Gastro-Oesophageal Reflux Disease (GORD) Flashcards
Define GORD
Symptoms or complications caused by reflux of gastric acid and/or bile
May occur with OR without oesophagitis
What is the pathophysiology of GORD?
GORD develops when reflux-promoting factors overcome protective mechanisms
Reflux-promoting factors:
- corrosiveness of the gastric juice
Protective mechanisms:
- LOS
- Oesophageal acid clearance (salivary bicarbonate neutralises acid and peristalsis moves the refluxed contents back to the stomach to limit exposure)
What is the aetiology of GORD?
Increased intra-abdominal pressure:
- Obesity
- Pregnancy
(Intragastric pressure > LOS pressure → LOS forced open → reflux)
Decreased LOS tone (LOS relaxation):
- Drugs (anti-muscarinics, CCBs, nitrates)
- Smoking (nicotine)
- Achalasia treatment
Hiatus hernia (portion of the stomach prolapses through diaphragmatic oesophageal hiatus → impairs the ability of the diaphragm to function as an external sphincter)
Gastric hypersecretion:
Dietary → alcohol, fat, coffee
Zollinger-ellison syndrome → gastrin secreting neuroendocrine tumour
(Intragastric pressure > LOS pressure → LES forced open → reflux)
What are the risk factors of GORD?
- Family history of heartburn or GORD
- Older age
- Hiatus hernia
- Obesity
- Pregnancy
- Smoking
- Alcohol
What is the epidemiology of GORD?
Common - occurs in 5-10% of adults
What are the presenting symptoms of GORD?
TYPICAL:
- Substernal burning discomfort (i.e. heartburn)
Heartburn aggravated by:
- Lying supine
- Bending
- Large meals
- Drinking alcohol
Heartburn relieved by antacids
- Regurgitation of gastric contents → water brash (sour taste in mouth due to excessive saliva production mixing with gastric contents)
OTHER:
Aspiration:
- Voice hoarseness
- Laryngitis
- Nocturnal cough
- Wheeze
- Pneumonia (rare)
Dysphagia (caused by formation of oesophageal stricture after long-standing reflux)
What investigations would you do if you were suspecting GORD and what would you expect to see?
PPI trial - 1st investigation:
- To see if symptoms improve with this
OGD, biopsy and cytological brushings:
- To show oesophagtis
- Should be done to exclude malignancy in all patients > 45 years
Barium swallow can detect:
- Hiatus hernia
- Peptic stricture (also known as oesophageal stricture)
- Extrinsic compression of the oesophagus
Chest x-ray:
- NOT specific for GORD
- can lead to the incidental finding of a hiatus hernia (gastric bubble behind the cardiac shadow)
24-hour oesophageal pH monitoring:
- pH probe placed in lower oesophagus to determine the temporal relationship between symptoms and oesophageal pH
What is the management of GORD?
Lifestyle changes:
- Weight loss
- Elevating head of bed
- Avoid provoking factors
- Stopping smoking
- Lower fat meals
- Avoiding large meals late in the evening.
Medical:
- PPI (e.g. lansoprazole) for 4 weeks
- H2 antagonists (e.g. ranitidine) if inadequate response to PPI
If severe oesophagitis:
- PPI for 8 weeks to heal
- PPI for long-term maintenance
Endoscopy:
- Annual surveillance for Barretts oesophagus
- May be necessary for stricture dilation or stenting
Surgery:
(for those with symptoms despite optimal medical management or in those intolerant of medication)
- Nissen fundoplication
(fundus of the stomach is wrapped around the lower oesophagus and held with sutures → results in a narrowing of the gastro-oesophageal junction to prevent reflux)
What are the complications of GORD?
- Oesophageal ulceration → chronic bleeding → anaemia
- Peptic stricture (oesophageal stricture)
- Barretts oesophagus → oesophageal adenocarcinoma.
- Chronic laryngitis and asthma exacerbation (due to aspiration)
What is the prognosis for GORD?
- 50% respond to lifestyle measures alone
- In patients who require drug therapy withdrawal is often associated with relapse
- 20% of patients undergoing endoscopy for GORD have Barrett’s oesophagus
