Heartburn and gastro-oesophageal reflux disease – how to support patients

GORD is a common condition with debilitating symptoms that should not be underestimated

GORD is a common condition with debilitating symptoms – find out how you can help patients to manage their gut health

  • GORD and its effects on individuals – improve your knowledge and nursing practice
  • How to advise patients on lifestyle changes and self-management strategies to reduce heartburn symptoms
  • Understand complications of GORD, also known as GERD, and the role of pharmacological therapies

Gastro-oesophageal reflux disease (GORD) can cause distressing symptoms and adversely affect a person’s quality of life.

Although it is extremely common – 1 in 4 UK adults have heartburn, one of the main symptoms, according to charity Guts UK – its impact is often

GORD is a common condition with debilitating symptoms – find out how you can help patients to manage their gut health

  • GORD and its effects on individuals – improve your knowledge and nursing practice
  • How to advise patients on lifestyle changes and self-management strategies to reduce heartburn symptoms
  • Understand complications of GORD, also known as GERD, and the role of pharmacological therapies
Picture: iStock

Gastro-oesophageal reflux disease (GORD) can cause distressing symptoms and adversely affect a person’s quality of life.

Although it is extremely common – 1 in 4 UK adults have heartburn, one of the main symptoms, according to charity Guts UK – its impact is often trivialised and patients are expected to put up with symptoms, say specialist nurses.

But they say all nurses need to be aware of the condition so they can advise and support people to manage it.

Here, we look at the causes, signs and symptoms of GORD, and steps you can take to help your patients.

What is gastro-oesophageal reflux disease?

GORD is usually a chronic condition where there is reflux of gastric contents, particularly acid, bile and the stomach enzyme pepsin, into the oesophagus, causing symptoms including heartburn and acid regurgitation.

This can result in bloating, belching, nausea, vomiting, hoarseness and a persistent cough or wheezing, which may be worse at night.

‘Reflux is incredibly common and something every nurse should be aware of’

Leigh Donnelly, upper gastrointestinal nurse specialist

GORD occurs when there is a weakening of the lower oesophageal sphincter. Normally, this protective muscular valve relaxes to allow food to pass into the stomach, closing afterwards and allowing only a small amount of stomach acid to flow back up.

Any acid that does flow into the oesophagus is quickly cleared back into the stomach by normal muscular action of the oesophagus.

Left, a healthy lower oesophageal sphincter; right, the reflux that occurs when the sphincter does not close the stomach off from the oesophagus Picture: iStock

However, GORD may occur when:

  • There is a weakness of the lower oesophageal sphincter so that it does not close effectively.
  • This sphincter relaxes and opens too frequently.
  • The oesophagus fails to clear refluxed acid back into the stomach.
  • The stomach is slow to empty after a meal.

Risk factors for developing GORD

According to NHS Inform, Scotland’s national health information service, several factors increase someone’s risk of developing GORD.

These include:

Obesity is a risk factor for GORD Picture: iStock
  • Being overweight or obese, which places increased pressure on the stomach and can weaken the lower oesophageal sphincter.
  • Eating citrus fruits and tomatoes, which are highly acidic.
  • Smoking, which can affect the pressure near the lower oesophageal sphincter and delay clearance of stomach acid.
  • Alcohol, which may worsen symptoms and cause damage to the inner lining of the oesophagus.
  • Caffeine, which can relax the lower oesophageal sphincter.
  • Pregnancy, which can also cause the muscles in lower oesophageal sphincter to relax more frequently.
  • Hiatus hernia, which can weaken the lower oesophageal sphincter and cause it to open.
  • Gastroparesis (delayed gastric emptying).
  • Medications, including calcium-channel blockers used to treat high blood pressure, nitrates used to treat angina and non-steroidal anti-inflammatory drugs.
  • Stress, which can provoke and worsen symptoms such as heartburn.

Diagnosis in primary care and why specialist referral may be required

GORD is usually diagnosed in primary care by a GP, who will make the diagnosis based on the patient’s description of their symptoms, without the need for further tests.

However a patient may be referred to a specialist for tests if:

  • Symptoms are persistent, severe or unusual.
  • Prescription medications are not working.
  • There are signs potentially signalling a more severe condition, specifically difficulty swallowing or unexplained weight loss.

These tests may include an endoscopy, a barium swallow prior to X-ray, a manometry, where is tube is passed through the nose into the oesophagus to check function, 24-hour acidity level monitoring or blood tests, particularly if the patient is anaemic.

