Gastro-oesophageal reflux disease (GI) Flashcards
Define GORD.
The condition in which the reflux of gastric contents into the oesophagus results in symptoms and/or complications
Symptoms of oesophagitis secondary to refluxed gastric contents due to transient relaxation of LOS
What are the two typical symptoms of GORD?
Heartburn and acid regurgitation
Describe the aetiology of GORD.
- lowered oesophageal pressure causes acid reflux causing oesophagitis –> oedema and erosion
- tissue damaged –> scar formation
- eventually wall thickens and lumen becomes smaller –> oesophageal stenosis
- change to columnar epithelia –> Barret’s oesophagus
- reflux can go into pharynx and larynx –> laryngitis and asthma
What are the risk factors for GORD? (4 + 9)
- Fx heartburn/GORD
- older age
- hiatus hernia - reduces competence of gastro-oesophageal junction and inhibits clearance of oesophageal acid post-reflux
- obesity
- smoking
- alcohol
- dietary: fat-rich, caffeine
- stress and anxiety
- pregnancy
- NSAIDs
- asthma
- LOS tone-reducing drugs e.g. nitrates, CCBs, a&B-adrenergic agonists, theophylline, anticholinergics
- Zollinger Ellison syndrome: gastrinoma secretes gastrin = excess HCl
What are the clinical features of GORD? (10)
- heartburn (after meals, can be worse after lying down/bending over)
- acid regurgitation - leaves bitter taste in mouth
- dysphagia
- dyspepsia
- laryngitis (+chronic cough/hoarseness)
- bloating/early satiety
- globus (lump in throat despite swallowing)
- enamel erosion
- halitosis - bad breath
- waterbrash - increased salivation
What is the 1st line investigation for GORD?
Proton-pump inhibitor (PPI) trial (therapeutic 8 week trial) - if symptoms do not improve / alarm symptoms present, further tests (OGD) done
What investigations can we consider for GORD? (6)
- oesophagogastroduodenoscopy (OGD) - normal or may show oesophagitis or Barrett’s oesophagus
- ambulatory pH monitoring (pH<4 more than 4% of time is abnormal)
- oesophageal manometry (may suggest achalasia, oesophageal spasm etc)
- barium swallow (to exclude other causes of dysphagia)
- combined impedance-pH testing
- oesophageal capsule endoscopy
What are the indications for an upper GI endoscopy (OGD) in GORD? (5)
- age >55
- symptoms >4 weeks or persistent symptoms despite treatment
- dysphagia
- weight loss
- relapsing symptoms
- (indicated for alarm symptoms or symptoms suggesting complicated disease - atypical, persistent or relapsing symptoms)
What do we do with PPIs prior to OGD in GORD?
Stop PPIs two weeks before
If OGD is normal for GORD, what do we then consider?
24 hour oesophageal pH monitoring (gold-standard test for diagnosis)
Describe the potential progression of GORD.
GORD (normal mucosa) –> Barrett’s oesophagus (columnar epithelium) –> Barrett’s mucosa + dysplasia –> oesophageal carcinoma
What are some differential diagnoses for GORD?
- ACS
- stable angina
- functional oesophageal disorder/functional heartburn
- achalasia
- functional (non-ulcer) dyspepsia
- peptic ulcer disease
- eosinophilic oesophagitis
- PPI-responsive oesophageal eosinophilia
- malignancy
- laryngopharyngeal reflux
- non-acid reflux
What diagnostic criteria is used to diagnose GORD?
Montreal definition classifies oesophageal syndromes
What lifestyle changes do we recommend for GORD? (4)
- weight loss
- smoking cessation
- small regular meals
- avoid foods that may exacerbate e.g. acidic fruits, coffee, alcohol
What is the 1st line treatment for GORD?
- initial: standard-dose or high-dose PPI e.g. 20mg omeprazole PO od (or 40mg bd)
- ongoing: continue PPI that was working before e.g. omeprazole 20mg od (for those with symptoms if PPI discontinued/erosive oesophagitis/Barrett’s oesophagus)
- if absent/inadequate response to PPI - treatment can proceed to high-dose PPI + endoscopy
- consider adding H2 antagonist e.g. famotidine (if nocturnal component etc)
