Heartburn and gastro-oesophageal reflux disease - Treatment 

Treating gastro-oesophageal reflux disease 

Weight loss tips

Losing weight can help improve the symptoms of GORD. In this video people talk about how they have successfully lost weight and an NHS dietitian offers useful tips.

Media last reviewed: 14/11/2013

Next review due: 14/11/2015

Treating GORD in babies and infants

In many cases, babies and infants with mild symptoms of GORD do not require treatment as they often grow out of the condition in a few months.

If symptoms are more troublesome then you should see your GP.

Possible treatment options include:

  • adding feed thickeners such as alginate (sold under the brand name Gaviscon Infant) to breast milk or formula
  • if you are breastfeeding, then removing cow milk from your diet can often lead to an improvement in symptoms (but only if your baby is allergic to cow milk – if there is no improvement then there is little point in continuing to avoid milk); soya milk can be used as an alternative

If none of these treatments lead to an improvement in symptoms, your GP may refer you to a doctor who specialises in the treatment of children (paediatrician). They may recommend using medication such as proton-pump inhibitors (PPIs) or H2-receptor antagonists.

A number of self-care techniques may help relieve symptoms of gastro-oesophageal reflux disease (GORD). They are described below.

  • If you are overweight, losing weight may help reduce the severity and frequency of your symptoms because it will reduce pressure on your stomach.
  • If you are a smoker, consider quitting. Tobacco smoke can irritate your digestive system and may make symptoms of GORD worse.
  • Eat smaller, more frequent meals, rather than three large meals a day. Make sure you have your evening meal three to four hours before you go to bed.
  • Be aware of triggers that make your GORD worse. For example, alcohol, coffee, chocolate, tomatoes, or fatty or spicy food. After you identify any food that triggers your symptoms, remove them from your diet to see whether your symptoms improve.
  • Raise the head of your bed by around 20cm (8 inches) by placing a piece of wood, or blocks under it. This may help reduce your symptoms of GORD. However, make sure your bed is sturdy and safe before adding the wood or blocks. Do not use extra pillows because this may increase pressure on your abdomen.

If you are currently taking medication for other health conditions, check with your GP to find whether they may be contributing to your symptoms of GORD. Alternative medicines may be available. Do not stop taking a prescribed medication without consulting your GP first.

Medication

A number of different medications can be used to treat GORD. These include:

  • over-the-counter medications
  • proton-pump inhibitors (PPIs)
  • H2-receptor antagonists
  • prokinetics

Depending on how your symptoms respond, you may only need medication for a short while or alternatively on a long-term basis.

These are described below.

Over-the-counter medications

A number of over-the-counter medicines can help relieve mild to moderate symptoms of GORD.

Antacids are medicines that neutralise the effects of stomach acid. However, antacids should not be taken at the same time as other medicines because they can stop other medicines from being properly absorbed into your body. They may also damage the special coating on some types of tablets. Ask your GP or pharmacist for advice.

Alginates are an alternative type of medicine to antacids. They work by producing a protective coating that shields the lining of your stomach and oesophagus from the effects of stomach acid.

Proton-pump inhibitors (PPIs)

If GORD fails to respond to the self-care techniques described above, your GP may prescribe a one month course of proton-pump inhibitors (PPIs) for you. PPIs work by reducing the amount of acid produced by your stomach.

Most people tolerate PPI well and side effects are uncommon.

When they do occur they are usually mild and may include

In order to minimise any side effects, your GP will prescribe the lowest possible dose of PPIs that they think will be effective in controlling your symptoms. Therefore, inform your GP if they prescribe PPIs for you that prove ineffective. A stronger dose may be needed.

Sometimes, the symptoms of GORD can return after a course of PPIs has been completed. Go back to see your GP if you have further or persistent symptoms. 

In some cases you may need to take PPIs on a long-term basis.

H2-receptor antagonists

If PPIs cannot control your symptoms of GORD, another medicine known as an H2-receptor antagonist (H2RA) may be recommended to take in combination with PPIs on a short-term basis (two weeks), or as an alternative to them.

