Dr Anan S. Raghunath.
General Practitioner, Hospital Endoscopist, Honorary Senior Clinical Lecturer, Hull York Medical School and St Andrews Group Practice, Marmaduke Health Centre, Hull
The nurse’s role in managing gastro-oesophageal reflux disease (GORD) is vital because early identification and regular monitoring can prevent disease progression to Barrett’s oesophagus.
Recent research has highlighted variation in the way reflux disease is managed by health-care professionals (REFORM, 2002) - in itself an indicator of the need for clear guidance on this subject. Consequently, REFORM (The Reflux Forum) has produced Reflux Disease: Simple Practice Solutions, a set of best-practice guidelines for the management of reflux disease in primary and secondary care. REFORM is a professional group whose membership includes GPs, pharmaceutical advisers, prescribing advisers and endoscopists, using their extensive clinical experience and supported by published research. There are plans to recruit a nurse to the group this year. REFORM is sponsored by an unrestricted educational grant from pharmaceutical company AstraZeneca.
While GORD is an extremely common disease, affecting a quarter of the UK population (Jones, 1995), there is still considerable confusion about its aetiology, epidemiology and best practice management. For example, a recent survey on behalf of REFORM found 53% of 202 GPs thought that obesity and eating spicy foods caused GORD (REFORM, 2002), despite extensive research suggesting these factors only aggravate the condition rather than cause it (Dent et al, 1999).
It is to address such misconceptions and to provide health-care practitioners with practical help that the REFORM guidelines were produced. They focus on quality of care as a key determinant of treatment choice. REFORM stresses that a critical aim of effective GORD management is to prevent its progression to more serious conditions such as Barrett’s oesophagus, a pre-cancerous condition in which the squamous lining of the oesophagus is irreversibly altered.
Patients with Barrett’s oesophagus have a 40-fold increased risk of developing oesophageal adenocarcinoma (Fennerty, 1997).
Breaking this cycle is complicated by the fact that symptoms of GORD do not necessarily correlate to the severity of the condition (Green, 1993). Thus both patients and health-care professionals are prone to dismissing occasional and mild symptoms that could be masking something more sinister. Consequently, the disease is often left to progress untreated and any damage caused left unhealed, increasing the likelihood of disease progression.
Nurses have a key role to play in the care of patients with GORD, both in identifying the disease - patients are more likely to discuss what they perceive to be less severe conditions with nurses and be open about which over-the-counter medications they are taking - and managing it. Careful monitoring and long-term review of patients is vital to ensure symptoms are controlled effectively.
Reflux occurs when a weakening of the sphincter at the bottom of the oesophagus allows stomach acid to flow up into the oesophagus. This acid, which has a pH of 1-2.5, burns and scars the oesophageal lining, which is equipped only to deal with a pH greater than 5, causing heartburn and acid reflux into the mouth (Fennerty, 1997).
With repeated acid reflux, the mucosal layer of the oesophagus becomes inflamed. This is known as oesophagitis, and in 15% of patients with chronic GORD, this will progress into metaplastic columnar mucosal changes, known as Barrett’s oesophagus (Fennerty, 1997).
Barrett’s oesophagus is irreversible (Fennerty, 1997). The risks of developing oesophageal adenocarcinoma increase in proportion to the frequency, severity and duration of GORD symptoms (Lagergren et al, 1999). For every year a patient lives with Barrett’s oesophagus, their chance of developing cancer increases by about 1% (Jarvis and Barr, 2003).
Questions to ask patients
The following questions will help in the assessment of both the severity of the patient’s GORD and the impact of symptoms on their quality of life in order to recommend the most appropriate treatment:
- How many times a week do you experience heartburn?
Frequency of symptom occurrence can be broken down as follows: less than twice a week, two to five times a week or more than five times a week. This will help assess the severity of the conditio
- How long have you been experiencing symptoms of heartburn?
In my experience patients may wait years before presenting to their GP with symptoms that are later identified as GORD. Therefore it is vital to find out how long they have been experiencing discomfort
- How troublesome are your symptoms?
It is important to assess whether symptoms affect the patient’s sleep, work or even social engagements, because quality of life is a key determinant of symptom severity (Moayyedi and Mason, 2002).
- Have you treated yourself with anything?
- What do you take to relieve your symptoms?
Details of any over-the-counter medication the patient uses, including the frequency with which they self-medicate, the types of medication they have tried and the efficacy of these products in relieving symptoms, can help to direct appropriate prescribing.
