Self-care

There are a number of self-care techniques that may help to relieve the symptoms of gastro-oesophageal reflux disease (GORD). They are described below.

• If you are overweight, losing weight may help to reduce the severity and frequency of your symptoms because it will reduce the pressure on your stomach.
• If you are a smoker, you should consider quitting. Tobacco smoke can irritate your digestive system and may make the symptoms of GORD worse.
• Eat smaller, more frequent meals rather than three large meals a day. Make sure that you have your evening meal three to four hours before you go to bed.
• Be aware of triggers that make your GORD worse. For example, alcohol, coffee, chocolate, tomatoes, or fatty or spicy food. After you identify any food that triggers your symptoms, remove them from your diet to see whether your symptoms improve.
• Raise the head of your bed by placing a piece of wood or blocks under it. This may help to reduce your symptoms of GORD. However, make sure that your bed is sturdy and safe before adding the wood or block. Do not use extra pillows because this may increase the pressure on your abdomen.

If you are currently taking medication for other health conditions, check with your GP to find out whether they may be contributing to your symptoms of GORD. Alternative medicines may be available. Do not stop taking a medication that has been prescribed without consulting your GP first.

Medication

A number of different medications can be used to treat GORD. These include:

• over-the-counter (OTC) medications
• proton-pump inhibitors (PPIs)
• H2-receptor antagonists
• prokinetics

These are described below.

Over-the-counter (OTC) medications

A number of over-the-counter (OTC) medicines can help to relieve the symptoms of mild to moderate GORD.

Antacids are medicines that neutralise the effects of stomach acid. However, antacids should not be taken at the same time as other medicines because they can stop other medicines from being properly absorbed into your body. They may also damage the special coating on some types of tablets. Ask your GP or pharmacist for advice.

Alginates are an alternative type of medicine to antacids. They work by producing a protective coating that shields the lining of your stomach and oesophagus from the effects of stomach acid.

Proton-pump inhibitors (PPIs)

If GORD fails to respond to the self-care techniques described above, your GP may prescribe a one month course of proton-pump inhibitors (PPIs) for you. PPIs work by reducing the amount of acid that is produced by your stomach.

Possible side effects of PPIs include:

• headaches
• diarrhoea
• nausea
• abdominal pain
• constipation
• dizziness
• skin rashes

The side effects of PPIs are usually mild and should stop once you have finished taking them. In order to minimise any side effects, your GP will prescribe the lowest possible dose of PPIs that they think will be effective in controlling your symptoms. Therefore, inform your GP if they prescribe PPIs for you that prove to be ineffective. A stronger dose may be needed.

Sometimes, the symptoms of GORD can return after a course of PPIs has been completed. Go back to see your GP if you have further or persistent symptoms. 

H2-receptor antagonists

If PPIs cannot control your symptoms of GORD, another medicine known as a H2-receptor antagonist (H2RA) may be recommended to take in combination with PPIs on a short-term basis (two weeks), or as an alternative to them.

H2RAs block the effects of the chemical histamine, which is used by your body to produce stomach acid. H2RAs therefore help to reduce the amount of acid in your stomach.

Side effects of H2RAs are uncommon. However, possible side effects may include:

• diarrhoea
• headaches
• dizziness
• tiredness
• a rash

Some types of H2RAs are available as over-the-counter (OTC) medicines. These types of HR2As are taken in a lower dosage than the ones available on prescription. Ask your GP or pharmacist if you are not sure whether these medicines are suitable for you.

Prokinetics

If your GORD symptoms are particularly severe and they are not responding to other forms of treatment, your GP may prescribe a short-term dose of a prokinetic.

Prokinetics speed up the emptying of your stomach, which means that there is less opportunity for acid to irritate your oesophagus. However, the long-term use of prokinetics is not recommended. It is likely that you will only be advised to take them if your symptoms are particularly severe.

Around 1% of people who take prokinetics have what is known as ‘extrapyramidal symptoms’. Extrapyramidal symptoms are a series of related side effects that affect your nervous system.
Extrapyramidal symptoms include:

• muscle spasms
• problems opening your mouth fully
• a tendency to stick your tongue out of your mouth
• slurred speech
• abnormal changes in body posture

If you have the above symptoms while taking prokinetics, stop taking them and contact your GP or out-of-hours doctor immediately. They may recommend that your dose is discontinued.
Extrapyramidal symptoms should stop within 24 hours of the medicine being withdrawn.

Prokinetics are not usually recommended for people under 20 years old because of an increased risk of extrapyramidal symptoms. The use of prokinetics is also not recommended for pregnant or breastfeeding women.

Surgery

Surgery is usually only recommended in cases of GORD that fail to respond to the treatments listed above.