H2RAs block the effects of the chemical histamine, used by your body to produce stomach acid. H2RAs therefore help reduce the amount of acid in your stomach.

Side effects of H2RAs are uncommon. However, possible side effects may include:

  • diarrhoea
  • headaches
  • dizziness
  • tiredness 
  • a rash

Some types of H2RAs are available as over-the-counter medicines. These types of HR2As are taken in a lower dosage than the ones available on prescription. Ask your GP or pharmacist if you are not sure whether these medicines are suitable for you.

Prokinetics

If your GORD symptoms are not responding to other forms of treatment, your GP may prescribe a short-term dose of a prokinetic.

Prokinetics speed up the emptying of your stomach, which means there is less opportunity for acid to irritate your oesophagus.

A small number of people who take prokinetics have what is known as ‘extrapyramidal symptoms’. Extrapyramidal symptoms are a series of related side effects that affect your nervous system. Extrapyramidal symptoms include:

  • muscle spasms
  • problems opening your mouth fully
  • a tendency to stick your tongue out of your mouth
  • slurred speech
  • abnormal changes in body posture

If you have the above symptoms while taking prokinetics, stop taking them and contact your GP or out-of-hours doctor immediately. They may recommend your dose is discontinued.

Extrapyramidal symptoms should stop within 24 hours of the medicine being withdrawn.

Prokinetics are not usually recommended for people under 20 years old because of an increased risk of extrapyramidal symptoms.

Surgery

Surgery is usually only recommended in cases of GORD that fail to respond to the treatments listed above.

Alternatively, you may wish to consider surgery if you have persistent and troublesome symptoms but do not want to take medication on a long-term basis.

While surgery for GORD can help relieve your symptoms, there are some associated complications that may result in you developing additional symptoms, such as:

  • dysphagia (difficulty swallowing)
  • flatulence 
  • bloating
  • an inability to belch (burp)

Discuss the advantages and disadvantages of surgery with your GP before making a decision about treatment.

Surgical procedures that are used to treat GORD include:

  • laparoscopic nissen fundoplication (LNF)
  • endoscopic injection of bulking agents
  • endoluminal gastroplication
  • endoscopic augmentation with hydrogel implants
  • endoscopic radiofrequency ablation

These procedures are discussed below.

Laparoscopic nissen fundoplication (LNF)

Laparoscopic nissen fundoplication (LNF) is one of the most common surgical techniques used to treat GORD.

LNF is a type of keyhole surgery that involves the surgeon making a series of small incisions (cuts) in your abdomen (tummy). Carbon dioxide gas is then used to inflate your abdomen to give the surgeon room to work in.

During LNF, the surgeon will wrap the upper section of your stomach around your oesophagus and staple it in place. This will contract (tighten) your lower oesophageal sphincter (LOS), which should prevent any acid moving back out of your stomach.

LNF is carried out under general anaesthetic, which means you will not feel any pain or discomfort. The surgery takes 60 to 90 minutes to complete.

After having LNF, most people can leave hospital once they have recovered from the effects of the general anaesthetic. This is usually within two to three days. Depending on the type of job you do, you should be able to return to work within three to six weeks.

For the first six weeks after surgery, it is recommended you only eat soft food, such as mince, mashed potatoes or soup. Avoid eating hard food that could get stuck at the site of the surgery, such as toast, chicken or steak.

Common side effects of LNF include:

  • dysphagia (difficulty swallowing)
  • belching
  • bloating
  • flatulence 

These side effects should resolve over the course of a few months. However, in about 1 in 100 cases they can be persistent. In such circumstances, further corrective surgery may be required.

New surgical techniques

In the last decade, a number of new surgical techniques have been introduced for the treatment of GORD.

The National Institute for Health and Clinical Excellence (NICE) has looked at a number of these surgical techniques. It has recommended they are safe enough to be made available on the NHS.

However, NICE has also recommended that people considering having these new techniques be aware there is little evidence regarding their effectiveness in the medium to long-term.

