Managing the Symptoms of GORD

Symptoms

Managing the Symptoms of GORD

Introduction
Management Options

Introduction

Gastro-oesophageal reflux disease (GORD) is a common and chronic gastrointestinal disorder. Nearly 80% of the population will experience symptoms of reflux at some stage in their lives. GORD is associated with prolonged exposure of the lower oesophageal mucosa to gastric contents, leading to symptoms of heartburn, regurgitation (feeling like the stomach contents are coming back up) and waterbrash (excess saliva in the mouth). Symptoms are often made worse by lying flat, are related to meals (especially fatty foods) and may be worsened by hot liquids or alcohol.

The severity of your symptoms does not always correspond to how badly your oesophagus is scarred or damaged. It is therefore important that you see a doctor so your condition can be properly investigated. GORD often requires life-long and regular use of anti-reflux therapies.

Treatment tends to pursue three main aims:

Healing the damage to the oesophagus.
Preventing complications such as Barrett's oesophagus, strictures (narrowing) and adenocarcinoma of the oesophagus.
Alleviating your symptoms and improving your quality of life.

Only the latter aim is considered in detail in this write-up. For more information on the management of complications of GORD, refer to our gastro-oesophageal reflux disease (GORD) article.

In general a step-wise approach is used in the management of GORD symptoms. Usually you will be trialled on simple lifestyle measures and then slowly have more aggressive treatments added if your symptoms don't improve.

Before starting anti-reflux therapies, it is important that other causes of similar symptoms have been excluded. In particular, cardiac chest pain from angina can present quite similarly to reflux. Failure to treat an underlying cardiac problem could have serious consequences.

Management Options

If your GORD is mild it is likely that you will respond satisfactorily with simple lifestyle changes and over-the-counter antacids. In many cases, patients are able to control their own symptoms and do not necessarily need to see a doctor. It is quite common for patients to present only when symptoms become very severe that they interfere with daily functioning. However, it is important that you realise that reflux symptoms may be a marker of more serious underlying conditions. GORD can cause nasty complications including oesophageal cancer which need to be monitored throughout your treatment. In general, the longer you have symptoms of reflux, the greater risk you have for additional complications.

There are a number of symptoms which may suggest more serious problems which require urgent investigation. These are referred to as 'alarm symptoms.' If you notice any of the flowing it is important you see your doctor so they can conduct further investigations:

Dysphagia (difficulty swallowing).
Odynophagia (pain when swallowing).
Bleeding- You may notice you have blood in your vomit or dark, tarry stools (melaena).
Weight Loss.
Anaemia- You may notice you are more pale (particularly in the skin creases and conjunctiva of the eyes) or fatigue more easily.

Lifestyle Changes

You should trial the following lifestyle changes in the management of your symptoms:

Weight reduction.
Elevation of the head of the bed.
Avoiding lying down or sleeping for 3 hours after a meal.
Reducing alcohol consumption.
Quitting smoking.
Avoiding fatty foods and typical foods that trigger symptoms (such as coffee, chocolate, alcohol, mint or orange juice).
Avoiding medications that trigger your reflux symptoms. You should discuss with your doctor whether any of your medications may be contributing to your symptoms.

Although some of these lifestyle changes can be difficult to achieve they are excellent therapies as they are low cost and have minimal side effects. These measures are recommended in virtually all patients and should be continued even when more potent therapies are started.

Over-The-Counter and Antacid Therapy

Depending on the severity of your symptoms your doctor may prescribe medications or recommend over-the-counter (OTC) preparations. These may be needed for a short-period of time while you have symptoms or on a long-term basis depending on the features of your symptoms.

Many patients self-treat themselves with over-the-counter medications. These include simple antacids (such as Mylanta) or alginates (such as Gaviscon). Antacids work by neutralising the gastric acid so that it is no longer damaging to the oesophagus. Alginates on the other hand work by forming a thick gel coating on the surface of the stomach contents to stop them from refluxing. Lots of studies have confirmed these agents produce rapid relief of symptoms but their effects only last for a short time so they need to be taken frequently. Furthermore, these treatments do not change the underlying amount of acid secretion or prevent complications so may be a more temporary measure in the treatment of symptoms.

