Gastro-oesophageal Reflux Disease Flashcards
Define
Inflammation of the oesophagus caused by reflux of gastric acid and/or bile.
Pronged reflux may cause:
- Oesophagitis
- Benign oesophageal stricture
- Barrett’s oesophagus
Causes & Risk factors
- Lower oesophageal sphincter hypotension Abdominal obesity
- Gastric acid hypersecretion
- Hiatus hernia
- Slow gastric emptying
- Overeating
- Smoking, alcohol, pregnancy
- Surgery for achalasia
- Drugs (tricyclics, anticholinergics, nitrates) Systemic sclerosis
Risk factors – any of the above
In addition: anything causing ↑intra-abdo pressure or inadequate cardiac sphincter (LOS) for anatomical reasons
A fatty meal will also delay gastric emptying
Epidemiology
Common
Prevalence 5-10% of adults
2-3 times more common in men > women
Symptoms
Oesophageal
- Heartburn: burning, retrosternal discomfort after meals/lying/alcohol/bending, relieved by antacids)
- Belching
- Acid brash: acid/bile regurgitation
- Water brash: ↑salivation
- Odynophagia: panful swallowing (due to oesophagitis or ulceration, long-standing reflux leads to peptic stricture)
- Dysphagia secondary to oesophageal stricture
Extra-oesophageal
- Nocturnal asthma
- Chronic cough
- Laryngitis (hoarseness, throat clearing due to aspiration)
- Sinusitis
- ±Non-cardiac CP (with no relationship to exercise)
Sings
Usually NORMAL
Occasionally - epigastric tenderness, wheeze on chest auscultation, dysphonia
Investigations
- Often a CLINICAL diagnosis : usually PPI trial
Upper GI endoscopy, biopsy and cytological brushings:
- Confirms presence of oesophagitis and can exclude malignancy
Barium Swallow can detect:
- Hiatus hernia
- NOTE: operation to repair hiatus hernia is called Nissen fundoplication
- Peptic stricture
- Extrinsic compression of the oesophagus
CXR:
This is NOT specific for GORD
- However, a CXR can lead to the incidental finding of a hiatus hernia (gastric bubble behind the cardiac shadow)
24 hr oesophageal pH monitoring:
- pH probe places in lower oesophagus determines the temporal relationship between symptoms and oesophageal pH
Management
Advice:
- Weight loss
- Elevating head of bed
- Avoid provoking factors
- Stop smoking
- Lower fat meals
- Avoid large meals late in the evening
Medical:
- Antacids
- Alginates
- H2 antagonists (e.g. ranitidine)
- Proton pump inhibitors (e.g. lansoprazole, omeprazole)
Endoscopy:
- Annual endoscopic surveillance - looking for Barrett’s Oesophagus
- May be necessary for stricture dilation or stenting
Surgery:
- Antireflux surgery if refractory to medical treatment
- Nissen Fundoplication:
- Fundus of the stomach is wrapped around the lower oesophagus - helps reduce the risk of hiatus hernia and reduce reflux
Complications
- Oesophageal ulceration
- Peptic stricture
- Anaemia
- Barrett’s oesophagus
- Oesophageal adenocarcinoma
- Associated with asthma and chronic laryngitis
Prognosis
- 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
