Gastro-oesophageal reflux disease (GORD) Flashcards
Define GORD.
Inflammation of the oesophagus caused by reflux of gastric acid and/or bile.
What is the epidemiology of GORD?
- Common
- Prevalence 5-10% adults
- Obesity is a risk factor
- Alcohol use, smoking, and intake of specific foods (such as coffee, mints, citrus fruits, or fats) may predispose to/trigger GORD
Describe the function of the lower oesophageal sphincter. How is it changed in GORD?
LOS regulates passage of food into stomach and contains both smooth and skeletal muscle. Transient lower oesophageal sphincter relaxations (TLOSRs) are part of normal physiology, but occur more frequently in patients with GORD.
Transient LOS relaxation is more common after meals and with fat in duodenum.
LOS relaxation and hiatus hernia:
- More common if there is a hiatal sac with acid
- Patients with severe reflux often have a hiatus hernia and decreased resting LOS pressure.
List some anti-reflux mechanisms.
Anti-reflux mechanisms:
- TLOSRs
- Peristalsis
- Rapid clearing of refluxate by secondary peristalsis, gravity and salivary bicarbonate
- Unimpeded gastric emptying
- Mucosal defences:
- Surface - mucus traps bicarbonate
- Epithelium - junctional complexes between cells limit diffusion of H+ into cells
- Postepithelium - bicarbonate buffers acid in cells and intracellular spaces
- Sensory mechanisms - activation of vanilloid receptor-1 in oesophagus initiates inflammation and stimulates release of pro-inflammatory substances –> pain. Pain can also be from contraction of longitudinal oesophageal muscle.
What is the aetiology of GORD?
-
Disruption of mechanisms that prevent reflux - two thirds of all cases
- physiological LOS
- mucosal rosette
- acute angle of junction
- intra-abdominal portion of oesophagus
- Prolonged oesophageal clearance contributes to 50% of cases
Acid pocket - food and fluid generally increase the gastric pH, but the acid pocket is an area of unbuffered gastric acid that accumulates postprandially in the proximal stomach. It serves as a reservoir. Occurs in hiatus hernias.
What are the risk factors for GORD?
- Pregnancy (increased IAP) or obesity
- Fat, chocolate, coffee or alcohol ingestion
- Large meals
- Cigarette smoking
- Drugs – antimuscarinic, calcium-channel blockers, nitrates
- Systemic sclerosis
- Treatment for achalasia
- Hiatus hernia
Other:
- Increased TLOSRs
- Low LOS pressure
- Acid pocket
What is a typical presentation of GORD?
- Substernal burning discomfort/”heartburn”
- Regurgitation of gastric contents/acid
- Made worse by lying down/bending forward
- Made worse by eating large meals/drinking alcohol
- Bloating/early satiety
- Relieved by antacids
- Waterbrash
- Aspiration → hoarseness, laryngitis, nocturnal cough, wheeze (+ pneumonia but rare)
- Dysphagia (caused by formation of peptic stricture after long-standing reflux, !exclude malignancy!)
Other:
- Globus - lump in throat despite swallowing
- Enamel erosion
- Halitosis - bad breath
- Dyspepsia - symptoms overlap with GORD in 25%
- Laryngitis
What are the signs of GORD on examination?
- Normal
- Epigastric tendeness
- Wheeze on auscultation
- Dysphonia
What investigations would you do for GORD?
- PPI trial - main symptoms are regurgitation and heartburn; check for symptom improvement in 8 weeks
-
OGD - for biopsy and cytological brushings - may show oesophagitis (erosion, ulceration, strictures) or Barrett’s. Helps exclude malignancy. NICE guidance for OGD within 2 week states:
- Any dysphagia OR
- >55yrs with weight loss with dyspepsia/ reflux/ upper abdo pain
Other:
- 24 hour oesophageal pH monitoring - pH of <4 more than 4% of the time is abnormal.
- Oesophageal manometry - study of the motor function of the UOS, oesophagus and LOS
- CXR - not specific for GORD. Incidental finding may chow hiatus hernia by gastric bubble behind cardiac shadow.
- Barium swallow - detect hiatus hernia, peptic stricture, extrinsic compression of oesophagus can be visualised. May exclude other causes of dysphagia.
Which of these can precipitate dyspepsia?
- Calcium antagonists
- Nitrates
- Theophylines
- Biphosphonates
- Corticosteroids
- NSAIDs
- H2 receptor antagonists
All except H2 receptor antagonists which are used in the treatment of dyspepsia
How do you manage GORD?
Lifestyle - weight loss, elevated head of bed, avoid provoking factors only if specific ones exist for that person, stop smoking, lower fat meals, avoid large meals in evening
Medical -
- Antacids - mild GORD
- H2 antagonists e.g. ranitidine
- PPI e.g. 20mg omeprazole, start with lowest effective dose then taper up, high dose or switch if ineffective
- Refer to gastroenterologist if no resolution
Endoscopy - surveillance annually for Barrett’s
Surgical -
- Fundoplication - for those who do not wish to take PPIs longer but have had good response; more effective than PPIs
In which cases of dyspepsia should you consider referral?
Patients over 55 with unexplained and persistent recent onset dyspepsia –> should be referred for endoscopy
Otherwise, routine endoscopic investigation of patient of any age presenting with dyspepsia without any alarm signs is not necessary
What are the complications of GORD?
- Oesophageal ulceration
- Peptic strictures - caused by healing of ulceration –> dysphagia for solid food
- Anaemia
- Barrett’s oesophagus (squamous to columnar metaplasia)
- Oesophageal adenocarcinoma
- Asthma
- Chronic laryngitis
What is the prognosis in GORD?
- Most respond to PPIs
- Oesophageal adenocarcinoma is a serious but rare complication of GORD.
What symptoms should you enquire about in suspected GORD which may make you consider OGD early?
- WEIGHT LOSS and >55yrs
- Treatment-resistant dyspepsia, or
- Upper abdominal pain with low haemoglobin levels, or
- Raised platelet count with any of the following:
- Nausea,
- Vomiting,
- Weight loss,
- Reflux,
- Dyspepsia,
- Upper abdominal pain, or
- Nausea or vomiting with any of the following:
- Weight loss.
- Reflux.
- Dyspepsia.
- Upper abdominal pain.