Spectrum of symptoms and how they affect quality of life

The impact of GORD on patients varies, says Guts UK information manager Julie Thompson.

‘It can be hard to live with and people can have distressing symptoms, long-term, that shouldn’t be underestimated,’ she says.

‘There will be gradations of severity: some will have more functional symptoms that perhaps prevent them from working. But healthcare professionals can make a difference, improving someone’s quality of life. Nurses are vital to providing that information and advice.’

Patients should be aware caffeine can compromise the action of the lower oesophageal sphincter Picture: iStock

Reflux symptoms can be trivialised, says Leigh Donnelly, an upper gastrointestinal nurse specialist at Northumbria Healthcare NHS Foundation Trust and a member of the Nurses’ Association Committee of the British Society of Gastroenterology.

‘But those with severe GORD can have terribly debilitating and unpleasant symptoms that affect all aspects of their quality of life. Some can’t bend down to fasten their shoe laces without having acid,’ she says.

Lack of knowledge of a common condition

Ms Donnelly says all nurses need to be mindful of GORD, regardless of their area of practice.

‘Reflux is incredibly common and something every nurse should be aware of,’ she says.

‘But I don’t think many know enough about it. Unless they’re working in the specialty, I don’t think most have any deeper knowledge.’

Nurses will encounter patients with GORD in almost any setting, she says.

‘You may see it on the wards, in the community or even in A&E, with quite dramatic symptoms,’ says Ms Donnelly. ‘Patients may also have had acid reflux for a long time and be used to managing it with over-the-counter medications. A lot of people think it’s just something they have to put up with.’

How to improve your practice – and questions to ask patients

Picture: iStock
  • Look to improve your own knowledge of GORD, by reading resources such as guidance from the National Institute for Health and Care Excellence, or looking out for online courses (see guidance and resources box, bottom)
  • When discussing symptoms with a patient, it is important to clarify potentially ambiguous terms they may use to describe their symptoms, advises upper gastrointestinal nurse specialist Leigh Donnelly. ‘Heartburn, reflux, indigestion and dyspepsia mean different things to different people,’ she says
  • Key questions to ask include: are your symptoms worse after food or when you lie down?
  • Remember gastrointestinal symptoms can be so vague they can point to anything from a normal investigation to a cancer, says Ms Donnelly. ‘That’s the difficulty, making diagnosis hard. If symptoms are prolonged, the patient must be investigated, especially if they are experiencing problems swallowing,’ she says
  • Direct patients to evidence-based, trustworthy sources of information. ‘A lot of what is out there online can be quite scary for patients,’ says Ms Donnelly. ‘Dr Google can be problematic. Steer people towards the right information, such as that provided by the NHS’

Supporting patients to manage their symptoms

Ms Donnelly says nurses can play a pivotal role in offering information to patients about GORD, including how self-management can help lessen unpleasant symptoms.

‘Patients with GORD become expert at dealing with their condition,’ she says. ‘They know what their triggers are and will avoid them.’

Patients with GORD who drink alcohol should be advised to reduce their intake Picture: iStock

Changes to lifestyle factors

Lifestyle changes can make a big difference, helping to alleviate symptoms. Actions recommended by both Guts UK and NHS Inform include:

  • Stopping smoking.
  • Cutting down on alcohol, and avoiding it altogether for 3-4 hours before going to bed.
  • Eating smaller, more frequent meals and avoiding eating later at night or having the largest meal of the day in the evening. Maintaining a good posture when eating can also help, says Ms Donnelly: ‘TV dinners should be avoided. Advise patients to eat sitting upright at a table, rather than lounging on the sofa.’
  • Avoid wearing tight clothing, which can constrict the stomach, and bending forwards after eating or drinking, as this can exacerbate symptoms of reflux.
  • Steering clear of trigger foods, such as coffee, chocolate, tomatoes and anything spicy or fatty.
  • Maintaining a healthy weight – if someone is overweight, losing the excess may reduce symptoms.
  • Trying to relax. ‘Stress can make heartburn and GORD worse, so learning relaxation techniques may help if you’re often feeling stressed,’ says NHS Inform.
  • NHS Inform recommends raising the head of the bed by around 10-20cm, by placing a piece of wood or blocks underneath the end, to reduce reflux while lying down at night.