All techniques discussed below are non-invasive, which means no incisions need be made into your body. Therefore, they can usually be performed under local anaesthetic on a day surgery basis, so you should not have to spend the night in hospital.

Endoscopic injection of bulking agents

Endoscopic injection of bulking agents involves the surgeon using an endoscope to find the site where stomach and oesophagus meet (known as the gastro-oesophageal junction).

A thin tube called a catheter is then passed down the endoscope, and used to inject a combination of plastic and liquid into the junction. This narrows the junction and helps to prevent acid leaking up from the stomach.

The most common side effect of this type of surgery is mild to moderate chest pain. This develops in around a half of all cases.

Other side effects include:

  • dysphagia
  • feeling sick
  • high temperature of 38ºC (100.4ºF) or above

These side effects should resolve within a few weeks.

Endoluminal gastroplication

Endoluminal gastroplication involves the surgeon using an endoscope to sew a series of pleats (folds) into the LOS. The pleats should restrict how far the LOS can open, preventing acid leaking up from your stomach.

Side effects of this type of surgery include:

These side effects should improve within a few days.

Endoscopic augmentation with hydrogel implants

Endoscopic augmentation with hydrogel implants is a similar technique to an endoscopic injection, except the surgeon uses hydrogel to narrow your gastro-oesophageal junction. Hydrogel is a type of flexible plastic gel very similar to living tissue.

The most common complication arising from this procedure is that the hydrogel starts to come out of the gastro-oesophageal junction. One study found this happened in one in five cases. However, this is a relatively new technique and success rates may well improve in future.

Endoscopic radiofrequency ablation

In endoscopic radiofrequency ablation, the surgeon passes a balloon down an endoscope to the site of your gastro-oesophageal junction. The balloon is then inflated.

Tiny electrodes are attached to the outside of the balloon and small pulses of heat generated. This creates small scars in the tissue of your oesophagus, causing it to narrow and making it more difficult for stomach acid to leak out of your stomach.

Out of all the new surgical techniques mentioned, there is little known about the safety of endoscopic radiofrequency ablation. Possible complications and side effects may include:

  • chest pain
  • dysphagia
  • injury to the oesophagus

LINX Reflux Management System

A new type of surgery introduced in 2011, not yet considered by NICE, is the LINX Reflux Management System.

This type of keyhole surgery uses magnetic beads to reinforce the LOS muscle.

The magnetic force of the beads helps keep the LOS closed when at rest, preventing stomach acid leaking upwards. The LOS opens normally when swallowing.

This type of surgery appears effective and safe in the short-term but as it is a new technique, its long-term effectiveness and safety are unclear.

The availability of this type of surgery on the NHS is currently limited, although a number of private clinics have started offering it. The price for private treatment is in the region of £8,000 to £9,000.




Page last reviewed: 07/06/2012

Next review due: 07/06/2014

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Comments

The 4 comments posted are personal views. Any information they give has not been checked and may not be accurate.

EricaH said on 18 July 2013

I've been stuck on PPIs, peptac liquid and ranitidine for two years and given no further advice or help. They have done absolutely nothing to relieve the symptoms and each time I mention this to my GP he says there is nothing more he can do! I cough cough cough all day long and am sick of it I really am. I am now considering going down the herbal route because I'm at the end of my tether.

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David L said on 08 November 2012

The new device is called LINX, not LINK.
Its there is little good quality evidence on its effectiveness and harms, but it looks promising. Its use in the UK should be within a national research framework, with a clinical audit register.
Also see NICE guidance 431
http://publications.nice.org.uk/laparoscopic-insertion-of-a-magnetic-bead-band-for-gastro-oesophageal-reflux-disease-ipg431

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Phil bus driver said on 31 July 2012

I was diagnosed with a reflux last October and since then I have been sick quite a few times and one time it was a load of blood came up and I have had an endoscopy procedure done and I take 40mg Omerprozole per day is this common?

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weesie3 said on 30 April 2012

How long do doctors usually prescribe PPIs? I have been on 40mg of omeprazole every day for the last seven years.

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