfred Hospital (RPAH), before completing his Gastroenterology training at RPAH and Concord Repatriation General Hospital (CRGH). Gokul also has a keen interest in teaching and currently holds a Clinical Associate Lecturer title with the University of Sydney.
Today, we’ll be discussing the topic of GORD (reflux disease).
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.
Gokul, thanks for talking with us on Pod MD today.
Gokul: Thank you for having me.
The topic of today’s discussion is GORD or Reflux Disease. Can you describe for our listeners what GORD is?
Gokul: Gastro-oesophageal reflux disease is a very common clinical condition, actually. One that’s very commonly diagnosed and managed by GPS across various clinical settings. Reflux is actually a physiological process, so the reflux of acidic gastric contents occurs quite commonly after meals and at various other times, but it becomes a pathological event or a pathological process when the frequency and the severity of the reflux episodes causes the patient to be exposed to risks of medical or physical complications such as strictures or cancers or Barretts oesophagus, or alternatively, causes a symptom burden that impairs the patients quality of life.
To summarise, the main pathological mechanism underpinning reflux disease, essentially it’s due to transient relaxation of the lower esophageal sphincter, which typically or normally normal states acts as a physical barrier preventing reflux. So when this mechanism fails then you get pathological reflux disease.
How would a patient with GORD typically present and what are the relevant risk factors?
Gokul: Burning discomfort usually postprandially and often at night time, but not exclusively. The other symptoms that can occur include indigestion or dyspepsia. Sour brash or water brash. And the slightly less common symptoms, but still very relevant, are chronic cough, particularly in those patients that experience laryngopharyngeal reflux or atypical pain, like angina like pain, changing voice quality or dis phonia, and in more severe cases you can even get nausea or vomiting. And patients often describe unwanted or uncontrolled belching.
In those with more advanced disease, so complications from reflux such as structuring you can have patients develop dysphagia or odynophagia if there’s quite severe erosive and ulcerating reflux disease, but these are often very symptomatic, very very severe severe cases. The relevant risk factors for patients would include being overweight because being overweight or obese increases the intra abdominal pressure on the lower oesophageal sphincter and is a risk factor. Alcohol intake, coffee, chocolate and other dietary triggers can reduce the lower oesophageal sphincter tone, increasing the likelihood of experiencing symptomatic relief. The risk factors would include large meals or late night meals which can increase gastric distention and gastric acid production right before lying down, which can increase the frequency of lower oesophageal sphincter relaxation.
And the other thing I should mention is that pregnant women often experience reflux due to. Lower oesophageal relaxation relating to hormonal changes in pregnancy as well as the physical stress on the sphincter from increasing printer abdominal pressure. And finally, patients who are hospitalised, who are in care facilities. Who are being nursed supine, having increased risk of reflux disease simply from their positioning as well as patients with impaired motility? Whether that be in the oesophagus from conditions like Scleroderma, or in the stomach from conditions like diabetic gastroparesis all have increased risks of developing reflux disease.
What are the risks of the condition?
Gokul: The primary risks of reflux disease sort of divided into physical stricturing phenomenon, as well as a cellular precancerous lesion known as Barretts oesophagus, so starting with the stricturing risk, over time, repeated episodes of acidic exposure to the Asafa Geo mucosa can result in scarring, and the scarring can eventually over time and with chronicity lead to what’s called a peptic stricture, usually in the distal oesophagus.
This can lead to food bolus obstruction, difficulty swallowing and overtime can lead to an increased risk for oesophagal adenocarcinoma. Uhm. The other a risk factor would be Barretts oesophagus, which is a precancerous lesion, and and is typically identified by the replacement of the normal oesophageal mucosa with columnar mucosa with intestinal metaplasia, which is sort of the pathognomonic hallmark of Barretts oesophagus.This is a precancerous lesion, and all patients who have identified Barretts oesophagus on Histology should really be offered an endoscopic and histologic surveillance programme to monitor its progress and close surveillance with the gastroenterologist.
What are the treatment options?
