Overview

Gastro-oesophageal reflux is a very common condition where the contents of your stomach, including stomach acid, digestive juices (like bile), and enzymes (like pepsin), flow back up into your oesophagus (the tube that carries food from your mouth to your stomach). This backward flow is often called "reflux." When this happens regularly and causes bothersome symptoms or damage, it's known as Gastro-oesophageal Reflux Disease, or GORD.

GORD is considered a chronic, or long-term, condition. It can lead to inflammation of the oesophagus, called oesophagitis. While many people think of reflux as just heartburn, it can also cause a range of other symptoms, some of which affect the throat, voice box, and even the breathing passages. When reflux specifically reaches the pharynx (the back of your throat) or larynx (your voice box), it's known as Laryngopharyngeal Reflux, or LPR. This can cause different symptoms that you might not immediately connect with your stomach.

Living with reflux can be challenging, but understanding the condition and how to manage it can significantly improve your quality of life. This leaflet aims to provide you with detailed information to help you understand gastro-oesophageal reflux better.

Symptoms and Causes

Understanding why reflux happens and what symptoms it can cause is the first step towards managing it effectively. Reflux occurs when the natural barrier between your stomach and oesophagus isn't working as it should, allowing stomach contents to travel upwards.

Symptoms

The symptoms of gastro-oesophageal reflux can vary greatly from person to person. They can be broadly divided into typical symptoms that affect the chest and stomach area, and atypical symptoms that often affect the throat, voice, and breathing.

• Heartburn: This is a burning sensation, usually felt in the chest, behind your breastbone. It can sometimes spread up towards your throat.
• Acid Reflux / Regurgitation: This is when stomach acid or food comes back up into your throat or mouth, leaving an unpleasant, sour, or bitter taste.
• Oesophagitis: This means the lining of your oesophagus has become inflamed due to repeated exposure to stomach acid. It can cause discomfort and pain.
• Difficulty or Pain When Swallowing (Dysphagia or Odynophagia): You might feel like food is getting stuck, or experience pain when trying to swallow.
• Bad Breath: The presence of stomach contents in the oesophagus can contribute to persistent bad breath.
• Bloating and Belching: Feeling full and uncomfortable in your stomach, often accompanied by frequent burping.
• Nausea and Vomiting: Feeling sick to your stomach, and in some cases, actually being sick.
• Hoarseness or Voice Changes (Dysphonia): If reflux reaches your voice box, it can irritate the vocal cords, leading to a rough or strained voice.
• Persistent Cough: A chronic cough, especially one that doesn't seem to have another cause, can be a symptom of reflux irritating the airways.
• Throat Clearing: A frequent need to clear your throat, often feeling like there's something stuck there.
• Globus Sensation: This is the feeling of a lump or something stuck in your throat, even when there isn't anything physically there.
• Sore Throat: A persistent or recurring sore throat, particularly if it's worse in the mornings.
• Asthma: Reflux can sometimes trigger or worsen asthma symptoms.
• Dental Erosions: The acid coming up from the stomach can wear away the enamel on your teeth over time.

Causes

Gastro-oesophageal reflux happens because a ring of muscle at the bottom of your oesophagus, called the lower oesophageal sphincter, becomes weakened or relaxes too often. This muscle acts like a valve, opening to let food into your stomach and then closing tightly to prevent stomach contents from coming back up. When it doesn't close properly, reflux occurs.

Several factors can contribute to this muscle weakening or can trigger reflux symptoms:

