CPT2: GI 2 (GORD)

Question 1

What is the oesophagus and what is it made of?

What does it do and how?

Where is the oesophagus located?

Where are the sphincters and what are there purposes?

Answer 1

Question 2

What keeps the lower Gastro-oesophagal sphincter closed?

Answer 2

• Diaphragm:
  
  • Passes through diaphragm though gap called hiatus. Small ring round narrows as food passes to help keep closed
• Angle of entry into stomach (angle of His)
• Muscle tone
  
  • Smooth muscle regulated by vagus nerve
• Intra abdominal pressure differential

Question 3

What is the GORD?

What is used to confirm this? what can this reveal?

Answer 3

Gastro-oesophageal reflux disease is the chronic reflux of gastric contents (hydrochloric acid and pepsin) from the stomach into the oesophagus, resulting in oesophageal irritation and the symptoms of heartburn.

True diagnosis can only be made with an endoscopy – oesophagitis or endoscopy negative GORD.

Not everyone who visits their GP gets an endoscopy however.

• Oesophagitis – when mucosal erosion and oesophageal inflammation are seen on endoscopy
• Endoscopy negative GORD – when a patient has symptoms but endoscopy is normal

Question 4

Typical and atypical symptoms of GORD

Answer 4

Typical symptoms:

• Heartburn/dyspepsia
• Epigastric/retrosternal (behind sternum) burning sensation
• Regurgitation (water brash/acid brash (acid taste back of throat/ mouth) /vomiting)
• Belching (passing wind)
• May be precipitated by bending over, eating too much (both before - increase abnominal pressure) or lying down (fluid closer to stomach)

Atypical symptoms:

• Cough
• Laryngitis (inflammation of voice box)
• Severe chest pain – think cardiac!

Question 5

Warning signs!!!

Answer 5

Be aware of alarm symptoms – weight loss, difficulty swallowing, blood in vomit, abdominal mass, age >55 years

Question 6

What are the complications of GORD?

Answer 6

• Oesophageal ulcers
  
  • if severe can lead to haemorrhage.
• Oesophageal stricture
  
  • Narrowing of the oesophagus lumon
  • Dysphragea, difficulty swallowing
  • Due to damage and repair leading to scar tissue
• Barrett’s oesophagus (pre malignant)
  
  • Increased risk of oesophageal carcinoma
  • The cells of the lower oesophagus change to become more like those of the stomach
• Oral problems such as dental erosions, gingivitis (gum inflammation), and halitosis (bad breath)
  
  • Due to acid in mouth
• Decreased quality of life

Question 7

What is the epidimeology?

Answer 7

• Prevalence up to 26% of population in Europe
• Prevalence increases with age
• More common in women
• 10–15% of people with GORD symptoms will develop Barrett’s oesophagus
• 1–10% of Barrett’s will develop oesophageal adenocarcinoma over the following 10–20 years
• 40% of those with dyspepsia who get an endoscopy will have GORD

Question 8

What are aetiologies of GORD?

Answer 8

• •Obesity/pregnancy – increased abdominal pressure
• Smoking
• Diet
  
  • Coffee, mints, dietary fat, onion, citrus fruit, tomatoes, alcohol
• Medication
• Calcium channel blockers, theophylline, nitrates, bisphosphonates, anticholinergics
• Structural
• Hiatus hernia (occurs in 30% of population over 50), pregnancy
• Up to 50% of pregnant women can experience GORD due to increased pressure but also hormonal changes in progesterone that is thought to influence oesophageal tone.
• Smoking (likely nicotine) and some medications (nitrates/calcium channel blockers) can cause the lower oesophageal sphincter to relax, allowing reflux of acid. Alcohol, coffee and chocolate can also relax the lower oesophageal sphincter.
• Bisphosphonates if not taken correctly can irritate the oesophagus leading to GORD symptoms and oesophagitis

Question 9

What is a hiatus hernia?

Answer 9

Pregnancy and obesity increase intra-abdominal pressure, forcing gastric acid up into the oesophagus. They can also move the lower oesophageal sphincter up past the diaphragm causing a hiatus hernia and loss of pressure gradient between the stomach and the oesophagus which is necessary to keep the sphincter closed.

Question 10

Treatment

(This will be discussed more in sperate lecture)

Answer 10

• Lifestyle advice
  
  • Weight loss, smoking cessation, dietary advice, stress control
  • Avoid trigger foods – spice, fatty foods, chocolate, alcohol, coffee
  • Eat smaller meals
  • Avoid having meals prior to going to bed
  • Don’t use pillows to prop yourself up – this leads to increased abdo pressure and can worsen GORD
• Medication review
  
  • Nitrates, theophylline, calcium channel blockers, anticholinergics, benzodiazepines, bisphosphonates (COUNSELLING)
• Elevation of head of bed by 10-20cm
• Intervention with medicines
  
  • Proton pump inhibitor for 4 weeks (GORD) or 8 weeks (severe oesophagitis)
  • H2RA if nocturnal symptoms or PPI ineffective
  • Antacid/alginate as required
  • Consider need for long term PPI treatment if symptoms recur

Question 11

GORD in childre, signs and tretament

Answer 11

Infants (<1 year) commonly regurgitate their food and is considered entirely normal. 90% of infants will stop this prior to their 1st birthday

Ongoing regurgitation along with retrosternal pain, refusal to feed, distress and faltering growth is suggestive of GORD.

• Change frequency and volume of meals
• Add thickener if formula fed
• Add alginate therapy with Gaviscon Infant
• Consider PPI or H2RA (unlicensed)
• Refer to paediatrician