Gokul: The treatment options. I split them up into three main categories, starting to become four main categories. The more common ones that GPS will be well versed in our lifestyle measures medical therapies for which the mainstay is PPI therapy, and then surgical therapy, including the Nissan fundoplication. The fourth category that’s becoming more accessible is the less invasive endoscopic therapy, and this is particularly in the case over the last 10 years. However, this is still not a mainstay and and I’ll go into that a little bit more detail. Lifestyle modifications are very simple and can improve symptom burden associated with reflux and this and can include any non pharmacological advice which would mainly include reduction of alcohol intake, dietary modification based on you know foods that trigger the symptoms for the patient.
Weight loss, raising the head of the bed and even sleeping in the left lateral position due to the anatomical positioning and positioning of the gastric acid pocket in the left position. But patients that have more severe oesophagitis or have ulcerated or erosive oesophagitis are unlikely to benefit from lifestyle modifications, only they’re going to need more significant acid suppression with medical therapy or even surgical therapy if failing medical therapy. So the medical therapies that the GPS will be quite aware of include alginet antacids. So things like gaviscon or renies can help patients who have very mild disease and just need a PRN type approach. However, the more common long term treatments include histamine that arm to antagonise receptor antagonists such as ranitidine and Nadine. Although Ranitidine is now no longer available and then of course PPI’s, which provide much more potent acid suppression, are the more common treatment. Typically, patients that present to a GP clinic should really be offered a 6 to 8 week therapeutic trial of once daily PPI therapy.
These patients should really be well screened to make sure that they don’t have any significant red flags, because patients with red flags should really be referred on quite promptly for endoscopic assessment, and we’ll talk a little bit more about red flags a bit later on. Patients who then have persistent symptoms despite that two month trial of PPI therapy warrant a referral for endoscopic evaluation. Occasionally patients will have some improvement on PPI therapy and just need additive therapy, and this could. This could mean increasing the dose of PPI, or adding in a histamine antagonist. However, in patients that are requiring step up therapy, I still recommend having endoscopic assessment. As well, potentially as having a 24 hour pH, pH and impedance measurement just to confirm that these patients aren’t incept experiencing functional dyspepsia or some other pathology that will not benefit from further acid suppression.
Surgical options have not changed dramatically in the last few decades apart from moving from open to laparoscopic, and as we discussed the mainstay of that is the Nissen fundoplication. The laparoscopic approach nowadays is much less invasive than the open Nissen fundoplication, but it’s still an invasive procedure procedure with its own safety and a side effect profile. But to summarise, it basically involves wrapping surgically wrapping the gastric fundus around Dolores offer deals sphincter to reinforce it and prevent unwanted reflux.
And finally, there’s a small but growing sealed of endoscopic options for the management of reflux disease and, and this includes endoscopic fundoplication or suturing devices, as well as radiofrequency ablation therapy to the gastroesophageal junction. The issue with endoscopic therapies has been or the limitation has been, that they don’t. We don’t really have adequate long term data or data regarding the durability of the outcomes in these patients.
And my main takeaway sought for treatments beyond medical therapies, or whether that be endoscopic therapy or surgical therapy, is that patients should definitely have had. But apart from an upper endoscopy, they should really have had manometry as well as a 24 hour pH and impedance test just to confirm that they insect have pathological reflux disease and they don’t have an undiagnosed manometric diagnosis such as achalasia or ineffective oesophageal motility or various other motility disorders which will become worse if they are to have a fundoplication or or some form of endoscopic therapy for reflux.
Have there been any developments in treatment in the last years or are there any in trials or development now?
Gokul: Look to be honest, reflux management hasn’t changed a lot. I think the main development has been what we just discussed with regards to endoscopic antireflux therapies and that will continue to be the case over the next 5 to 10 years, I would assume. And one device or procedure that I haven’t mentioned is the LINX device, and that essentially is quite a unique device, which is a ring of magnetic beads placed laparoscopically around the outside of the lower oesophageal sphincter, and this acts almost like a rubber band around the oesophageal sphincter to reinforce it.
The difference between this and some of the other surgical mechanisms such as fundoplication is that the the magnetic rings are expandable and do allow physiological relaxations of the lower oesophageal sphincter such as for swallowing, burping and those kind of things. So there is some good five year data regarding the durability of links devices, and there is actually less issue with things like abdominal bloating or trapped gas type syndromes with patients with the lynx device, but again The numbers of patients using this device is fairly low, and it’s not that easily accessible. apart from some really major tertiary centres offering, you know, multidisciplinary upper GI approaches to reflux.
