Gastro-oesophageal reflux disease Flashcards
Causes of GORD
Lower oesophageal sphincter hypotension Hiatus hernia Oesophageal dysmotility (e.g. systemic sclerosis) Obesity Gastric acid hyper secretion Delayed gastric emptying Smoking Alcohol Pregnancy Drugs: tricyclics, anticholinergics, nitrates Helicobacter pylori (controversial)
Oesophageal symptoms of GORD
Heartburn (burning, retrosternal discomfort after meals, lying, stooping or straining, relieved by antacids)
Belching
Acid brash (acid or bile regurgitation)
Waterbrash (increased salivation: “my mouth fills with saliva”)
Odynophagia (painful swallowing, e.g. from oesophagitis or ulceration)
Extraoesophageal symptoms of GORD
Nocturnal asthma
Chronic cough
Laryngitis (hoarseness, throat clearing)
Sinusitis
Complications of GORD
Oesophagitis Ulcers Benign stricture Iron deficiency Metaplasia --> dysplasia --> neoplasia: GORD may lead to Barrett's oesophagus (distal oesophageal epithelium undergoes metaplasia from squamous to columnar). 0.1-0.4%/yr of those with Barrett's progress to oesophageal cancer (higher if dysplasia is present).
Differential diagnosis of GORD
Oesophagitis from corrosives NSAIDs Herpes Candida Duodenal or gastric ulcers or cancers Non-ulcer dyspepsia Oesophageal spasm Cardiac disease
Tests for GORD
Endoscopy if dysphagia, or if >55yrs old with alarm symptoms or with treatment refractory dyspepsia.
24h oesophageal pH monitoring +/- manometry help diagnose GORD when endoscopy is normal.
Treatment of GORD: lifestyle
Weight loss. Smoking cessation. Small, regular meals. Reduce hot drinks, alcohol, citrus fruits, tomatoes, onions, fizzy drinks, spicy foods, caffeine and chocolate. Avoid eating <3h before bed. Raise the bed head.
Treatment of GORD: drugs
Antacids, e.g. magnesium trisilicate mixture (10mL/8h), or alginates, e.g. Gaviscon (10-20mL/8h PO) relieve symptoms.
Add a PPI, e.g. lansoprazole 30mg/24h PO.
For refractory symptoms, add an H2 receptor blocker and/or try twice daily PPI.
Avoid drugs affecting oesophageal motility (nitrates, anticholinergics, Ca2+ channel blockers- relax the low oesophageal sphincter) or that damage mucosa (NSAIDs, K+ salts, bisphosphonates).
Treatment of GORD: surgery
e.g. laparoscopic Nissen fundoplication, or novel options including laparoscopic insertion of a magnetic bead band or radiofrequency-induced hypertrophy. These all aim to raise resting lower oesophageal sphincter pressure. Consider in severe GORD (confirm by pH monitoring/ manometry) if drugs are not working. Atypical symptoms (cough, laryngitis) are less likely to improve with surgery compared to patients with typical symptoms.