• Weight: Being overweight or obese puts extra pressure on your stomach, which can push stomach contents upwards.
• Dietary Triggers: Certain foods and drinks can relax the oesophageal muscle or increase stomach acid production. Common culprits include coffee, chocolate, tomatoes, alcohol, fatty foods, spicy foods, caffeine, and onions. Hot drinks can also be a trigger for some people.
• Eating Habits: Eating large meals, eating too quickly, or lying down too soon after eating can all make reflux more likely.
• Smoking: Nicotine in cigarettes can relax the lower oesophageal sphincter and also reduce saliva production, which helps neutralise acid.
• Alcohol: Drinking alcohol can relax the oesophageal muscle and irritate the oesophagus.
• Tight Clothing: Clothes that are tight around your waist can put pressure on your stomach, encouraging reflux.
• Stress: While stress doesn't directly cause reflux, it can worsen symptoms in many people.
• Certain Medications: Some drugs can affect the muscle's ability to close properly or can directly irritate the oesophagus. These include non-steroidal anti-inflammatory drugs (NSAIDs like ibuprofen), anticholinergics, selective serotonin reuptake inhibitors (SSRIs), and calcium-channel blockers. If you are taking any of these and experience reflux, discuss it with your doctor.

Diagnosis and Investigations

If you are experiencing symptoms of gastro-oesophageal reflux, especially if they are frequent, severe, or not improving with over-the-counter remedies, it's important to consult your GP. They will be able to assess your symptoms and decide on the best course of action.

Diagnosis

Your GP will start by asking you detailed questions about your symptoms, including when they started, how often they occur, what makes them better or worse, and if you've tried any treatments already. This is called taking a medical history. They will also ask about your lifestyle, diet, and any medications you are currently taking.

For many people with typical GORD symptoms (like heartburn and acid regurgitation) and no worrying "alarm symptoms," your doctor might suggest an initial trial of medication called a proton pump inhibitor (PPI). This is often given once a day before a meal for a period of 4 to 8 weeks to see if your symptoms improve. This approach helps to diagnose GORD without needing immediate invasive tests.

However, it's crucial to be aware of certain "alarm symptoms" that require urgent attention and further investigation. You should contact your GP immediately if you experience:

• Difficulty swallowing (dysphagia)
• Persistent vomiting
• Vomiting blood (haematemesis)
• Unexplained weight loss
• New and persistent reflux symptoms if you are over 55 years old

If you have any of these alarm symptoms, your doctor will likely arrange for an urgent gastrointestinal endoscopy. In such cases, PPIs should not be prescribed before the endoscopy, as they could potentially mask a more serious underlying condition.

For Laryngopharyngeal Reflux (LPR), where throat and voice symptoms are the main concern, diagnosis can be more challenging. There isn't one single "gold standard" test. Your doctor might use a questionnaire like the Reflux Symptom Index to assess your symptoms. Often, treatment for LPR is started based on your symptoms, especially if typical GORD symptoms are also present.

Investigations

Depending on your symptoms and how you respond to initial treatments, your doctor might recommend further investigations:

• Endoscopy (Oesophagogastroduodenoscopy - OGD): This procedure involves a thin, flexible tube with a camera on the end being passed down your throat into your oesophagus, stomach, and the first part of your small intestine. It allows the doctor to visually inspect the lining of these organs for inflammation (oesophagitis), ulcers, or other abnormalities. It's also used to check for conditions like Barrett's oesophagus, which is a change in the lining of the oesophagus that can sometimes develop in people with long-term reflux.
• Flexible Nasopharyngolaryngoscopy: This is a procedure often performed by an ENT specialist. A very thin, flexible scope is passed through your nose to examine your pharynx (throat) and larynx (voice box). This helps the ENT specialist look for signs of irritation or damage caused by reflux, such as redness, swelling, or small growths (granulomas) on the vocal cords.
• Oesophageal Physiology Tests: These tests measure how well your oesophagus is working. They can include:
• • pH monitoring: This involves placing a small probe in your oesophagus for 24-48 hours to measure how much acid is refluxing and for how long.
  • Impedance monitoring: This test can detect both acid and non-acid reflux episodes.
• Helicobacter pylori (H. pylori) testing: This is a common bacterium that can live in the stomach and cause inflammation or ulcers. Your doctor might test for H. pylori, as treating it can sometimes improve dyspepsia (upper stomach discomfort) symptoms.

These investigations help your medical team get a clear picture of what's causing your symptoms and guide the most effective treatment plan for you.