Histamine-2 receptor antagonists (H2RA) such as cimetidine (Tagamet) and ranitidine (Zantac) are also available over-the-counter. These agents have been proven in clinical trials to reduce gastric acid levels. The different drugs of this class vary slightly in their potencies and onset of action. H2RA can be taken prior to activities that are known to trigger reflux such as heavy meals or exercise, in order to prevent the onset of symptoms.

Antisecretory Medications

Suppressing the amount of acid produced in the stomach has been shown to be the most successful treatment for GORD. Proton pump inhibitors (PPIs) work by inhibiting a special enzyme on the surface of acid producing cells in the stomach. This leads to a block in acid production and reduces the overall level of acid in the stomach. PPIs are considered the most effective medications for symptomatic relief and should be used in nearly all cases except perhaps if your disease is very mild. These PPI medications are only available via a prescription from your doctor.

Examples of PPI drugs available in Australia include:

Rabeprazole (Pariet)
Pantoprazole (Somac)
Omeprazole (Losec)
Esomeprazole (Nexium)
Lansoprazole (Zoton)

Clinical trials have confirmed that these medications are all successful in treating symptoms such as heartburn, acid regurgitation and painful swallowing. They are effective in approximately 80% of patients. PPIs are able treat symptoms and heal oesophageal damage more rapidly than any other therapy available. There is still debate over which of the above agents is the most effective so different doctors may prescribe different medications based on their experience.

If you have severe reflux you will probably be treated long-term with a PPI medication. Often the maintenance dose is smaller than that prescribed in an acute period of symptoms. If you are on long-term treatment and suddenly stop taking your medication, it is likely you will experience a recurrence or relapse in your symptoms. In addition, even with adequate therapy it is not uncommon to have some occasional flares of symptoms. You should take your PPI medication prior to meals as prescribed by your doctor. Usually the daily dose will be split into a morning and evening dose.

PPI medications are generally well tolerated and tend to have few side effects. However, the following adverse effects may occasionally occur (in approximately 5 out of 100 patients taking these medications):

Most side effects are only mild and temporary during the start of treatment. A more serious side effect of vitamin B12 deficiency has been reported but this is exceedingly rare. Overall the PPIs are excellent medications in terms of efficacy and minimal side effects. Perhaps the only factor limiting more widespread use is cost as some of the agents can be quite expensive. Learn more about PPIs here.

Prokinetic Medications

Some drugs such as metoclopramide and domperidone may be used as add-on therapies to help control symptoms. These agents work by enhancing the contractions of the stomach and increasing its rate of emptying. This essentially reduces the contents of the stomach so that less is available to reflux back into the oesophagus, thus reducing damage. These agents can have side effects such as neurological side effects from metoclopramide or gynaecomastia from domperidone.

Surgery

Surgery is usually only used in cases of very severe reflux symptoms, particularly in younger patients who would otherwise need long-term drug therapy to manage symptoms. Approximately 80% of patients undergoing surgery will demonstrate improvement in symptoms. However, controversy exists over the long-term effectiveness of this mode of treatment and indications for surgery are less clear cut than for other types of treatment.

Endoscopic Therapy

Occasionally reflux symptoms may be treated endoscopically by inserting a tube down the throat and either sewing, burning or injecting damaged areas of the mucosa (lining). Recent trials have confirmed these therapies are superior to no treatment in improving quality of life and heartburn. Unfortunately the long-term efficacy of these treatments is unknown so their role is limited to a very select number of patients. In addition, endoscopic treatment can cause significant complications such as pain, gastrointestinal injury and short-term dysphagia.

Managing GORD in Children

Reflux is a very common condition in children but the symptoms are often non-specific. To date there is no ideal method of diagnosing or treating the problem in infants and children. However, you may gain some comfort from knowing that the symptoms of reflux are extremely common and that the condition is not due to any fault on your part. Often simple reassurance from a medical practitioner is helpful in improving both your and your child's quality of life.

