Gastro-oesophageal reflux: causes and remedies

By Cristiano Antonino On Jan 12, 2023

Gastro-oesophageal reflux is a very common disorder, occasional or chronic, that occurs when stomach acid backs up into the oesophagus, typically causing burning behind the sternum and acid regurgitation

This situation occurs especially with excessively large and elaborate meals, in a supine position or by bending the upper body and may be accompanied by acidity and heaviness of the stomach.

Sometimes the symptoms of this disease can affect other systems and therefore be difficult to interpret.

In most cases, this is not a serious condition, but it is important that it be correctly diagnosed and treated to avoid more serious consequences.

What is gastro-oesophageal reflux disease

Gastroesophageal reflux disease (GERD) is the set of symptoms and complications caused by the rising of gastric contents into the oesophagus.

The passage between the oesophagus and the stomach is regulated by the presence of a complex anatomical and functional region called the oesophago-gastric junction, which acts as a valve.

In healthy subjects, this high-pressure area allows the transit of food to the stomach and limits the rise of acid/bile content.

During the day, particularly after meals, everyone experiences occasional episodes of ‘physiological’ reflux, which remain completely asymptomatic and without consequences.

When these events intensify in quantity or duration, however, the patient may experience pain, caused by the activation of nerve endings, and the oesophageal mucosa may suffer damage, which is more or less reversible.

In most cases, gastro-oesophageal reflux disease is paucisymptomatic

It can be kept under control by simple lifestyle and dietary measures and/or medical therapy.

In a small percentage of cases, however, a more extensive diagnostic investigation is required.

Typical symptoms are

Heartburn, i.e. a burning sensation felt in the region commonly identified as the ‘mouth of the stomach’ and behind the sternum, sometimes with posterior radiation and interscapular pain. This symptomatology is similar to that of a heart attack, so cardiological problems must always be ruled out in the first instance;
regurgitation, described as the perception of rising gastric contents in the mouth, resulting in a feeling of bitterness.

There is also a wide spectrum of ‘atypical’ symptoms that are often difficult to diagnose and treat, including:

dry cough;
halitosis;
asthma;
discomfort in the throat;
hoarseness;
laryngitis.

What causes gastro-oesophageal reflux

Our organism is equipped with various defence systems to counteract reflux, but when the delicate balance between protective and supportive factors is disrupted, this disease occurs.

The most frequent cause of gastro-oesophageal reflux disease is the loss of function of the oesophago-gastric barrier, which in turn is due to a structural defect, resulting in increased acid production, or alterations in oesophago-gastric motility.

Other favourable or aggravating factors are:

increased pressure in the abdomen mainly due to obesity, constipation, respiratory problems, work or sports activities;
pregnancy;
supine position;
hiatal hernia, which occurs in association with gastro-oesophageal reflux disease in about half of the cases. In this case, part of the stomach ‘slips’ from the abdomen into the chest, weakening the defensive action of the lower oesophageal sphincter valve and favouring the gastric contents to flow back up into the oesophagus.

Why it is important not to underestimate reflux

It is essential not to underestimate reflux and its complications, since the mucous membrane of the oesophagus, during exposure of acid/biliary material, activates a series of defensive mechanisms that lead the cells to undergo changes, a phenomenon called ‘metaplasia’ in medical jargon.

The most severe expression of this phenomenon is the so-called ‘Barrett’s oesophagus’, a lesion that predisposes to evolution into cancer of the oesophagus.

How gastro-oesophageal reflux disease is diagnosed

Symptoms alone are not sufficient to diagnose MRGE, but they are useful in raising suspicion.

Therefore, it is necessary to communicate them to the doctor in order to perform all the necessary investigations.

To define gastro-oesophageal reflux disease and its degree of severity, it is indicated to perform:

Rx oesophageal transit, an X-ray study to visualise the upper gastrointestinal tract using contrast medium by mouth;
oesophagogastroduodenoscopy, performed using a flexible endoscope to directly assess the morphology of the oesophago-gastric junction, evaluate the mucosa of the oesophagus and, if necessary, perform biopsies
pH-impedancometry, by means of which a thin probe is placed trans-nasally for 24 hours to calculate the number, type and extent of reflux;
high-resolution oesophageal manometry, by means of a thin trans-nasal probe equipped with special sensors, enables the motility of the oesophagus and lower oesophageal sphincter to be studied.

Remedies against reflux: the importance of diet and lifestyle

The first approach is to adopt some simple behavioural and dietary rules:

maintain a normal weight or lose weight in patients with BMI (body mass index) > 25;
wait 2-3 hours after a meal before going to bed and sleep with the head elevated;
avoid large, high-fat meals that promote gastric overdistension
avoid, or at least limit, the intake of spicy or spicy foods and drinks containing chocolate, caffeine or sugary, carbonated drinks and alcohol
avoid sports activities that increase intra-abdominal pressure (e.g. lifting weights);
maintain good intestinal regularity;
stop smoking.

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Treating reflux with medication

Medical therapy is necessary in patients who do not benefit from daily measures.

Of the different categories of medication, the most widespread and well-tolerated are the so-called ‘pump inhibitors (PPIs)’, which act on the production of acid by the stomach wall.

Other categories of drugs that can be used, also in combination, are ‘antacids’, which have the function of neutralising stomach acid, and ‘prokinetics’, which increase the mobility of the walls of the oesophagus and stomach, thereby promoting their emptying.

When it is necessary to consult a specialist

When the 2 previous therapeutic approaches have proved ineffective, a gastroenterological surgical examination is recommended.

Not every patient with MRGE is a candidate for surgery: surgery is generally proposed to young patients with a long life expectancy, in cases of intolerance or poor compliance with medical therapy, or in the presence of large hiatal hernias.

However, it is necessary to carefully assess each individual case and plan the appropriate approach on the individual patient, after he or she has performed all the indicated investigations.

What does surgery consist of?

Surgery for MRGE is called ‘fundoplicatio’ or antireflux surgery and aims to restore the malfunctioning antacid barrier.

It is a short-term surgical procedure, usually performed using a minimally invasive technique and usually requiring a few days’ hospital stay.

The technique variants for this operation are chosen according to the individual patient’s characteristics and the surgeon’s preferences.

The operation offers good results in terms of quality of life due to good control of typical reflux symptoms and prevention of complications such as severe oesophagitis, oesophageal ulcers and stenosis, bleeding and precancerous lesions.

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