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9. GI system > Gastro-Oesophageal Reflux Disease (GORD) > Flashcards

Gastro-Oesophageal Reflux Disease (GORD) Flashcards

1
Q

What is GORD?

A

Gastro-Oesophageal Reflux Disease (GORD):

Where acid from the stomach refluxes through the lower oesophageal sphincter and irritates the lining of the oesophagus; and it causes troublesome symptoms (defined as 2 or more heartburn episodes a week) and/or complications.

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2
Q

Give risk factors for GORD.

A
  1. Stress
  2. Drink + smoking
  3. Obesity
  4. Pregnancy
  5. Soda + caffeine
  6. High-fat foods + fried foods
  7. Hiatus hernia
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3
Q

Give 4 causes of GORD.

A

1.Lower oesophageal sphincter hypotension
2. Hiatus hernias
3. Abdominal obesity
4. Gastric acid hypersecretion
5. Smoking
6. Alcohol, caffeine, NSAIDs
7. Pregnancy

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4
Q

What are the 2 main types of hiatus hernias?

What are they?

A
  1. Sliding hiatus hernia (80%)
    - Where the gastro-oesophageal junction and part of the
    stomach ‘slides’ up into the chest via the hiatus so that it lies
    above the diaphragm
  2. Rolling or para-oesophageal hiatus (20%)
    - Where the gastro-oesophageal junction remains in the
    abdomen but part of the fundus of the stomach prolapses
    through the hiatus alongside the oesophagus
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5
Q

Explain the pathophysiology of GORD.

A

Normal physiology:
When swallowing is initiated, the lower oesophagus sphincter (LOS) relaxes to allow food to enter the stomach and some transient lower oesophageal relaxations are normal.

In GORD:
1. LOS has reduced tone
2. MUCH MORE transient lower oesophageal sphincter
relaxations
3. Allowing gastric acid to flow back into the oesophagus

  1. Clinical features of GORD appear when:
    = the anti-reflux mechanisms fail, thus allowing acid gastric contents to make prolonged contact with the lower oesophageal mucosa.
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6
Q

Give 3 oesophageal symptoms of GORD.

A
  1. Heart burn.
  2. Acid reflux ((food, acid or bile regurgitation).
  3. Dysphagia (difficulty swallowing).
  4. Epigastric pain
  5. Dyspepsia (indigestion)
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7
Q

Give 3 non-oesophageal symptoms of GORD.

A
  1. Nocturnal asthma / cough
  2. Chronic cough
  3. Laryngitis (hoarseness and throat clearing) - hoarse voice
  4. Sinusitis
  5. Bloating
  6. Chest pain
  7. Retrosternal / epigastric pain
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8
Q

Red flags for GORD.

A

Red flag signs = ALARMS:
A - Anaemia (internal bleeding)
L - Loss of weight
A - Anorexia
R - Recent onset
M - Melaena (blood in stool) or haematemesis
S - Swallowing difficulties (dysphagia)

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9
Q

Clinical diagnosis for GORD.

A

Diagnosis can usually be made without investigation, provided there are no ALARM BELL SIGNS such as weight loss, haematemesis (coughing up blood) and especially dysphagia (swallowing difficulties), patients under the age of 45 can safely be treated initially without investigation.
If ALARM signs present, carry out investigations.

Clinical investigations:
1. Upper GI endoscopy

  • 24-hour oesophageal pH monitoring
    = pH <4 for more than 4% of the time is abnormal
  • Use Los Angeles classification of GORD/Oesophagitis when doing endoscopy to gauge extent of damage
  1. FBC
    - Anaemia
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10
Q

What are the 3 categories for GORD treatment?

A
  1. Lifestyle change
  2. Pharmacology
  3. Surgery
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11
Q

Criteria to refer for endoscopy.

A

2-week endoscopy referral in people with:

  1. Dysphagia or
  2. Age ≥ 55yo with weight loss and 1 of the following:
    • Upper abdo pain
    • Reflux
    • Dyspepsia
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12
Q

Outline the different pharmacotherapies for GORD.
Give an example of each.

A
  1. Antacids
    - relieves symptoms by forming a gel or ‘foam raft’ with gastric contents to reduce reflux
    - E.G. magnesium trisilicate mixture
  2. Alginates
    - relieves symptoms
    - E.G. gaviscon
  3. Proton pump inhibitor (PPI)
    - reduces gastric acid production
    - E.G. lansoprazole
  4. H2 receptor antagonists
    - reduces acid release by blocking histamine receptors on parietal cells
    - E.G. cimetidine
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13
Q

What is a side effect of magnesium-containing antacids?

A

Side effect of magnesium containing antacids is that they
tend to cause diarrhoea.

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14
Q

When is the best time to take PPIs?

A

PPIs are best taken on an empty stomach (food can decrease bioavailability up to 50%) once daily 30 minutes to 1 hour before the first meal of the day.

So that, the peak serum concentration coincides with the maximum activation of the proton pumps.

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15
Q

What surgery is used for GORD?

A

Aims to laparoscopically increase the resting LOS pressure - only in severe GORD
- Use when not responding to therapy
- Complications include dysphagia and bloating

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16
Q

What are the 2 main complications of GORD?

A
  1. Peptic stricture
  2. Barrett’s oesophagus
17
Q

Define peptic stricture and its treatment.

A

Inflammation of the oesophagus (oesophagitis) resulting from gastric (peptic) acid exposure, resulting in the narrowing and thus stricture of the oesophagus.

  • Usually occurs in patients over 60
  • Presents as gradually worsening dysphagia

Treatment:
* Endoscopic dilatation and long-term PPI therapy

18
Q

Define Barrett’s oesophagus.

A

Metaplasia of the distal oesophageal epithelium from stratified squamous to simple columnar epithelium.

19
Q

What can cause Barrett’s oesophagus?

A
  1. As a complication of GORD
  2. Obesity
20
Q

What is always present in Barrett’s oesophagus?

A

Always a hiatus hernia present!

21
Q

Barrett’s oesophagus is considered a “X” condition.
What is X?

A

Premalignant

22
Q

What condition is Barrett’s oesophagus considered a premalignant condition for?

A

Oesophageal adenocarcinoma

23
Q

Describe how Barrett’s oesophagus can lead to oesophageal adenocarcinoma.

A
  1. GORD damages normal oesophageal squamous cells.
  2. Glandular columnar epithelial cells replace squamous cells (metaplasia).
  3. Continuing reflux leads to dysplastic oesophageal glandular epithelium.
  4. Continuing reflux leads to neoplastic oesophageal glandular epithelium - adenocarcinoma.
24
Q

Investigations for Barrett’s oesophagus.

A
  1. Upper GI Endoscopy
  2. Biopsy
    - Mandatory because Barrett’s oesophagus is a pathological diagnosis
    - Positive if metaplasia ≥1 cm above the gastro-oesophageal junction (GOJ)
    - Test for H.pylori
25
Q

Management for Barrett’s oesophagus.

A
  1. PPI + lifestyle medications
  2. Endoscopic surveillance

If dysplasia present:
-> Endoscopic ablation

26
Q

Differential diagnosis for Barrett’s oesophagus.

A
  1. GORD
  2. Oesophagitis
  3. Oesophageal carcinoma

9. GI system (15 decks)

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