Gastro-oesophageal reflux disease

Question 1

What is GORD?

Answer 1

GORD = symptoms/complications resulting from abnormally increased reflux of stomach contents into the oesophagus and beyond

May or may not exist with oesophageal inflammation (50%)
May or may not exist with erosions

Question 2

What is the aetiology of GORD?

Answer 2

Increased abdominal pressure – delay gastric emptying + pressure on LOS
Obesity
Pregnancy
Big meals

LOS relaxation
Drugs: smoking (nicotine), anti-muscarinics, CCBs, nitrates, achalasia treatment (botox)
Hiatus hernia

Increased gastric acid production
Diet: fat, alcohol, coffee, large meals, carbonated drinks, citrus food, spicy food
Smoking
Zollinger-Ellison tumour

Question 3

What are the risk factors for GORD?

Answer 3

Family history - 3x more likely
Older age
Hiatus hernia
Obesity
LOS tone-reducing drugs - nitrates, CCBs, adrenergic agonists, anticholinergics, TCAs
Psychological stress
Asthma
NSAIDs, aspirin, steroids, bisphosphonates
Smoking
Alcohol
Dietary factors - Caffeinated foods/drinks, carbonated drinks, chocolate, citrus, spicy foods

Question 4

What is the epidemiology of GORD?

Answer 4

Affects 10-20% of Western population - 7-20% on a daily basis

Affects only 5% of Asian population

Many self-medicate (antacids)

Affects all ages - Increased prevalence in people older than 40

No gender predilection

Question 5

What are the symptoms of GORD?

Answer 5

Dyspepsia (heart burn) + chest pain
Burning sensation in chest after meals
Worse after lying down/bending down – therefore during night

Nausea

Acid regurgitation

Coughing (in morning)

Dysphagia (33%)

Early satiety

Asthma

Laryngitis – sore throat – hoarse voice – foul taste in mouth (in morning)

Question 6

What are the signs of GORD?

Answer 6

Bloating
Wheezing
Enamel decay

Question 7

What are the appropriate investigations for GORD?

Answer 7

PPI trial (8 weeks) - Diagnostic + therapeutic

Other investigations
OGD – 2nd line
Oesophagitis (erosion, strictures, ulcerations)
Barrett’s oesophagus
If positive = BIOPSY

Ambulatory pH monitoring (naso-oesophageal)
pH<4 for >4% of the time = abnormal

Oesophageal manometry
Functional disorders - achalasia, oesophageal spasm, motor disorders

Barium swallow
Hiatus hernia

Oesophageal capsule endoscopy (swallow capsule – sedation not required, less invasive)
Oesophagitis
Barrett’s oesophagus

Question 8

How is GORD managed?

Answer 8

First presentation
Standard dose PPI (e.g. 20mg omeprazole OD) - Rapid symptom relief

Lifestyle changes - Weight loss (if overweight)
Head-of-bed elevation
Avoidance of late-night eating + trigger foods
Smoking cessation
Discontinue causative drugs

Ongoing
PPI - Standard dose
High dose (if incomplete response) – 40mg
Nissen Fundoplication – hiatus hernia
H2 antagonist (if nocturnal component)

Question 9

What are the complication of GORD?

Answer 9

Oesophageal ulcer, haemorrhage, or perforation
Oesophageal stricture -> dysphagia
Barrett’s oesophagus
Oesophageal adenocarcinoma

Question 10

What is the prognosis of GORD?

Answer 10

Most patients respond to PPI treatment (80%)
Most patients relapse when off PPI therapy
Need long term maintenance

Adenocarcinoma development at 7 year follow up is 0.1% (if initial endoscopy absent of stricture/Barrett’s)

High-risk patients who undergo Nissen fundoplication have a 92% rate of asymptomatic after surgery
50% develop oesophagitis