Gastro-oesophageal reflux disease (GERD) is a discomforting condition encountered by many. Besides treating the symptoms, it is important to know the extent of injury due to acid reflux and exclude a premalignant condition known as Barrett’s oesophagus at the distal gullet. Treatment ranges from using simple antacids to surgery, depending on the extent and severity of the condition. Oesophageal cancer surveillance is also recommended for patients with Barrett’s oesophagus.

What is GERD?

Gastro-oesophageal reflux disease (GERD) is a highly prevalent gastrointestinal (GI) disorder and is one of the most common GI conditions encountered in our clinical practice. GERD refers to a combination of signs and symptoms resulting from the reflux of stomach and duodenal contents into the gullet, also known as the oesophagus. These symptoms may be severe in nature and may occur frequently enough to negatively impact a patient’s quality of life. Patients with GERD frequently experience interrupted sleep at night. Their performance at work and social life may also be affected.

Symptoms

• Heartburn and regurgitation, where a hot, burning sensation in the chest or throat is usually experienced and corresponds mainly to the amount of gastric content being propelled upwards from the stomach into the oesophagus, which induces local inflammation.

• Sour taste and throat discomfort.

• Although a majority of patients experience all of the above symptoms, others may have unusual presentations including angina-like chest pains or airway-related problems such as asthma.

Besides these disturbing symptoms, one major concern is the presence of oesophageal erosions caused by gastric acid. The other worry is the development of a pre-malignant condition at the distal oesophagus, known as Barrett’s oesophagus, associated with the acid reflux in patients suffering from GERD.

The main reason for gastric contents returning to the oesophagus may be related to either an incompetent valve at the distal oesophagus, known as the lower oesophageal sphincter or an abnormal relaxation of this valve. The resultant two-way movement of food content, coupled with any increase in the intra-abdominal pressure due to various conditions, may result in a significant amount of gastric acid gushing back into the oesophagus. Depending on the frequency and extent of this regurgitation, oesophageal injuries of varying degrees may occur.

Diagnosis
To diagnose GERD, the most practical way is a thorough and accurate review of the patient’s history. Typical symptoms of heartburn or regurgitation will provide the basis for diagnosis in most cases. In the absence of these symptoms, a short course of acid suppression treatment with proton pump inhibitors (PPIs) may be employed as a strategy to aid in the diagnosis.

In more difficult cases, more elaborate investigations including a 24-hour pH and impedance study may be required to confirm acidic or weakly-acidic reflux. Besides arriving at the diagnosis, one frequent challenge faced in the management of GERD is to estimate the extent of oesophageal injury. This information is crucial in deciding the long-term management plan.

Unfortunately, the magnitude and duration of symptoms do not necessarily correlate well with the actual physical injury in the oesophagus. Patients with more severe symptoms may have minimal or no oesophageal injury, while others with mild or minimal symptoms may suffer from severe oesophageal erosions.
The other challenge is to have an effective way to filter out cases that exhibit a higher risk of developing lower oesophageal cancer due to Barrett’s oesophagus.

Upper Gatrointestinal Tract Endoscopy (Gastroscopy)

Through a simple and quick procedure like upper gastrointestinal tract endoscopy (gastroscopy or OGD), physicians can directly inspect the oesophagus and stomach to determine the extent of injury due to acid reflux. Gastroscopy involves inserting a flexible video endoscope through a patient’s mouth and oesophagus into the stomach under direct vision. This procedure can be completed within 10-15 minutes with minimal risk or discomfort. Light sedation may be given before the procedure, although it may not be necessary.

With the gastroscope being flexible and steerable, the physician is able to inspect the oesophagus, stomach and the first two segments of the duodenum in a single setting. Tissue samples can also be taken via the working channel of the scope for histological analysis when necessary. This allows the extent of injury and the presence of Barrett’s oesophagus to be confirmed to guide the subsequent management and surveillance strategy.

Treatment

The goals in the treatment of GERD are to relieve recurring symptoms and prevent any serious complications.

Simple measures including lifestyle modifications such as raising the head of the bed when sleeping and over-the-counter medication like antacids may help. In established cases, on-demand PPI treatment driven by patients’ symptoms may be one of the common strategies employed by healthcare professionals. In more advanced cases, long-term medicine or even surgery may be required to alleviate symptoms and prevent further complications.

It is not uncommon for patients with GERD to undergo repeated upper endoscopy at regular intervals, to look for any malignant tissue transformation from Barrett’s oesophagus.

This is usually performed at intervals of two to three years, depending on the clinical and preceding histological findings. In the event of early malignant transformation, endoscopic therapy or surgery may be required as part of the definitive treatment.

By Dr Quan Wei Leong
Consultant in the Department of Gatroenterology and Hepatology and the Director of the Endoscopy Centre at Tan Tock Seng Hospital.