Gastro-Oesophageal Reflux Disease

Question 1

Definition

Answer 1

Inflammation of the oesophagus caused by reflux of gastric acid and/or bile

Question 2

Aetiology/Risk factors

Answer 2

• Caused by disruption of mechanisms that prevent reflux

• Mechanisms that prevent reflux:
o Lower oesophageal sphincter
o Acute angle of junction
o Mucosal rosette
o Intra-abdominal portion of oesophagus (diaphragm acts as a sphincter)

• Prolonged oesophageal acid clearance contributes to 50% of cases

Question 3

Epidemiology

Answer 3

• COMMON

* 5-10% of adults

Question 4

Presenting symptoms

Answer 4

• Substernal/epigastric burning discomfort or ‘heartburn’

• Aggravated by:
o Lying supine
o Bending
o Large meals
o Drinking alcohol
• Pain is relieved by antacids

• Waterbrash (regurgitation of an excessive accumulation of saliva from the lower part
of the oesophagus often with some acid material from the stomach)

• Aspiration - may result in hoarseness, laryngitis, nocturnal cough and wheeze
• Dysphagia - caused by formation of peptic stricture after long-standing reflux

Question 5

Signs on physical examination

Answer 5

• Usually NORMAL

* Occasionally - epigastric tenderness, wheeze on chest auscultation, dysphonia

Question 6

Investigations

Answer 6

• Often a CLINICAL diagnosis

• Upper GI endoscopy, biopsy and cytological brushings
o Confirms presence of oesophagitis and can exclude malignancy

• Barium Swallow can detect:
o Hiatus hernia
• NOTE: operation to repair hiatus hernia is called Nissen fundoplication
o Peptic stricture
o Extrinsic compression of the oesophagus

• CXR:
o This is NOT specific for GORD
o However, a CXR can lead to the incidental finding of a hiatus hernia (gastric
bubble behind the cardiac shadow)

• 24 hr oesophageal pH monitoring:
o pH probe places in lower oesophagus determines the temporal relationship
between symptoms and oesophageal pH

Question 7

Management plan (advice)

Answer 7

o Weight loss
o Elevating head of bed
o Avoid provoking factors
o Stop smoking
o Lower fat meals
o Avoid large meals late in the evening

Question 8

Management plan

Answer 8

• Medical:
o Antacids
o Alginates
o H2 antagonists (e.g. ranitidine)
o Proton pump inhibitors (e.g. lansoprazole, omeprazole)

• Endoscopy:
o Annual endoscopic surveillance - looking for Barrett’s Oesophagus
o May be necessary for stricture dilation or stenting

• Surgery:
o Antireflux surgery if refractory to medical treatment

• Nissen Fundoplication:
o Fundus of the stomach is wrapped around the lower oesophagus - helps reduce
the risk of hiatus hernia and reduce reflux

Question 9

Possible complications

Answer 9

• Oesophageal ulceration
• Peptic stricture
• Anaemia
• Barrett’s oesophagus
• Oesophageal adenocarcinoma
• Associated with asthma and chronic laryngitis

Question 10

Prognosis

Answer 10

• 50% respond to lifestyle measures alone
• In patients that require drug therapy, withdrawal is often associated with relapse
• 20% of patients undergoing endoscopy for GORD have Barrett’s oesophagus