As demonstrated above, there are many different treatments available for symptoms of reflux. Unfortunately there is limited experience with these therapies in children. Therefore when considering treatment for your child it is very important that you consider the potential side effects of the medications. You should remember that mild reflux is generally not a serious condition and that your child is otherwise well and healthy.

In most cases, symptoms of reflux will resolve spontaneously by approximately 12 months of age. Your doctor can help explain the condition more so that you understand that it is usually better for your child NOT to have extensive investigations or multiple drug therapies. This will avoid unnecessary side effects from unnecessary treatments.

Some management options for reflux symptoms in children are:

Reassurance and education- Learning more about your child's condition can frequently allay some of your fears about the seriousness of the condition. Please go to our Supportive Care section for doctor accredited support and public awareness groups on reflux.
Posturing- There is some evidence that certain positions whilst feeding increase the incidence of reflux. Laying your child prone (on their stomach) with their head slightly elevated during feeding is associated with the least amount of reflux. It can be helpful to keep your child upright for approximately half an hour after feeds. However caution should be taken positioning your child on their stomach as there is an increased risk of SIDS.
Dietary treatment- Milk thickeners and thickened feeds have shown to reduce regurgitation but there is limited evidence that they reduce reflux. Infants with mild acid reflux may respond well to simple thickening of their feeds.
Alginates- There is limited experience with antacids in infants but clinical experience suggests there may be some benefits in improving symptoms of mild GORD. However, side effects on bone metabolism (including rickets), diarrhoea and constipation can occur from these medications.
Proton-pump inhibitors- These are the recommended treatments for severe reflux in children. Once again these treatments can cause side effects which should be discussed with your doctor. The pros and cons of treatment should be weighed up on an individual basis.

Children with very severe reflux symptoms and persistent vomiting can develop more serious complications such as failure to thrive and malnutrition. In these cases more drastic measures may be required such as feeding through a nasogastric tube (a tube passed through the nose and down into the stomach, through which nutrient-rich pureed foods can be fed) or very rarely surgery.

Reference

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Goyal R. 'Diseases of the Esophagus' in Braunwald, Fauci, Kasper, Hauser, Longo, Jameson. Harrison's Principles of Internal Medicine. 15th Edition. McGraw-Hill. 2001.
Ip S, Bonis P, Tatsioni A, et al. Comparative effectiveness of management strategies for gastroesophageal reflux disease. Evidence Report/Technology Assessment No. 1. (Prepared by Tufts-New England Medical Center Evidence-Based Practice Center under Contract No. 290-02-0022.) Rockville, Md: Agency for Healthcare Research and Quality. December 2005. Available online at URL: http://effectivehealthcare.ahrq.gov/repFiles/GERD Final Report.pdf
Kumar P, Clark M. Clinical Medicine. WB Saunders, Company, 2002.
MIMS online- Prescribing Information, MIMS Australia Pty Ltd 2003.
Tutuian R. Castell DO. Management of gastroesophageal reflux disease, American Journal of the Medical Sciences, 2003; 326(5): 309-18.
Vandenplas Y. Gastroesophageal reflux: medical treatment, Journal of Pediatric Gastroenterology & Nutrition 2005; 41 S41-2.

Drugs used in the treatment of Managing the Symptoms of GORD:

Somac Tablets (20mg or 40mg on Prescription)
(Pantoprazole)
Somac Injection
(Pantoprazole)
Acimax Tablets
(Omeprazole magnesium)
Gaviscon
(Alginic acid; Aluminium hydroxide; Calcium carbonate; Magnesium trisilicate; Sodium alginate; Sodium bicarbonate)
GenRx Cimetidine
(Cimetidine)
Maxor
(Omeprazole)
Nexium
(Esomeprazole magnesium trihydrate)
Pepcid
(Famotidine)
Tazac
(Nizatidine)
Zantac
(Ranitidine hydrochloride)
Pariet
(Rabeprazole sodium)