Heartburn, acid regurgitation and Barrett’s oesophagus

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Chapter 3 HEARTBURN, ACID REGURGITATION AND BARRETT’S OESOPHAGUS

• Gastro-oesophageal reflux disease (GORD) is defined as a condition that develops when the reflux of stomach contents causes troublesome symptoms or complications.

• Most GORD is non-erosive. About one-third of patients have oesophagitis (erosions).

• GORD is associated with excessive oesophageal acid exposure. Some patients have symptoms triggered by weakly acidic reflux episodes.

• Dysphagia occurs with GORD but this and weight loss, anaemia or bleeding is an indication for endoscopy to exclude strictures or malignancy.

• GORD symptoms overlap with peptic ulcer disease and functional dyspepsia. In some GORD patients, epigastric pain may be the major symptom of GORD.

• A positive response to a therapeutic trial of protein pump inhibitor (PPI) therapy supports the diagnosis of GORD.

• Endoscopy is warranted if the diagnosis is unclear or when symptoms persist or are refractory or there are alarm symptoms.

• Goals of management are to relieve symptoms, reduce risk and restore quality of life.

• Proton pump inhibitors (PPIs) are the most effective pharmacotherapy for GORD providing rapid and reliable symptom resolution and healing of oesophagitis in most patients.

• Management involves an initial trial of PPI therapy then a tailored long-term treatment plan using the lowest effective PPI dose and frequency. Surgery is an option for a selected minority.

• Barrett’s oesophagus confers an increased risk of oesophageal adenocarcinoma.

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

Symptom recognition and assessment

The diagnosis of GORD is mostly based on symptom assessment. The most characteristic and common symptom is heartburn. However, it is important to use descriptive language such as ‘a burning feeling rising up from the stomach or lower chest towards the neck’, as the term ‘heartburn’ is widely interpreted and has variable meaning in different cultures. Regurgitation is also common. Excessive belching, odynophagia and waterbrash (sudden filling of the mouth with saliva) also occur in GORD. Periodic dysphagia is not infrequent, but new onset, frequent or progressive dysphagia is an indication for prompt endoscopy to exclude mechanical obstruction due to peptic strictures or malignancy. Overt bleeding occurs occasionally but is rarely severe. Occult iron deficiency may result from oesophagitis or from Cameron lesions (linear erosions caused by mechanical trauma due to the effect of the diaphragm on a hiatal hernia sac). However, iron deficiency should not be ascribed to oesophagitis or hiatal hernia without considering colonic causes for blood loss.

Accurate recognition of heartburn has reasonable sensitivity for the diagnosis of reflux. Assessment of the duration, frequency and severity of this and other symptoms and of the impact of symptoms on quality of life will determine if GORD is present and allow grading of the severity of the condition, which in turn guides the intensity of therapy.

Atypical symptoms include chest pain, which may mimic cardiac pain, and symptoms associated with extra-oesophageal manifestations of GORD including cough, sore throat, hoarseness and wheeze. GORD should be considered in patients who present with no other apparent cause for these symptoms although most patients with reflux-induced extra-oesophageal symptoms will also have typical GORD symptoms.

Symptoms of GORD may be similar to those of other upper gut disorders, especially peptic ulcer disease and functional dyspepsia. About two-thirds of patients with reflux symptoms will also complain of upper abdominal pain or discomfort (dyspepsia). In some GORD patients epigastric pain may be the major symptom of GORD and in these cases it is difficult to distinguish GORD from other conditions.

About 40% of patients with irritable bowel syndrome also complain of reflux symptoms. Such an overlap suggests both conditions may be part of the spectrum of a broader gastrointestinal disorder representing variations in the presentation of an irritable gut.

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