Gastro-oesophageal Reflux Disease

Question 1

How common is it?

Answer 1

• Population-based studies have shown that between 21% and 40% of people report suffering from “heartburn” in any 6- to 12-month period.

Question 2

Who does it affect?

Answer 2

• Reflux is two to three times more common in men than in women.
• Adults over 40 are mainly affected.

Question 3

What causes it? What risk factors are there (and how can they be reduced)?

Answer 3

• When reflux of stomach contents (acid ± bile) cause troublesome symptoms and/or complications.

Causes

• Lower oesophageal sphincter hypotension
• Hiatus hernia
• Loss of oesophageal peristaltic function
• Abdominal obesity
• Gastric acid hypersecretion
• Slow gastric emptying
• Overeating
• Smoking
• Alcohol
• Pregnancy
• Surgery in achalasia
• Drugs (tricyclics, anticholinergics, nitrates)
• Systemic sclerosis
• H.Pylori.

Question 4

How does it present?

symptoms

Answer 4

Symptoms (oesophageal)

• Heartburn (burning, retrosternal discomfort after meals, stooping or straining, relieved by antacids).
• Belching
• Acid brash (acid or bile regurgitation)
• Waterbrash (↑↑salivation: “my mouth fills with saliva”)
• Odynophagia (painful swallowing, eg. From oesophagitis or ulceration).

Symptoms (extra-oesophageal)

• Nocturnal asthma
• Chronic cough
• Laryngitis (hoarseness, throat clearing)
• Sinusitis

Question 5

Complications?

Answer 5

• Oesophagitis
• Ulcers
• Benign stricture
• Iron-deficiency

Metaplasia→Dysplasia→Neoplasia – GORD may induce Barrett’s oesophagus (distal oesophageal epithelium metaplasia: squamous→columnar). 0.6-1.6%/yr will progress to carcinoma. Overall risk of adenocarcinoma from GORD is 1/1000/yr.

Question 6

Which other conditions may present similarly?

Answer 6

∆∆ = Oesophagitis from corrosives, NSAIDS, herpes, Candida; duodenal or gastric ulcers or cancers; non-ulcer dyspepsia; sphincter of Oddi malfunction; cardiac disease.

Question 7

How would you investigate the patient?

Answer 7

• Endoscopy if:
• Symptoms for >4 wks
• Persistent vomiting
• GI bleeding/iron deficiency
• Palpable mass
• Age > 55
• Dysphagia
• Symptoms despite treatment
• Relapsing symptoms
• Weight loss
• Barium swallow may show hiatus hernia.
• 24h oesophageal pH monitoring ± manometry help diagnose GORD when endoscopy is normal.

Question 8

What treatment/s would you consider? What risks and benefits of treatment are there?

Answer 8

Lifestyle

• Encourage: raising the bed head ± weight loss; smoking cessation; small regular meals.
• Avoid: hot drinks, alcohol, citrus fruits, tomatoes, onions, fizzy drinks, spicy foods, coffee, tea, chocolate, and eating <3h before bed. Avoid drugs affecting oesophageal motility or that damage the mucosa.

Drugs

• Antacids (e.g. magnesium trisilicate mixture) or alginates (e.g. gaviscon) to relieve symptoms.
• For oesophagitis try a PPI (e.g. lansoprazole). PPIs are better than H2 blockers.

Surgery

• (e.g. laparoscopic) aims to increase resting lower oesophageal sphincter pressure. Consider in severe GORD if drugs not working.
• Atypical symptoms less likely to improve with surgery compared to patients with typical symptoms.
• Many options – eg. Nissen fundoplication; HALO or Stretta radiofrequency ablation of the gastro-oesophageal junction if high grade dysplasia.