Management and Treatment

Managing gastro-oesophageal reflux often involves a combination of lifestyle changes and medication. For some, surgery may be considered. The goal is to reduce symptoms, prevent complications, and improve your quality of life.

1. Lifestyle Modifications (First-line and Adjunctive Therapies): These are crucial and often the first steps recommended. Making these changes can significantly reduce your symptoms:

• Weight Reduction: If you are overweight or obese, losing weight can greatly reduce the pressure on your stomach and lessen reflux episodes.
• Elevate the Head of Your Bed: For nocturnal (night-time) symptoms, raising the head of your bed by 6-8 inches (about 15-20 cm) can help gravity keep stomach contents down. You can do this by placing blocks under the bedposts or using a wedge pillow. Simply using extra pillows under your head is usually not effective.
• Avoid Lying Down After Meals: Try to avoid lying down for at least 2-3 hours, or ideally 3-4 hours, after eating. This gives your stomach time to digest food before gravity can work against you.
• Eat Smaller, More Frequent Meals: Instead of three large meals, try having several smaller meals throughout the day. This prevents your stomach from becoming overly full.
• Identify and Avoid Trigger Foods: Pay attention to what foods and drinks seem to worsen your symptoms and try to avoid them. Common triggers include coffee, chocolate, tomatoes, alcohol, fatty foods, spicy foods, caffeine, and onions. Hot drinks can also be a trigger for some.
• Reduce Alcohol Consumption: Alcohol can relax the muscle at the bottom of your oesophagus and irritate its lining.
• Stop Smoking: Smoking significantly worsens reflux by relaxing the oesophageal muscle and reducing protective saliva.
• Avoid Tight Clothing: Clothes that are tight around your waist can put pressure on your stomach, pushing contents upwards.
• Manage Stress: While stress doesn't cause reflux, it can make symptoms feel worse. Finding ways to manage stress, such as relaxation techniques or mindfulness, can be helpful.
• Review Medications: Discuss with your doctor if any of your current medications (e.g., NSAIDs, anticholinergics, SSRIs, calcium-channel blockers) might be contributing to your reflux. Do not stop taking any prescribed medication without consulting your doctor first.

2. Medications: If lifestyle changes aren't enough, or for more severe symptoms, your doctor may recommend medication.

• Antacids and Alginates: For mild, occasional symptoms, over-the-counter antacids (like Co-magaldrox or Peptac) can provide quick relief by neutralising stomach acid. Alginates (like Gaviscon®) form a protective raft on top of stomach contents, which can be particularly effective for persistent throat symptoms associated with LPR. These are typically taken after meals and at bedtime.
• Proton Pump Inhibitors (PPIs): These are stronger medications that reduce the amount of acid your stomach produces. They are very effective for GORD symptoms. Your GP might prescribe a course of a PPI, such as omeprazole (e.g., 40mg once daily) or lansoprazole (e.g., 30mg once daily), usually for 4-8 weeks. PPIs are generally taken once daily before a meal. For long-term management, the aim is to find the lowest effective dose, and for some, taking them "on demand" for mild or intermittent symptoms might be possible.

3. Specialist Referral and Surgery:

• Specialist Advice: If your symptoms continue despite taking higher doses of PPIs, or if you have confirmed GORD that doesn't respond to PPIs, your GP may refer you to a specialist (such as a gastroenterologist or an ENT surgeon) for further assessment and management.
• Multidisciplinary Team (MDT): For complex cases, especially those involving LPR, a team approach involving an ENT specialist, your GP, a speech and language therapist, and a gastroenterologist can be very beneficial.
• Surgery: If medication is not effective, or if you prefer not to take long-term medication, surgery might be an option. Surgical procedures aim to strengthen the barrier between the oesophagus and stomach. Examples include laparoscopic fundoplication, LINX®, and RefluxStop™. These procedures are typically performed in specialist centres after thorough evaluation.

Prevention

Preventing gastro-oesophageal reflux largely involves adopting and maintaining the lifestyle changes discussed in the management section. By consistently following these recommendations, you can significantly reduce the likelihood of reflux occurring and minimise its symptoms.

