Gastro-oesophageal Reflux Disease (GORD)

Question 1

What is the epidemiology of GORD?

Answer 1

M>F at 2-3:1

25% of adults experience it; 5% daily

Recognised as a risk factor for oesophageal cancer

Question 2

What is the aetiology of GOD?

Answer 2

Before time and space were,

God is

Question 3

What is the aetiology of GORD?

Answer 3

Risk factors:

• Smoking, alcohol, fat, coffee, spicy food, chocolate, big meals
• Pregnancy, obesity, hiatus hernia, tight clothes
• Surgery in achalasia of the cardia, systemic sclerosis
• Drugs - tricyclics, anticholinergics, NSAIDs, dozycycline, bisphosphonates

Question 4

What is the pathophysiology of GORD?

Answer 4

Mostly through a combination of increased intra-abdominal pressure, delayed gastric emptying, increased acid secretion and abnormalities/relaxation of the tone of the cardiac sphincter

Bile is particularly caustic and duodenal reflux is more troublesome than gastric alone

Question 5

How does GORD present?

Answer 5

Heartburn:

• Burning pain
• Rising from the stomach/lower chest up the towards the neck
• Related to: meals, lying down, stooping, straining
• Relieved (at least in part) by antacids
• Often mistaken for chest pain

Water brash = excessive salivation
Taste of acid in mouth

Odynophagia (from oesophagitis or stricture)

Bloating/fullness

Chronic hoarseness of voice (Cherry-Donner syndrome), chronic cough, asthmatic wheeze/SOB

Episodic/chronic aspiration can cause pneumonia, lung abscess, interstitial pulmonary fibrosis

Question 6

How do you investigate GORD?

Answer 6

Usually a clinical diagnosis followed by a therapeutic trial of drugs

Endoscopy:

• Investigation of choice
• Should not take PPI or H2RA for a minimum of 2wks prior to appt.
• Graded with the Savary-Miller system - Grade 1 = mild up to grade 5 = Barrets Epithemium (columnar metaplasia) OR Los Angeles Grades A-D

Oesophageal pH monitoring:

• Naso-oseophageal pH catheter (24hrs)
• To see if symptoms coincide with acid in the oesophagus

Barium swallow:
- May show hiatus hernia

FBC:
- To exclude significant anaemia

Question 7

How do you initially manage GORD?

Answer 7

Ensure ruled out red flags for upper GI cancer e.g.

• Dysphagia
• Weight loss
• Proven anaemia
• Vomiting

Lifestyle:

• Reduce weight, cigarettes, alcohol, fatty/spicy food, hot drinks + eating in the 3hrs before bed
• Take small, regular meals, raise the head of the bed at night
• Avoid: nitrates, anticholinergics, tricyclics, NSAIDs, potassium salts, bisphosphonates (where possible)

Question 8

What OTC pharmacotherapy can you advise? How do they work?

Answer 8

Antacids:

• Sodium citrate, magnesium trisilicate
• Neutralises acid in the stomach as they are alkaline

Alginates:

• Sodium alginate
• Create a mechanical barrier by reacting with the stomach acid to form a raft which blocks acid from refluxing into the oesophagus

Can both be taken alongside further therapy when symptomatic

Question 9

What further pharmacotherapy can be used?

Answer 9

Proton pump inhibitor:

• Omeprazole, lanzoprazole, pantoprazole
• Full dose for 4-8wks depending on severity
• If symptoms recur after initial treatment and long term treatment needed, offer at the lowest effective dose
• Educate patients on when to use
• Irreversibly binds to and blocks the H,K-ATPase (proton pump) in gastric parietal cells, reducing levels of acid secretion directly

If inadequate response…

H2 receptor antagonist:

• Ranitidine
• Competitively and reversibly binds to H2 receptors on gastric parietal cells, reducing the histamine induced stimulation to produce more acid

Question 10

What surgery might be indicated in GORD?

Answer 10

Fundoplication
- Wraps fundus of stomach around lower oesophagus to create a new sphincter

Can now have an artificial magnetic sphincter inserted instead

Question 11

Who should be on long term PPIs?

Answer 11

People with NSAID-induced ulcers who must continue with NSAIDs e.g. severe RA

Severe reflux oesophagitis

Patients with complicated reflux disease i.e. stricture, ulcer, haemorrhage

People who have to take other medications that are destructive to the gastric mucosa
- Steroids

Question 12

What are some risks associated with GORD?

Answer 12

Barrets oesophagus -

• Metaplasia of cells in the distal oesophagus from stratified squamous to simple columnar epithelium (from stomach)
• These cells are precancerous - may need monitoring +/- radiofrequency ablation or surgery if becomes full oseophageal adenocarcinoma
• Associated with longer duration + frequency of symptoms
• Long term PPI use may also however, be associated with gastric cancer

Stricture

Ulcer

Anaemia (iron deficiency, including caused by PPI)