Gastro-Oesophageal Reflux Disease

Question 1

Define Gastro-Oesophageal Reflux Disease (GORD)?

Answer 1

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

Question 2

What is the aetiology of GORD?

Answer 2

Caused by disruption of mechanisms that prevent reflix

Question 3

What are the mechanisms that prevent reflux?

Answer 3

Lower oesophageal sphincter
Acute angle of junction
Mucosal rosette
Intra-abdominal portion of oseophagus (diaphragm acts as a sphincter)

Question 4

What contributes to most cases of GORD?

Answer 4

Prolonged oesophageal acid clearance contributes to 50% of cases

Question 5

What is the epidemiology of GORD?

Answer 5

Common

5-10% of adults

Question 6

What are the presenting symptoms of GORD?

Answer 6

Substernal/epigastric burning discomfort or heartburn
Pain is relieved by antacids 
Waterbrash
Aspiration
Dysphagia

Question 7

What is the pain in GORD aggravated by?

Answer 7

Lying supine
bending
Large meals
Drinking alcohol

Question 8

What is Waterbrash?

Answer 8

Regurgitation of an excessive accumulation of saliva from the lower part of the oesophagus often with some acid material from the stomach

Question 9

What might Aspiration result in?

Answer 9

Hoarseness
Laryngitis
Nocturnal Cough
Wheeze

Question 10

What is Dysphagia caused by in GORD?

Answer 10

Formation of peptic stricture after long-standing reflux

Question 11

What are the signs of GORD on physical examination?

Answer 11

Usually normal

Occasionally - epigastric tenderness, wheeze on chest auscultation, dysphonia

Question 12

What investigations do you do for GORD?

Answer 12

Upper GI endoscopy, biopsy and cytological brushings
Barium Swallow
CXR
24 hr oesophageal pH monitoring

Question 13

Why do we do Upper GI endoscopy, biopsy and cytological brushings for GORD?

Answer 13

Confirms presence of oesophagitis and can exclude malignancy

Question 14

Why do we do a Barium Swallow for GORD?

Answer 14

Can detect:

• Hiatus Hernia
• Peptic Stricture
• Extrinsic compression of the oesophagus

Question 15

What is the operation to repair hiatus hernia called?

Answer 15

Nissen fundoplication

Question 16

Why do we do a CXR for GORD?

Answer 16

Not specific to GORD

However, a CXR can lead to the incidental finding of a hiatus hernia (gastric bubble behind the cardiac shadow)

Question 17

How does a 24 hr Oesophageal pH monitoring help in GORD?

Answer 17

pH probe placed in lower oesophagus determines the temporal relationship between symptoms and oesophageal pH

Question 18

What advice do we give for someone with GORD?

Answer 18

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

Question 19

What is the medical management plan for GORD?

Answer 19

Antacids
Alginates
H2 antagonists (e.g. ranitidine)
PPI (e.g. lansoprazole, omeprazole)

Question 20

What is the management plan with regards to Endoscopy for GORD?

Answer 20

Annual endoscopic surveillance - look for Barrett’s Oesophagus
May be necessary for stricture dilation or stenting

Question 21

What is the surgical management plan for GORD?

Answer 21

Antireflux surgery if refractory to medical treatment

Question 22

What is Nissen Fundoplication?

Answer 22

Fundus of the stomach is wrapped around the lower oesophagus - helps reduce the risk of hiatus hernia and reduce reflux

Question 23

What are the possible complications of GORD?

Answer 23

Oesophageal ulceration
Peptic Stricture 
Anaemia 
Barrett's Oesophagus 
Oesophageal adenocarcinoma 
Associated with asthma and chronic laryngitis

Question 24

What is the prognosis for patients with GORD?

Answer 24

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