• Maintain a Healthy Weight: Keeping your weight within a healthy range reduces pressure on your abdomen, which helps prevent stomach contents from pushing upwards.
• Eat Mindfully: Opt for smaller, more frequent meals rather than large, heavy ones. Eat slowly and chew your food thoroughly.
• Time Your Meals: Avoid eating or drinking alcohol within 3-4 hours of going to bed. This allows your stomach to empty before you lie down.
• Identify and Avoid Trigger Foods: Pay attention to foods and drinks that seem to worsen your reflux, such as coffee, chocolate, tomatoes, alcohol, fatty or spicy foods, caffeine, and onions. Once identified, try to limit or avoid them.
• Quit Smoking: Smoking is a major contributor to reflux. Stopping smoking can significantly improve your symptoms and overall health.
• Limit Alcohol Intake: Reducing how much alcohol you drink can help prevent the oesophageal muscle from relaxing and reduce irritation.
• Elevate Your Head During Sleep: If you experience night-time reflux, raising the head of your bed by 6-8 inches (15-20 cm) can use gravity to your advantage.
• Wear Loose-Fitting Clothing: Avoid tight belts or clothing that puts pressure on your stomach area.
• Manage Stress Levels: While not a direct cause, stress can exacerbate reflux symptoms. Incorporate stress-reducing activities into your daily routine.
• Review Medications with Your Doctor: Regularly discuss all your medications with your GP to ensure none are contributing to your reflux symptoms.

By making these preventative steps a regular part of your routine, you can take an active role in managing and reducing the impact of gastro-oesophageal reflux on your daily life.

Outlook / Prognosis

The outlook for people with gastro-oesophageal reflux is generally good, especially with appropriate management. Many individuals find significant relief from their symptoms through lifestyle changes, medications, or a combination of both. However, it's important to understand that GORD is often a chronic condition, meaning it can be long-lasting and may require ongoing management.

Without consistent treatment, there is a high chance of symptoms returning. For instance, about 50% of people with untreated GORD may experience symptoms again within a year, and up to 80% may have a recurrence over their lifetime. If you have severe inflammation of the oesophagus (oesophagitis), the risk of symptoms coming back is even higher without continuous treatment.

The good news is that with maintenance therapy, such as taking the lowest effective dose of PPIs, or by strictly adhering to lifestyle modifications, many people can effectively control their symptoms and prevent them from returning. For those who undergo surgical procedures, the aim is to provide a long-term solution to reflux, often reducing or eliminating the need for daily medication.

While reflux is common, if left untreated or poorly managed, it can lead to certain complications over time:

• Oesophagitis: Persistent inflammation of the oesophagus can cause discomfort and, in severe cases, lead to bleeding or ulcers.
• Upper Oesophageal Strictures: Long-term inflammation can cause scarring and narrowing of the oesophagus, making it difficult and painful to swallow food.
• Laryngeal Granulomas: If reflux reaches the voice box, it can cause small, benign (non-cancerous) growths on the vocal cords, leading to hoarseness or voice changes.
• Glottic/Subglottic Stenoses: In rare, severe cases, chronic irritation from reflux can lead to narrowing of the airway in the voice box area, which can affect breathing.
• Barrett's Oesophagus: This is a condition where the normal lining of the oesophagus changes to a type of lining similar to that found in the intestine. While Barrett's oesophagus itself is not cancerous, it is considered a pre-cancerous condition, meaning it carries a small increased risk of developing oesophageal cancer. Regular surveillance (checking with an endoscopy) may be recommended for individuals with Barrett's oesophagus to monitor for any changes.
• Oesophageal and Gastric Cancer: Although rare, long-standing, severe GORD is a risk factor for oesophageal cancer. The Oesophageal Patients Association (OPA) highlights the importance of managing GORD to improve quality of life and reduce potential risks.

Regular follow-ups with your GP or specialist are important to ensure your treatment plan remains effective and to monitor for any potential complications. By actively managing your condition, you can live a full and healthy life with gastro-oesophageal reflux.