Gastro-oesophageal Reflux Disease (GORD)

Question 1

Aetiology

Answer 1

• prolonged acid reflux secondary to incompetent lower oesophageal sphincter/ oesophageal dysmotility and often a/w hiatus hernia
• repeated vomiting (duodenal ulcer with high acid content of gastric juice)
• long-standing nasogastric intubation
• resection of cardia with gastro-oesophageal anastomosis
• presence of ectopic acid-secreting gastric mucosa within oesophagus

Question 2

Hiatus Hernia

Answer 2

Type I: sliding hiatus hernia (90%)

• cardio-oesophageal junction located above the dirphragm
• stomach slide up into chest –> reflux

Type II: rolling / paraoesoohageal hiatus hernia

• cardio oesophageal junction located below diaphragm
• stomach roll up alongside oesophagus –> dysphagia

Question 3

Hiatus hernia

Answer 3

Type I: sliding hiatus hernia (90%)

• cardio-oesophageal junction is above diaphragm
• stomach slides up into chest–> reflux

Type II: rolling/ paraoesophageal hiatus hernia

• cardio-oesophageal junction is below diaphragm–> X reflux
• stomach roll up alongside oesophagus–> dysphagia

Question 4

Clinical feature

Answer 4

• retrosternal burning pain (heartburn) worse on bending, stooping, lying supine
• acid regurgitation into mouth
• pain may radiate into jaw or left arm (mimic angina)
• large hernia: cough, palpitation, hiccups by mechanical effect

Question 5

Investigation

Answer 5

• FBC
• U&E
• upper GI endoscopy: presence of oesophagitis and hiatus hernia, biopsy to exclude carcinoma or presence of gastric-type epithelium
• 24 hour oesophageal pH studies: demonstrate reflux of gastric acid and its temporal relation to pain
• barium swallow: confirm hiatus hernia and demonstrate reflux, dysmotility or presence of stricture

Question 6

Treatment

Answer 6

Conservative

• weight loss, reduction in caffeinated drinks/ alcohol consumption, not eating before going to bed
• alginate antacid (Gaviscon): take after meals neutralize acidity and lining the gullet
• PPI (omeprazole, lansoprazole): complete reduction in gastric acidity
• prokinetic drugs (metoclopramide): increase gastric emptying

Surgical

• antireflux surgery (following oesophageal mobilization and histal dissection, the crura are approximated and fundus of stomach is wrapped around gastro-oesophageal junction)
  1. Nissen (360) fundoplication
  2. Toupet/ Lind (partial posterior) fundoplication
  3. Dor (anterior) fundoplication