Gastroesophageal reflux: causes, symptoms, tests for diagnosis and treatment

What is gastroesophageal reflux disease? Gastroesophageal reflux disease is a disorder characterised by acid or bile content from the stomach rising into the oesophagus, causing a range of symptoms including burning in the back and regurgitation

The passage of material from the stomach into the oesophagus occurs physiologically throughout the day, especially after meals, and in most cases is not associated with symptoms.

However, when reflux episodes occur frequently and for a long period of time, it becomes a real disease.

This disorder affects about 10-20% of the adult population in Europe and is associated with an impaired quality of life.

What are the symptoms of gastroesophageal reflux disease?

The ‘typical’ symptoms of gastroesophageal reflux disease are retrosternal heartburn, a burning sensation behind the sternum (behind the chest) that can radiate posteriorly between the shoulder blades, to the neck and up to the ears, and acid regurgitation, the perception of bitter or acidic liquid that in some cases can reach the mouth.

Other symptoms, termed ‘atypical’, include:

  • Chest pain
  • Frequent belching
  • Sore throat
  • Hoarseness and lowered voice
  • Dry cough
  • Hiccups
  • Difficulty swallowing
  • Nausea
  • Asthma-like episodes
  • Otitis media

Symptoms may occur only at certain times of the day (usually after meals or at night), and in certain positions (supine or while bending forward) or they may occur continuously.

Gastro-oesophageal reflux can vary in severity, it can be mild and occasional or severe and persistent and can also lead to complications such as ulcers and erosions of the oesophageal wall, defined as erosive oesophagitis (30-35% of cases) or narrowing of the oesophagus defined as stenosis (3-5%).

Causes of gastroesophageal reflux disease

Between the oesophagus and stomach there is a structure called the lower oesophageal sphincter, which regulates the passage of material between the two organs.

The tone of this junction varies throughout the day and physiologically reduces temporarily following swallowing to allow food to pass from the oesophagus into the stomach.

The basis of gastroesophageal reflux disease may be a condition of reduced sphincter tightness, which allows acid or alkaline material to rise pathologically from the stomach into the oesophagus.

In turn, reduced sphincter tightness can be caused by a variety of factors – anatomical, dietary, hormonal, pharmacological and functional.

Obesity, overweight and pregnancy, for example, increase intra-abdominal pressure, which can alter the tone of the oesophageal-gastric junction, thus encouraging reflux episodes.

Foods such as chocolate, mint and alcohol have the ability to act on the lower oesophageal sphincter by reducing its tone.

Other causes can be the consumption of fatty foods or alcohol, which reduce the rate of gastric emptying and can lead to gastro-oesophageal reflux.

Diagnosing gastro-oesophageal reflux: what tests to do

A gastroenterological examination should be carried out as soon as the first symptoms appear.

The presence of “typical” symptoms (heartburn and acid regurgitation) already enables the specialist to diagnose gastro-oesophageal reflux disease and to start a period of therapy with proton pump inhibitors.

If no results are obtained after a period of therapy, or if there are warning symptoms such as weight loss, difficulty swallowing or anaemia, the gastroenterologist will recommend further diagnostic tests.

Useful tests to diagnose this disorder include:

  • Esophagogastrododenoscopy (EGDS): an examination that uses a flexible probe with a diameter of a few millimetres and equipped with a video camera, inserted through the mouth, to assess the walls of the oesophagus, stomach and duodenum and, if necessary, to take small tissue samples (biopsy).
  • X-ray of the digestive tract with contrast medium: this examination is carried out by having the patient drink a small amount of contrast medium and allows the anatomy and function of the first digestive tract (oesophagus, stomach and first part of the small intestine) to be visualised.
  • Esophageal manometry: an examination used to assess any abnormalities in the motility of the esophagus and lower esophageal sphincter, carried out using a probe introduced transnasally and the simultaneous administration of small sips of water.
  • 24-hour pH-impedance testing: this test uses a thin transnasal probe placed in the stomach to monitor the amount of material refluxed from the stomach over a 24-hour period.

Treatment of gastro-oesophageal reflux disease

Correct treatment of gastro-oesophageal reflux is based initially on an appropriate lifestyle modification and, if the symptoms persist, on the use of specific drugs such as proton pump inhibitors and antacids.

The role of lifestyle

Lifestyle modifications are usually suggested initially:

  • stop smoking;
  • achieving and/or maintaining a healthy weight (especially reducing abdominal circumference);
  • avoid going to bed immediately after meals, but wait at least 3 hours;
  • pay particular attention to the foods you eat, avoiding or at least limiting certain foods that could worsen the symptoms, acidity and reflux such as chocolate, coffee, alcohol, tomatoes, citrus fruits, fizzy drinks, mint, kiwi, vinegar, stock cubes, spicy foods, spices (with the exception of turmeric and ginger, which, however, can reduce reflux symptoms by promoting the motility of the oesophagus), fatty and/or fried foods (e.g. gravies, mature cheeses, cured cheeses, etc.), spices and condiments: gravies, mature cheeses, fried food, etc.). It is better to prefer light meals, steamed, baked or grilled.

Drug therapy

If lifestyle changes are not enough to relieve symptoms, the doctor may prescribe specific drugs.

These include

  • antacids: these act quickly by neutralising the acid present in the stomach and reducing the symptoms of gastroesophageal reflux. Overuse can lead to constipation or diarrhoea;
  • drugs that block the production of acid in the stomach: this class of drugs includes proton pump inhibitors (such as omeprazole, lansoprazole, rabeprazole, pantoprazole and esomeprazole), which are the most commonly used drugs in reflux therapy. They begin to take effect about 48 hours after starting to take them, and are effective both in relieving symptoms and in curing complications such as erosive oesophagitis;
  • prokinetic drugs: these obstruct reflux by promoting correct motility and emptying of the stomach and oesophagus, particularly after meals. In this class of drugs we find domperidone, metoclopramide and levosulpiride. In rare cases, unwanted effects may occur with the use of these drugs, including tremors, neurological disorders, QT prolongation on the electrocardiogram, and an increase in prolactin levels.
    Only rarely, in the absence of a response to medication and in the presence of anatomical changes, may surgery (laparoscopy) be considered.

How to prevent gastro-oesophageal reflux disease

The prevention of reflux (or its reappearance) is based on a correct lifestyle, as already indicated as a first-line treatment.

In addition to the good eating habits already described, it is good to

  • correct any postural defects, such as scoliosis and kyphosis, as they contribute to worsening reflux;
    exercise regularly;
  • learn and practise relaxation and breathing techniques;
  • not chewing gum, as this promotes the ingestion of air;
  • manage and reduce stress as it promotes contraction of the stomach lining.

Acid reflux and the COVID-19 pandemic

The typical symptoms of gastroesophageal reflux have intensified during the COVID-19 pandemic.

Let’s not forget, in fact, that the lockdown negatively affected the daily habits of millions of people, for example by cancelling sports routines and/or worsening eating habits.

That’s not all: the pandemic has subjected many people to intense stress. Stress is a factor that can affect reflux in two ways: on the one hand, it increases the release of hydrochloric acid and, on the other, it reduces the intragastric barriers (mucus and prostaglandins) naturally produced against the acid insult.

Consequently there is an increased risk of reflux and possible complications.

In addition to this indirect action, the Sars-Cov-2 virus also has a direct relationship with reflux: in sporadic cases (1%), it stimulates the release of excess hydrochloric acid in the stomach, which then, once back in the oesophagus, leads to the onset of the classic symptoms.

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