Gastro-oeospageal reflux disease

Question 1

What is GORD?

Answer 1

GORD is common and is said to exist when reflux of stomach contents (acid + bile) causes troublesome symptoms (>2 heartburn symptoms/wee) and/or complications.

If reflux is prolonged it may cause:

• Oesophagitis
• Benign oesophageal stricture
• Barrett’s oesophagus

Question 2

What are the causes of GORD?

Answer 2

Lower Oesophageal sphincter hypotension
Hiatus Hernia
Loss of oesophageal peristaltic function
Abdominal obesity
Gastric acid hyper-secretion
Slow gastric emptying
Overeating
Smoking
Alcohol
Pregnancy
Surgery in achalasia
Drugs (tricyclics, anti-cholinergics, nitrates)
Systemic Sclerosis
H. Pylori?

Question 3

What are the symptoms of GORD?

Answer 3

Heart burn (burning, retrosternal discomfort after meals, lying, stopping or straining, relieved by antacids)
Belching
Acid brash (acid or bile regurgitations
Water brash (increased saliva)
Odynophagia (painful swallowing e.g. from oesophagitis or ulceration)

Extra-oesophageal: nocturnal asthma, chronic cough, laryngitis (throat clearing, hoarseness), sinusitis

Question 4

How can GORD become complicated?

Answer 4

Oesophagitis
Ulceration
Benign stricture
Iron deficiency
Metaplasia --> dysplasia --> neoplasia
Barrett's oesophagus

Question 5

How is GORD investigated?

Answer 5

Endoscopy if:

• Symptoms for >4 weeks
• Persistent vomiting
• GI bleeding/iron deficiency
• Palpable mass
• Age >55
• Dysphagia
• Symptoms despite treatment
• Relapsing symptoms
• Weight loss

Barium swallow to show hiatus hernia
24 hr oesophageal pH monitoring monometry

Question 6

Treatment for GORD?

Answer 6

Lifestyle:

• Weight loss
• Smoking cessation
• Small regular meals
• Avoid certain foods (hot drinks, alcohol, citrus fruits, tomatoes, onions, fizzy drinks, spicy foods, coffee, tea, chocolate)
• Avoid eating <3 hours before bed.
• Avoid nitrates, anticholinergics, Calcium channel blockers (relax lower oeosophageal sphincter)
• Avoid NSAIDs, potassium salts, bisphosphonates (damage mucosa)

Medication
Antacids e.g. gaviscon, magnesium trisilicate mixture
PPI e.g. lansoprazole

Surgery:
- increase resting lower oeosophageal sphincter pressure

Question 7

How is GORD classified?

Answer 7

Los Angeles classification of GORD
1. >1 mucosal break(s), <5 mm long not extending beyond 2 mucosal fold tops

2. Mucosal break >5 mm long, limited to the space between 2 mucosal fold tops
3. Mucosal break continuous between the top of 2 or more mucosal folds but which involves less than 75% of the oeosophageal circumference
4. Mucosal break involving >75% of the oesophageal circumference