Over-the-counter and prescription medications

Over-the-counter antacids to neutralise stomach acid, or alginates, which form a protective foaming barrier on top of the stomach contents, are usually the first option.

But patients who aren’t responding to lifestyle changes or over-the-counter medications will usually be prescribed a proton-pump inhibitor (PPI).

Tomatoes are among the trigger foods for GORD Picture: iStock

PPIs reduce the amount of acid produced by the stomach, and some people may need to take them in the long-term.

When is surgery appropriate?

If medication does not work, their side effects are troublesome or there is reluctance to take them in the long-term, surgery may be an option.

The most common procedure is a laparoscopic Nissen fundoplication (LNF). This tightens the ring of muscle at the bottom of the oesophagus, which helps to stop acid leaking up from the stomach. It is carried out under general anaesthetic and most patients stay in hospital for two or three days and are usually able to return to work within three to six weeks.

‘It’s a fantastic alternative for some patients, but isn’t without its consequences,’ says Ms Donnelly.

‘There are side effects, such as patients not being able to have fizzy drinks life-long or eat certain things. But once someone is treated, either with medication or surgery, they will get their quality of life back and can live an almost normal life.’

Complications of GORD

Many patients may be concerned about the risk of further complications with GORD, says Guts UK’s Ms Thompson.

‘Although we’re a charity that covers all the digestive issues, reflux is an area that people very much want to come and talk to us about,’ says Ms Thompson.

Peptic strictures – the narrowing or tightening of the oesophagus, causing swallowing difficulties – are a complication of GORD.

‘It’s a consequence of the repeated cycle of healing and scarring,’ explains Ms Donnelly.

‘What you eventually get is a fibrous ring of tissue, caused by acid exposure over the years. Patients will find that they can’t eat solid foods.’

This is treated by a procedure called a gastroscopy and an oesophageal dilatation, where a balloon is passed into the narrowed area and inflated to help improve dyshphagia.

Other complications include oesophagitis, in which ulcers can form, then bleed, causing pain that can result in dysphagia.

‘Here the gullet has been significantly burned by acid, becoming very inflamed and ulcerated,’ explains Ms Donnelly.

‘It’s very sore. Often someone will have difficulty swallowing or they find drinking anything hot or cold causes a lot of discomfort.’

Barrett’s oesophagus and the risk of developing cancer

Another key concern for GORD patients is Barratt’s oesophagus, says upper gastrointestinal nurse specialist Leigh Donnelly.

This is a condition that slightly elevates risk of developing oesophageal cancer.

Symptoms of GORD, such as heartburn, that persist for longer than three weeks should always be investigated, she adds.

According to Macmillan Cancer Support, around 5% of people with GORD will develop Barrett’s oesophagus – cell changes on the inner lining of the lower end of the oesophagus.

These squamous cells change to columnar or column-shaped, and over time, the cell changes may lead to dysplasia, which may be low or high grade.

In turn, for a small number of people, dysplasia may develop into oesophageal cancer.

According to Cancer Research UK, between three and 13 people out of 100 with Barrett’s oesophagus in the UK will go on to develop oesophageal cancer in their lifetime.

Barrett’s oesophagus tends to be more common in men, those who smoke and those aged over 50.

‘We’re really not sure why some people get it and others don’t,’ says Ms Donnelly.

Diagnosis of Barrett’s oesophagus is usually made via endoscopy.

Treatments vary depending on severity, but include surveillance, proton-pump inhibitor (PPI) or a surgical procedure called fundoplication, to strengthen the valve at the lower end of the oesophagus and reduce acid.

The affected abnormal cells can be removed through an endoscope – called endoscopic mucosal resection (EMR) –or destroyed using radio frequency ablation, light therapy (photodynamic therapy) or cryotherapy.

‘Patients will need lifelong PPI and regular endoscopies,’ Ms Donnelly adds.

Red-flag signs and symptoms

Red flags in patients with GORD include difficulty in swallowing, unexplained weight loss and associated upper abdominal discomfort.

Delayed presentation is a particular factor of oesophageal cancer, which is the 14th most common cancer in the UK, says Cancer Research UK (CRUK), with around seven in ten people being diagnosed at a late stage.

‘Most patients struggle with symptoms for a long time,’ says Ms Donnelly.

‘By the time they present, their tumour is quite advanced. As a nurse, it’s important to always have this in the back of your mind, so you drill down into the detail of what the patient is telling you, so you know exactly what’s going on.’

GORD guidance and resources for nurses

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