Gastro-oesophageal reflux disease (GORD)

Question 1

Define GORD

Answer 1

Inflammation of the oesophagus caused by reflux of gastric acid &/or bile

Question 2

Aetiology of GORD

4

Answer 2

Caused by disruption of mechanisms that prevent reflux:

• Lower oesophageal sphincter
• Acute angle of junction
• Mucosal rosette
• Intra-abdominal portion of oesophagus

Question 3

Contribution to aetiology of GORD

Answer 3

Prolonged oesophageal acid clearance contributes to 50% of cases

Question 4

Epidemiology of GORD

prevalence

Answer 4

Common (5-10% adults)

Question 5

Presenting symptoms

4

Answer 5

Substernal/epigastric burning discomfort or “heartburn”

Waterbrash

Aspiration

Dysphagia

Question 6

Definition of waterbrash

Answer 6

Regurgitation of excessive accumulation of saliva from the lower part of the oesophagus (often w/ some acid material from the stomach)

Question 7

Heartburn aggravating & relieving factors

4 + 1

Answer 7

Aggravated by:
lying supine
bending
large meals
drinking alcohol

Pain relieved by antacids

Question 8

Effects of aspiration

4

Answer 8

hoarseness, laryngitis, nocturnal cough & wheeze

Question 9

Cause of dysphagia

Answer 9

formation of peptic stricture after long standing reflux

Question 10

Signs on physical examination

1 + 3

Answer 10

Usually NORMAL

Occasionally epigastric tenderness, wheeze on chest auscultation, dysphonia

Question 11

Investigations for GORD

type of diagnosis + 4

Answer 11

Often a CLINICAL diagnosis

Upper GI endoscopy, biopsy & cytological brushings

Barium swallow

CXR

24hr oesophageal pH monitoring

Question 12

Findings of investigations for GORD

4 - 2,3,1,1

Answer 12

Upper GI endoscopy, biopsy & cytological brushings
Confirms presence of oesophagitis & can exclude malignancy

Barium swallow
Can detect:
-Hiatus hernia
-Peptic stricture
-Extrinsic compression of oesophagus

CXR
Not specific for GORD
-Can lead to incidental finding of hiatus hernia (gastric bubble behind cardiac shadow)

24hr oesophageal pH monitoring
pH probe in lower oesophagus determines temporal relationship between symptoms & pH

Question 13

Approach to management of GORD

4

Answer 13

Advice
Medical
Endoscopy
Surgery

Question 14

Management of GORD - advice

3

Answer 14

Weight loss

Elevating head of bed

Avoid provoking factors -
lower fat meals, avoid large meals in evening, stop smoking

Question 15

Management of GORD - medical

4

Answer 15

Antacids
Alginates
H2 antagonists
Proton pump inhibitors

Question 16

Management of GORD - endoscopy

2

Answer 16

Annual endoscopic surveillance (for Barrett’s oesophagus)

May be necessary for stricture dilation or stenting

Question 17

Management of GORD - surgery

2

Answer 17

Antireflux surgery if refractory to medical treatment

Nissen fundoplication

Question 18

Complications of GORD

6

Answer 18

Oesophageal ulceration
Peptic stricture
Anaemia
Barrett’s oesophagus
Oesophageal adenocarcinoma
Associated w/ asthma & chronic laryngitis

Question 19

Prognosis for GORD

3

Answer 19

50% respond to lifestyle measures alone

Withdrawal of drug therapy often associated w/ relapse

20% patients undergoing endoscopy for GORD have Barrett’s oesophagus