Gastro-oesophageal reflux disease (GORD)

Question 1

Who is affected?

Answer 1

10-20% of people in Western countries

All age groups

5% of adults affected

Question 2

What is the aetiology of GORD?

Answer 2

Episodes of transient lower oesophageal sphincter relaxation occur more frequently&raquo_space;» causing reflux of gastric contents into the oesophagus

Question 3

Patients with severe reflux often have what?

Answer 3

A hiatus hernia

Question 4

The severity of mucosal damage depends on what 3 factors?

Answer 4

1. Duration of contact with gastric contents
2. Characteristics of the gastric contents
3. Resistance of the epithelium to damage

Question 5

The duration of contact with gastric contents depends on what 3 factors?

Answer 5

1. Number of episodes of reflux
2. Efficacy of oesophageal peristalsis
3. Neutralisation of acid by saliva

Question 6

What are the risk factors for GORD?

Answer 6

Heartburn / ‘dyspepsia’

Acid regurgitation

Dysphagia

Belching, N&V

Bloating/early satiety

Laryngitis

Globus sensation

Halitosis

Question 7

What are the red flags associated with GORD?

Answer 7

Upper abdo mass, dysphagia, aged 55+, weight loss

Question 8

What is the 1st line investigation for GORD?

Answer 8

PPI trial. Further tests are indicated if symptoms do not improve within 8 weeks or if pt has alarm symptoms.

Question 9

What investigations would be done if red flags were present?

Answer 9

Endoscopy + pH monitoring

Question 10

Apart from 1st line investigations, what other investigations would you consider?

Answer 10

OGD (oesophagogastroduodenoscopy) - may show oesophagitis (erosion, ulceration, strictures) or Barrett’s oesophagus

Ambulatory pH monitoring

Question 11

What are the differential diagnoses?

Answer 11

Oesophagitis

CAD (coronary artery disease)

Functional oesophageal disorder/functional heartburn

Achalasia

Peptic ulcer disease

Malignancy

Question 12

What is the initial/acute treatment?

Answer 12

1st line - Standard-dose PPI

Plus - Lifestyle changes - weight loss, head-of-bed elevation, avoid late night eating, food eliminations (caffeine, alcohol, acidic and/or spicy food)

Question 13

What is the ongoing/PPI responsive treatment?

Answer 13

1st line - Continued standard-dose PPI

2nd line - Surgery - if have good response to PPIs but do not wish to take long-term medical treatment

Question 14

What is the treatment when there is an incomplete response to PPI?

Answer 14

1st line - High dose PPI and further testing - dosing is twice daily (before breakfast + dinner)

With nocturnal component - adjunct a H2 antagonist

Question 15

What complications can occur?

Answer 15

Oesophageal ulcer, haemorrhage or perforation

Oesophageal stricture

Barrett’s oesophagus

Adenocarcinoma of the oesophagus