Gastro-Oesophageal Reflux Disease Flashcards
What is the oesophageal hiatus?
Oval apeture in right crus of diaphragm at T10
What structures pass through the oesophageal hiatus?
Oesophagus
Vagal nerve trunks
Oesophageal branches of L. gastric vessels/lymphatics
What is a hiatus herniae?
Herniae allowing part of the stomach into the thoracic cavity
How do hiatus herniae typically present?
Asymptomatic
Occasionally reflux causing pain
What are the two anatomical types of hiatus herniae?
Sliding hiatus herniae
Para-oesophageal herniae (rolling)
Describe the anatomical change in a sliding hiatus herniae
Gastro-oesophageal junction slides through hiatus to lie above diaphragm
Describe the anatomical change in a para-oesophageal hiatus herniae
Fundus rolls up through herniae alongside oesophagus but sphincter remains competent below diaphragm
What are the anatomical risk factors for gastro-oesophageal disease?
Hiatus hernia
What are the physiological risk factors for gastro-oesophageal disease?
Raised IAP Large meals/late at night Smoking High caffeine intake High fatty food intake Drugs (anticholinergic, nitrates, tricyclics, CCBs)
How do sliding hiatus herniae present?
30% of adults >50
Typically insignificant
Sx may occur due to associated reflux
How do para-oesophageal herniae present?
Severe pain
Gastric volvulus/strangulus (requires surgical intervention)
What is Dyspepsia?
Chronic upper abdominal pain/discomfort
What are the subtypes of dyspepsia?
Reflux (heartburn/regurgitation eg. GORD)
Ulcer (epigastric pain)
Dysmotility (bloating/nausea)
When do sx of GORD occur?
When there is prolonged contact of gastric contents w/ oesophageal mucosa –> oesophagitis
What are the common features of GORD?
Dyspepsia Regurgitation of food/acid Waterbrash Odynophagia Atypical chest pain
What are the features of the dyspepsia present in GORD?
Worse on bending/lying down
Hot liquids/alcohol
Relieve by antacids
What is waterbrash?
Sudden filling of mouth w/ dilute saliva
What are the features of the atypical chest pain present in GORD?
Nocturnal cough/wheeze
Due to distal oesophageal muscle spasm
How is GORD diagnosed?
Clinically (generally)
What are the red lag sx indicating a need for endoscopy?
ALARMS 55
- anaemia (Fe deficient)
- loss of wt
- anorexia
- recent onset
- melaena/haematemesis
- swallowing difficulties
- > 55yrs
What is the empirical treatment of GORD?
PPI
-unless ALARMS 55 sx
What further investigations may be appropriate in GORD?
Barium swallow (?hiatus herniae) 24hr luminal pH monitoring/manometry
What lifestyle measures are used to manage GORD?
Wt loss Smoking cessation Eat small/regular meals >3h before bed Avoid hot drinks/alcohol Raised head of bed at night Avoid exacerbating drugs/mucosa damaging drugs (NSAIDs, K salts)
What medical options are used to manage GORD?
Antacids +/- alginates
H2RAs/PPIs
Prokinetic drugs (metoclopramide/domperidone)
Antibiotics
What are the common types of antacids/alginates?
Magnesium Hydroxide
Aluminium Hydroxide
Gaviscon
What are the side effects of antacids?
Aluminium salts - constipation
Magnesium salts - diarrhoea
What is the main side effect of PPIs?
Achlorrhydia
-increased risk of food poisoning (campylobacter)
When should H. pylori ‘test & treat’ be offered?
If sx return after 2wks of PPI treatment
What is the main side effect of prokinetic drugs?
ESPEs in pts w/ Parkinson’s
What are the long term complications of GORD?
Oesophagitis/ulcers
Benign strictures
Barrett’s oesophagus/oesophageal adenocarcinoma
How common is Barratt’s Oesophagus?
2% of adults in UK
What is the underlying pathophysiology of Barratt’s Oesophagus?
In pts w/ long standing reflux normal stratified squamous epithelium undergoes metaplasia to glandular columnar epithelium
How does Barratt’s Oesophagus present?
Asymptomatic
Pt will have sx of GORD
How is Barratt’s Oesophagus confirmed?
Upper GI endoscopy & biopsy
What are the potential complications of Barratt’s Oesophagus?
Dysplasia/malignant change
-adenocarcinoma of lower 1/3 of oesophagus
What are the management options for Barratt’s Oesophagus?
Regular endoscopic surveillance w/ biopsies
Dysplasia/carcinoma in situ treated w/ endoscopic resection
What is the risk of malignant change in Barratt’s Oesophagus?
0.5%/pt/yr
