FN: GORD

Question 1

Pathophysiology

Answer 1

􏰀 LOS dysfunction → reflux of gastric contents → oesophagitis.

Question 2

RF

Answer 2

􏰀 Hiatus hernia
􏰀 Smoking
􏰀 EtOH
􏰀 Obesity
􏰀 Pregnancy
􏰀 Drugs: anti-AChM, nitrates, CCB, TCAs
􏰀 Iatrogenic: Heller’s myotomy

Question 3

symptoms Oesophageal

Answer 3

􏰀 Heartburn
􏰁 Related to meals
􏰁 Worse lying down / stooping
􏰁 Relieved by antacids
􏰀 Belching
􏰀 Acid brash, water brash
􏰀 Odonophagia

Question 4

Extra-oesophageal symptoms

Answer 4

􏰀 Nocturnal asthma
􏰀 Chronic cough
􏰀 Laryngitis, sinusitis

Question 5

Complications

Answer 5

􏰀 Oesophagitis: heartburn
􏰀 Ulceration: rarely → haematemesis, melaena, ↓Fe
􏰀 Benign stricture: dysphagia
􏰀 Barrett’s oesophagus
􏰁 Intestinal metaplasia of squamous epithelium
􏰁 Metaplasia → dysplasia → adenocarcinoma
􏰀 Oesophageal adenocarcinoma

Question 6

Differential Dx

Answer 6

Oesophagitis
􏰁 Infection: 
- CMV, candida
- 􏰁 IBD
- 􏰁 Caustic substances / burns
PUD Oesophageal Ca

Question 7

Ix

Answer 7

1. Isolated symptoms don’t need Ix
2. Bloods: FBC
3. CXR: hiatus hernia may be seen
4. OGD if:
   􏰁 - >55yrs
   􏰁 - Symptoms >4wks
   􏰁- Dysphagia
   -􏰁 Persistent symptoms despite Rx
   􏰁 - Wt. loss
   􏰁- OGD allows grading by Los Angeles
   Classification
5. Ba swallow: hiatus hernia, dysmotility
6. 24h pH testing ± manometry
   􏰁 pH <4 for >4hrs

Question 8

Conservative Rx

Answer 8

􏰀 Lose wt.
􏰀 Raise head of bed
􏰀 Small regular meals ≥ 3h before bed
􏰀 Stop smoking and ↓ EtOH
􏰀 Avoid hot drinks and spicy food
􏰀 Stop drugs: NSAIDs, steroids, CCBs, nitrates

Question 9

Medical Rx

Answer 9

􏰀 OTC antacids: Gaviscon, Mg trisilicate
􏰀 1: Full-dose PPI for 1-2mo
􏰁 Lansoprazole 30mg OD
􏰀 2: No response → double dose PPI BD
􏰀 3: No response: add an H2RA
􏰁 Ranitidine 300mg nocte
􏰀 Control: low-dose acid suppression PRN

Question 10

Surgical Mx

Answer 10

Nissen Fundoplication
􏰀 Indications: all 3 of:
􏰁 Severe symptoms
􏰁 Refractory to medical therapy
􏰁 Confirmed reflux (pH monitoring)

Question 11

Nissen Fundoplication

Answer 11

􏰀 Aim: prevent reflux, repair diaphragm
􏰀 Usually laparoscopic approach
􏰀 Mobilise gastric fundus and wrap around lower
oesophagus
􏰀 Close any diaphragmatic hiatus
􏰀 Complications:
􏰁 Gas-bloat syn.: inability to belch / vomit 􏰁 Dysphagia if wrap too tight

Question 12

Hiatus Hernia classification

Answer 12

sliding
Rolling
Mixed

Question 13

Hiatus Hernia Sliding

Answer 13

80%
Gastro-oesophageal junction slides up into chest
􏰀 Often assoc. ̄c GORD

Question 14

Hiatus Hernia Rolling

Answer 14

􏰀 15%
Gastro-oesophageal junction remains in abdomen but a bulge of stomach rolls into chest alongside the oesophagus
􏰀 LOS remains intact so GORD uncommon 􏰀 Can → strangulation

Question 15

Hiatus Hernia Mixed

Answer 15

5%

Question 16

Hiatus Hernia Ix

Answer 16

􏰀 CXR: gas bubble and fluid level in chest
􏰀 Ba swallow: diagnostic
􏰀 OGD: visualises the mucosa but can’t exclude hernia
􏰀 24h pH + manometry: exclude dysmotility or achalsia

Question 17

Hiatus Hernia Rx

Answer 17

􏰀 Lose wt.
􏰀 Rx reflux
􏰀 Surgery if intractable symptoms despite medical Rx.
􏰁 Should repair rolling hernia (even if asympto) as it may strangulate.