Gastro-oesophageal Reflux Disease (GORD)

Question 1

Symptoms of GORD? (oesophageal + extra-oesophageal)

Answer 1

Oesophageal (typical)

• heartburn (retrosternal burning/pain when lying/after eating)
• dysphagia (food getting stuck)
• regurgitation

Extra-oesophageal (atypical)

• coughing
• hoarseness
• non-cardiac chest pain
• dental erosions (HCl from stomach regurgitation)

Question 2

Risk factors for GORD?

Answer 2

Raised intra-abdominal pressure
- obesity, pregnancy

Lower oesophageal sphincter relaxation
- drugs (anti-muscs, CCBs, nitrates, smoking), treatment of achalasia, hiatus hernia

Gastric hypersecretion
- diet, smoking, ZES

Question 3

What is a hiatus hernia?

Answer 3

Portion of the stomach prolapses through the diaphragmatic oesophageal hiatus, predisposing to reflex or worsening existing reflux

Question 4

Risk factors for hiatus hernia?

Answer 4

Increased IAP (obesity, ascites, pregnancy)
Defect in containing wall
(similar to other hernias)

Question 5

How are most hiatus hernias found?

Answer 5

Incidentally on CXR or endoscopy

Question 6

Types of hiatus hernia?

Answer 6

Congenital or acquired

acquired splits into non-traumatic and traumatic hernias

Question 7

Investigations in suspected hiatus hernia?

Answer 7

Barium swallow
CXR
Endoscopy

Question 8

Barium swallow evidence of hiatus hernia?

Answer 8

• Outpouching of barium at lower end of oesophagus
• Wide hiatus through which gastric folds are seen in continuum with those in the stomach
• Occasionally, free reflex of barium
  (can help distinguish a sliding from a paraoesophageal hernia (types of non-traumatic acquired hiatus hernia)

Question 9

Management of hiatus hernia?

Answer 9

Conservative - risk factor modification (diet, smoking, weight loss)

Pharmacological - PPI (or H2 antagonist if PPI inadequate)

Surgery - Nissen fundoplication

Question 10

Investigations for GORD?

Answer 10

GORD is a clinical diagnosis (unless red flag/atypical symptoms present)

• trial of PPI is both diagnostic and therapeutic, therefore first-line
• if trial of PPI fails/atypical symptoms develop, then proceed to UGI endoscopy
• presence of oesophagitis/Barrett’s oesophagus may require biopsy (and confirms GORD)

Question 11

Management of GORD?

Answer 11

Conservative
- diet (avoid precipitants and lose weight), sleep (head of bed elevation), smoking/drug cessation

Pharmacological
- PPI or H2 antagonist

Surgical
- Nissen fundoplication (hiatus hernia as cause), endoluminal gastroplication

Question 12

Complications of GORD?

Answer 12

Barrett’s oesophagus leading to adenocarcinoma of the oesophagus

Strictures - lead to dysphagia

Question 13

Histological changes from GORD to Barrett’s to adenocarcinoma?

Answer 13

Metaplasia from normal to Barrett’s

Dysplasia from Barrett’s to oesophageal carcinoma

Question 14

What is Barrett’s oesophagus?

Answer 14

Metaplasia of the oesophagus due to chronic oesophagitis

Question 15

Histological change in Barrett’s oesophagus?

Answer 15

Squamous epithelium - metaplasia - columnar epithelium

Question 16

Main threat of Barrett’s oesophagus and (specific) management requirement?

Answer 16

11x increased risk of oesophageal cancer

- regular surveillance with endoscopy and biopsy

Question 17

Management of Barrett’s oesophagus?

Answer 17

Depends on endoscopy findings:

High-grade dysplasia (high risk of malignancy)
- radiofrequency ablation then PPI (ablates metaplasia and prevents any further metaplasia)

Nodule (malignancy)
- endoscopic resection of the nodule (or oesophagectomy) and then PPI to prevent recurrence/progression

Question 18

Oesophageal cancer symptoms?

Answer 18

• Progressive dysphagia from solid to liquids
• Burning chest pain
• Red flags (weight loss, anaemia)

Question 19

Types of oesophageal cancer, location + risk factors?

Answer 19

Adenocarcinoma (commonest)

• lower 1/3rd oesophagus
• Barrett’s oesophagus

Squamous cell

• middle 1/3rd
• smoking, alcohol

Question 20

Investigations in suspected oesophageal cancer?

Answer 20

UGI endoscopy + biopsy to diagnose/grade

CT to stage the cancer (spread)