Gastro-oesophageal reflux disease

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Case history

A 42-year-old woman has heartburn after meals and a sour taste in her mouth. For the past 4-6 months she has had symptoms several times per week. Symptoms are worse when she lies down or bends over. Antacids help somewhat. She has no dysphagia, vomiting, abdominal pain, exertional symptoms, melaena, or weight loss. Past medical history and family history are non-contributory. The patient drinks alcohol occasionally and does not smoke. On physical examination, height is 1.63 m, weight 77.1 kg, and blood pressure 140/88 mmHg. The remainder of the examination is unremarkable.

Other presentations

Patients may have only nocturnal symptoms. Traditional alarm symptoms are anaemia, dysphagia, haematemesis, melaena, persistent vomiting, and involuntary weight loss (>5% body weight), which raise the possibility of oesophagitis, peptic stricture, or cancer.[9]

Extra-oesophageal symptoms are hoarseness (acid laryngitis), persistent non-productive cough, pressure deep in the throat, and throat clearing. Extra-oesophageal manifestations include asthma, bronchitis, chest pain, oral disease, sinusitis, and recurrent pneumonia.[1][4][5][6] In patients with GORD-associated asthma, there may be a negative family history; adult onset; wheezing exacerbated by exercise, meals, or supine position; nocturnal wheezing or cough; or reflux symptoms preceding asthma symptoms.[10]

Pregnancy and GORD

GORD symptoms (heartburn and regurgitation) are frequently observed during pregnancy. Prevalence of 30% to 80% has been reported.[11][12] Symptoms are usually noted late in the first trimester or during the second trimester and tend to progress during the course of pregnancy.[11][12][13] Symptoms typically resolve after delivery but may continue in some women after giving birth.[12] The other common gastrointestinal symptoms in pregnant women are nausea and vomiting, which can exacerbate oesophageal injury and GORD symptoms. See Nausea and vomiting in pregnancy. Women with a history of GORD have higher chances of developing heartburn during pregnancy.[12] An early occurrence of GORD during pregnancy has been attributed to elevated levels of progesterone, which leads to the relaxation of smooth muscles, including the lower oesophageal sphincter. Elevated progesterone decreases lower oesophageal sphincter pressure, which results in gastro-oesophageal reflux. Elevated oestrogen does not have a direct effect on lower oesophageal sphincter pressure; however, an indirect contribution has been noted.[12][14] As serious complications are rarely encountered, upper endoscopy and other diagnostic tests are usually not required.[13]

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