In addition to symptoms, it is important to obtain information on any family history of gastrointestinal disorders, history of smoking and concurrent medications, such as NSAIDs, aspirin, biphosphates, calcium channel blockers or statins, all of which can cause upper gastrointestinal symptoms (BMA and RPSGB, 2002).
Differential diagnosis between GORD and dyspepsia can also be difficult as they share similar symptoms. People with GORD complain of the following three symptoms to a greater extent than those with other dyspeptic complaints:
- Acid in the mouth
- Heartburn more than twice a week may suggest GORD, in which case patients should be referred to a GP to begin immediate treatment. If no heartburn is reported, conditions other than GORD should be suspected
- Symptoms do not necessarily correlate with disease severity, so patients with very mild symptoms can be found to have severe disease upon endoscopic investigation
- Heartburn is unreliably interpreted by patients so REFORM suggests using the definition: ‘a burning feeling rising from the stomach or lower chest up towards the neck’ (Dent, 1999).
For a copy of the REFORM guidelines, tel: 020-73315468. Next month, we look at the nurse’s role and treatment options in more depth
- One in four people in the UK will suffer from GORD at some point in their life (Jones, 1995). Putting this into context, each GP carries out about 210 consultations for dyspeptic symptoms every year (British Society of Gastroenterology, 2002)
- GORD is associated with a 10-15% increased risk of developing Barrett’s oesophagus (Fennerty, 1997) which in turn is linked to a 40% increased risk of developing oesophageal adenocarcinoma (Fennerty, 1997)
- Oesophageal adenocarcinoma has been the fastest growing cancer in England and Wales in the past 30 years (Fennerty, 1997). Between 1996 and 2000 oesophageal adenocarcinoma caused 29 743 deaths in the UK compared with 27 794 10 years previously (Office of National Statistics, 2001).
- Men and women are equally likely to suffer from this condition (Revicki, 1998).
Exclude patients with alarm symptoms such as dysphagia, gastrointestinal bleeding, new onset in those over 55 years, and unintentional weight loss or vomiting - these patients should all be sent for urgent endoscopy (Department of Health, 2000; British Society of Gastroenterology, 2002).
- Heartburn occurring more than twice a week
- Acid in the mouth
- Difficulty sleeping/lying down or normal physical activity as more acid flows up into the oesophagus.
Clinical evidence also suggests a clear definition of GORD comes from evaluating a patient against the following symptoms:
- The main symptom is a burning sensation starting at lower retrosternum moving to upper retrosternum
- Heartburn symptoms are relieved by a proton pump inhibitor (PPI)
- Heartburn symptoms are made worse by bending down.
British Medical Association, Royal Pharmaceutical Society of Great Britain. (2002)British National Formulary: 44. London: British Medical Association/ Royal Pharmaceutical Society of Great Britain.
British Society of Gastroenterology. (2002)Dyspepsia Management Guidelines. London: British Society of Gastroenterology.
Dent, J., Brun, J., Fendrick, A.M. et al. (1999)An evidence-based appraisal of reflux disease management - the Genval workshop report. Gut 44: (suppl 2), 1-16.
Department of Health. (2000)Referral Guidelines for Suspected Cancers. London: The Stationery Office.
Fennerty, B. (1997)Barrett’s esophagus: what do we really know about this disease? American Journal of Gastroenterology 92: 1-3.
Garner, S. (2002)Reflux or dyspepsia? Chemist and Druggist 257: 6335, 21.
Green, J.R.B. (1993)Is there such an entity as mild oesophagitis? European Journal of Clinical Research 4: 29-34.
Jarvis, S., Barr, H. (2003)Barrett’s oesophagus. Update 66: 5, 270-271.
Jones, R. (1995)Gastro-oesophageal reflux disease in general practice. Scandinavian Journal of Gastroenterology 211: (suppl), 35-38.
Lagergren, J., Bergstrom, R., Lindgren, A. et al. (1999)Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma. New England Journal of Medicine 340: 11, 825-831.
Moayyedi, P., Mason, J. (2002)Clinical and economic consequences of dyspepsia in the community. Gut 50: (suppl iv), iv10-iv12.
Office of National Statistics. (2001)Mortality Statistics. Review of the registrar general on deaths by cause, sex and age, in England and Wales, 2000. London: The Stationery Office.
REFORM. (2002)GP Survey. Surrey: Taylor Nelson Sofres Healthcare.
Revicki, D.A., Wood, M., Maton, P.N. et al. (1998)The impact of gastroesophageal reflux disease on health-related quality of life. American Journal of Medicine 104: 3, 252-258.