Gastro-oesophageal reflux disease

Question 1

Define Gastro-oesophageal reflux disease

Answer 1

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

Question 2

Aetiology of Gastro-oesophageal reflux disease

Answer 2

Lower oesophageal sphincter intrinsic smooth muscle relaxes more frequently -> reflux

More common after meals, stimulated by fat in the duodenum

More likely to occur if there is hiatal sac containing acid

Question 3

Risk factors for Gastro-oesophageal reflux disease

Answer 3

Family history 
older age
Hiatus hernia 
Obesity 
Intake of specific foods 
Psychological stress
Asthma 
NSAIDs, CCBs
Alcohol 
Smoking

Question 4

Symptoms of Gastro-oesophageal reflux disease

Answer 4

Heartburn (after meals/alcohol intake | worse lying down or bending over | can occur at night | not usually exertion)
Acid regurgitation (sour or bitter taste after meals)
Dysphagia (peptic stricture formation)
bloating/early satiety
Globus
Halitosis
Dyspepsia
Aspiration: voice hoarseness, laryngitis, nocturnal cough, wheeze

Question 5

Signs of Gastro-oesophageal reflux disease on examination

Answer 5

Usually normal exam

May have:
Epigastric tenderness
Wheeze on auscultation (aspiration)
Dysphonia (aspiration)

Question 6

Investigations for Gastro-oesophageal reflux disease

Answer 6

PPI trial: symptom improvement (8 week trial)
OGD: oesophagitis (erosion, ulcerations, strictures), may see Barrett’s

UGI endoscopy + biopsy + brushings: normal/oesophagitis/malignancy

Ambulatory pH monitoring: pH<4 4% of the time

Oesophageal manometry: suggest achalasia, oesophageal spasm or other motility disorders

Barium swallow: may suggest oesophagitis, mucous may be nodular/granular

CXR: normal (look for hiatus hernia)

Question 7

Management for Gastro-oesophageal reflux disease on initial presentation

Answer 7

Standard dose PPI e.g. omeprazole

Lifestyle advice and changes:
Weight loss 
Head of bed elevation
Avoid late night eating 
Eliminate coffee, chocolate, alcohol, acidic foods
Smoking cessation

Question 8

Management of Gastro-oesophageal reflux disease that is ongoing despite treatment

Answer 8

Continue PPi

Surgery (Lap. Nissen or Tourt or anterior fundoplication)

Question 9

Complications of Gastro-oesophageal reflux disease

Answer 9

Oesophageal ulceration -> haemorrhage, perforation 
Peptic stricture
Anaemia 
Barrett's oesophagus 
Adenocarcinoma

Question 10

Prognosis for Gastro-oesophageal reflux disease

Answer 10

Most patents respond to PPI

Most relapse off the PPI