Gastro-oesophageal reflux (GORD) Flashcards
Describe the metaplasia seen in Barrett’s oesophagus
Squamous epithelium lower down oesophagus becomes a specialised columnar cell layer
What cancer is someone with Barrett’s oesophagus predisposed to?
Adenocarcinoma
What is the oesophagus?
A muscular tube approximately 20cm long that connects the pharynx to the stomach just below the diaphragm
What is the function of the oesophagus
To transport food from the mouth to the stomach
What epithelium is the oesophagus lined by?
Stratified squamous
until the squamocolumnar junction where the oesophagus joins the stomach
Which oesophageal sphincter is responsible for the prevention of reflux?
Lower oesophageal sphincter
What separates the oesophagus from the pharynx
Upper Oesophageal sphincter
normally closed due to tonic activity of the nerves supplying the cricopharngeus
Describe the process of swallowing
The bolus of food is VOLUNTARILY moved from the mouth to the pharynx.
Before the food can enter the oesophagus, the upper oesophageal sphincter (OS) relaxes immediately and as soon as the food has passed through it immediately closes.
The reflex results in the initial relaxation of the smooth muscles of the lower OS followed by their contraction.
Pharyngeal and oesophageal peristalsis mediated by this swallowing reflex causes primary peristalsis.
Once in the oesophagus, food moves towards the stomach by a progressive wave of muscle contractions proceeding along the oesophagus. This secondary
peristalsis arises as a result of stimulation by a food bolus in the lumen,
mediated by a local intra-oesophageal reflex.
What mediates the voluntary movement of food bolus from the mouth to the pharynx in swallowing
Mediated by a complex reflex involving a swelling centre in the dorsal motor nucleus of the vagus in the brainstem
What is GORD
Abnormal reflux from the stomach refluxes into the oesophagus subsequently damaging the squamous oesophageal lining causing discomfort
GORD: clinical presentation (signs and symptoms)
Heartburn - pain is worse in certain positions e.g. lying down/stooping and is worse after heavy meals Acid taste in mouth - regurgitation Water brash (excess salivation) Dysphagia Nocturnal asthma/chronic cough Laryngitis Odynophagia (pain when swallowing)
GORD: Pathophysiology
Tone of the lower OS is reduced as well as frequent transient relaxations of the LOS.
Increased mucosal sensitivity to gastric acids.
Hiatus hernia (part of stomach pass through hiatus in diaphragm) can cause increased reflux, but reflex can occur without one
GORD: Aetiology
Smoking, alcohol, pregnancy, obesity, big meals.
Complication of hiatus hernia
Oesophageal dismobility
Any reason for inadequate LOS function (LOS hypotension)
Gastric acid hyper secretion
GORD: Epidemiology
2-3x more common in men
25% of adults experience heartburn
*GORD: Diagnosis
Endoscopy
Barium swallow
Example of a PPI
Omeprazole
Example of a H2 receptor antagonist
Ranitidine
GORD complications
Oesophageal stricture formation: worsening dysphagia. (**Peptic stricture)
**Barrett’s Oesophagus: abnormal columnar epithelium replaces the squamous epithelium of the distal oesophageus. Irreversible. Can develop into oesophageal cancer.
*What drugs can cause GORD
Tricyclics
Anticholinergics
Nitrates
What do investigations of GORD depend on?
Age
Investigations of GORD for <55 year old
Proceed to treatment unless they have ALARM symptoms e.g. unintentional weight loss, dysphagia, haematemesis, melaena and anorexia
Investigations of GORD for >55 year old (check correct age in mindmaps)
Send patient to endoscopy: diagnostic and allows for biopsy
24-h pH monitoring
Conservative treatment of GORD
Education, weight loss, raising head of bed at night and avoidance of precipitating factors e.g. smoking, large meals
**Medical treatment of GORD
Antacids e.g. aluminium hydroxide (or Gaviscon)
H2 receptor antagonists e.g. ranitidine
Proton pump inhibitors e.g. omeprazole
Surgical treatment of GORD
Nissens fundoplication
Causes
Genetic inheritance of angle of lower oesophageal sphincter
Oesophagitis
Sliding hiatus hernia
Rolling hiatus hernia
Risk factors
Stress
Increased abdominal pressure e.g. obesity or pregnancy
Hiatus hernia
Smoking
Excessive alcohol
Excessive coffee
Drugs e.g. calcium channel blockers, antimuscarinics and tricyclic antidepressants
*What is Barrett’s oesophagus
METAPLASIA of the normal squamous epithelium of the lower oesophagus to columnar epithelium. This occurs un patients who suffer with GORD for several years.
It is a premalignant lesion
Investigations of Barrett’s oesophagus
Endoscopy with biopsy in all 4 quadrants
Complications of Barrett’s oesophagus
Adenocarcinoma of oesophagus
*Treatment of Barrett’s oesophagus
HALO system radio-frequency ablation
or mucosal resection for highly dysplastic lesions
Treatment of Highly Dysplastic Barretts oesophagus lesions
Mucosal resection
*Differentials
Pericarditis
Pulmonary embolism
Myocardial infarction
*Red flags
Coughing blood
Weight loss
Dysphagia