What is the likelihood of recurrence of the condition?
Gokul: Look, unfortunately this is a fairly chronic condition for the vast majority of patients. Realistically, unless they have a very easily reversible risk factor such as pregnant women may not experience risk. Sorry reflex. Once they’ve delivered their baby. patients that have’s have been heavily drinking but then are able to cut out their alcohol. They may have a resolution of their reflux disease, but for the vast majority of patients, reflux will be an on and off. process for most of their life, so that’s that’s a real an issue for patients, so that’s why it’s really important for the patient to have a good relationship with their GP and for GPS to understand what this symptom burden is for patients and how they can best address the symptoms, whether that be long term, PPI, whether that be endoscopic or surgical options, or dietary modifications, and non pharmacological approaches, and it’s really important for the GP. To be aware of what is going to make the biggest difference for difference for that patient, UM, but unfortunately as I say, it’s quite a chronic relapsing condition.
When should a GP refer?
Gokul: So this is where I wanted to talk about red flags. The main reasons for referral to a gastroenterologist. So further assessment and probable endoscopic evaluation would include red flag features such as hematemesis or Melena. So evidence of upper GI bleeding, Iron deficiency anaemia. You’d be surprised by the number of patients that have severe erosive gastroesophageal reflux disease but just haven’t experienced major symptoms, and these patients often become quite iron deficient. The other red flag features would include dysphagia or odynophagia, which could represent A stricture or it could represent an alternative differential diagnosis, such as can Candidiasis. Unexplained weight loss, UM, which unfortunately, could you know, represent more concerning diagnosis such as oesophageal or gastric adenocarcinomas? That’s a red flag, obviously, and then a family history of upper gastrointestinal cancers, particularly, oesophageal, or gastric adenocarcinomas, would warrant referral.
The other reasons that aren’t red flags, but still would warrant referral would include the chronicity of symptoms with minimal improvement. So, for example, if a patient doesn’t respond to a therapeutic trial, UM, or if the patient’s been getting crescendo worsening symptoms despite having been on therapy for long periods of time, or had been previously stable and is now getting breakthrough symptoms, these patients may need reassessment with an endoscopy or with a pH study. The final one that I would advise GPS to refer for, would be even if patients have had reflux for a long period of time but are relatively well controlled, they may still need endoscopic assessment for the exclusion of Barretts oesophagus, because that is not a symptomatic condition and needs histological assessment to diagnose.
What role does the GP play in the treatment of the condition?
Gokul: Well, I think just to summarise what we’ve just talked about GPs really huge role in reflux. I think they are often the first practitioner that that sees these patients and must diagnose and monitor the bulk of patients with this condition. And it’s only the really severely refractory patients or patients with Barretts oesophagus end up regularly seeing a specialist. So I think GP is really need to have a good approach to risk stratify patients and manage them accordingly and workout who needs specialist input and work and make those referrals in a timely fashion but the the other role that falls to GPS is prescribing PPIs and unfortunately that’s been made a little bit more challenging due to changes by the PBS in authority script requirements. But patients that are particularly for higher dose PPI. But I think the thing to remember is if you’re having to increase doses and get into the authority script range of doses. Maybe these patients really need a reassessment and confirmation of their disease to ensure that that further higher doses are actually warranted and necessary for this patient.
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on GORD.
Gokul: I think the three main take home messages that I would have would be therapeutic trial of a PPI is a great diagnostic and therapeutic tool with really good diagnostic sensitivity.
The second point would be to always make sure that you’ve screened for red flags, because these patients really shouldn’t have any time wasted with a therapeutic trial and should be assessed quickly and referred on.
And then the third Point is that patients should really be on the lowest possible dose of PPI’s that controls reflux symptoms and where possible. Assessment should be made about whether a patient could have a dose reduction or a tapering of PPI dose to try and reduce the number of patients on PPI’s that don’t have a clear indication. And finally I know it was three takeaways but the 4th one is. Don’t forget about Barretts oesophagus and their relevance surveillance that’s required.
Thanks for your time and the insights you’ve provided.
Gokul: Thank you for having me