Alternatively, you may wish to consider having surgery if you have persistent and troublesome symptoms but you do not want to take medication on a long-term basis.

While surgery for GORD can help to relieve your symptoms, there are some associated complications that may result in you developing additional symptoms, such as:

• difficulty swallowing (dysphagia)
• flatulence (the excessive passing of wind)
• bloating
• an inability to belch (burp)

Discuss the advantages and disadvantages of surgery with your GP before making a decision about treatment.

Surgical procedures that are used to treat GORD include:

• laparoscopic nissen fundoplication (LNF)
• endoscopic injection of bulking agents
• endoluminal gastroplication
• endoscopic augmentation with hydrogel implants
• endoscopic radiofrequency ablation

These procedures are discussed below.

Laparoscopic nissen fundoplication (LNF)

Laparoscopic nissen fundoplication (LNF) is one of the most common surgical techniques that is used to treat GORD.

LNF is a type of keyhole surgery that involves the surgeon making a series of small incisions (cuts) in your abdomen (tummy). Carbon dioxide gas is then used to inflate your abdomen in order to give the surgeon room to work in.

During LNF, the surgeon will wrap the upper section of your stomach around your oesophagus and staple it in place. This will contract (tighten) your lower oesophageal sphincter (LOS), which should prevent any acid moving back out of your stomach.

LNF is carried out under general anaesthetic, which means that you will not feel any pain or discomfort. The surgery takes 60 to 90 minutes to complete.

After having LNF, most people can leave hospital once they have recovered from the effects of the general anaesthetic. This is usually within two to three days. Depending on the type of job that you do, you should be able to return to work within three to six weeks.

For the first six weeks after surgery, it is recommended that you only eat soft food, such as mince, mashed potatoes or soup. Avoid eating hard food that could get stuck at the site of the surgery, such as toast, chicken or steak.

Common side effects of LNF include:

• difficulty swallowing (dysphagia)
• belching (burping)
• bloating
• flatulence (the excessive passing of wind)

These side effects should resolve over the course of a few months. However, in about 1 in 100 cases they can be persistent. In such circumstances, further corrective surgery may be required.

New surgical techniques

In the last decade, a number of new surgical techniques have been introduced for the treatment of GORD.

The National Institute for Health and Clinical Excellence (NICE) has looked at a number of these surgical techniques. It has recommended that they are safe enough to be made available on the NHS.

However, NICE has also recommended that people who are considering having these new techniques should be made aware that there is little evidence regarding their effectiveness in the medium- to long-term.

All of the techniques discussed below are non-invasive, which means that no incisions (cuts) need to be made into your body. Therefore, they can usually be performed under local anaesthetic on a day surgery basis, so you should not have to spend the night in hospital.

Endoscopic injection of bulking agents

Endoscopic injection of bulking agents involves the surgeon using an endoscope to find the site where the stomach and oesophagus meet (known as the gastro-oesophageal junction).

A thin tube called a catheter is then passed down the endoscope, and is used to inject a combination of plastic and liquid into the junction. This narrows the junction and helps to prevent acid leaking up from the stomach.

The most common side effect of this type of surgery is mild to moderate chest pain. This develops in around a half of all cases.

Other side effects include:

• difficulty swallowing (dysphagia)
• nausea
• high temperature (fever) of 38ºC (100.4ºF) or above

These side effects should resolve within a few weeks.

Endoluminal gastroplication

Endoluminal gastroplication involves the surgeon using an endoscope to sow a series of pleats (folds) into the LOS. The pleats should restrict how far the LOS can open, preventing acid from leaking up from your stomach.

Side effects of this type of surgery include:

• chest pain
• abdominal (tummy) pain
• vomiting
• sore throat

These side effects should improve within a few days.

Endoscopic augmentation with hydrogel implants

Endoscopic augmentation with hydrogel implants is a similar technique to an endoscopic injection, except the surgeon uses hydrogel to narrow your gastro-oesophageal junction. Hydrogel is a type of flexible plastic gel that is very similar to living tissue.

The most common complication arising from this procedure is that the hydrogel starts to come out of the gastro-oesophageal junction. One study found that this happened in 1 in 5 cases. However, this is a relatively new technique and success rates may well improve in the future.

Endoscopic radiofrequency ablation

In endoscopic radiofrequency ablation, the surgeon passes a balloon down an endoscope to the site of your gastro-oesophageal junction. The balloon is then inflated.

Tiny electrodes are attached to the outside of the balloon and generate small pulses of heat. This creates small scars in the tissue of your oesophagus, causing it to narrow and making it more difficult for stomach acid to leak out of your stomach.

Out of all the new surgical techniques mentioned, there is very little known about the safety of endoscopic radiofrequency ablation. Possible complications and side effects may include:

• chest pain
• dysphagia
• injury to the oesophagus