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Gastroesophageal reflux disease Flashcards

1
Q

Define gastroesophageal reflux disease

A

When the reflux of gastric juices increases in frequency and volume to cause troublesome symptoms and/or damage to the oesophageal mucosa

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2
Q

What is the normal anti-reflux mechanism in humans?

A
  1. Mechanically effective LES
  2. Efficient esophageal clearance
  3. Adequately functioning gastric reservoir
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3
Q

What is the LES?

A

Specialized muscular thickening (collar sling musculature and clasp fibers) at the gastro-esophageal junction that acts as a one way valve to allow food into the stomach after swallowing while preventing backflow of gastric contents into the esophagus

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4
Q

Which mechanisms modulate the LES?

A

Neural mechanisms

Hormonal mechanisms

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5
Q

How does the LES maintain its barrier function?

A
  1. Resting pressure
  2. Overall length
  3. Intra-abdominal length
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6
Q

When does physiologic reflex occur more commonly?

A

During awake hours

Upright position

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7
Q

Why does physiological reflux occur more commonly during awake hours and upright position?

A
  1. Transient loss of the gastro-esophageal barrier
    - relaxation of LES
    - intragastric pressure > LES pressure
  2. Increased pressure gradient between abdomen and thorax in upright position
  3. Apposition of hydrostatic abdominal pressure to the abdominal sphincter portion in supine
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8
Q

How is a permanently defective sphincter defined?

A

Mean resting pressure <6mmHg
Total sphincter length <2cm
Intra-abdominal sphincter length <1cm

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9
Q

How does the LES open?

A

Receptive relaxation during swallowing and with stomach/fundus distension

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10
Q

Name causes of stomach distension

A

Excessive eating
Excessive air swallowing
Delayed gastric emptying

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11
Q

What does repeated distension of the stomach lead to?

A

Permanent attenuation of the LES collar sling and clasp muscle fibres -> loss of acute Angle of His + stretching of phreno-esophageal ligament -> hiatal hernia

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12
Q

What usually clears gastric refluxate?

A

Peristalsis

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13
Q

Name typical symptoms of GERD

A

Heartburn
Regurgitation
Dysphagia

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14
Q

Name atypical symptoms of GERD

A 
Cough
Hoarseness
Chest pain
Asthma
Bronchospasm
Aspiration
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15
Q

What is the most specific symptom of foregut pathology?

A

Dysphagia

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16
Q

What are the two theories behind reflux-induced respiratory symptoms?

A

Reflux theory

Reflex theory

17
Q

How is GERD classified?

A

Based on appearance of the esophageal mucosa on endoscopy

  1. Erosive esophagitis
    - endoscopically visible breaks in the distal esophageal mucosa w/wo symptoms
  2. Non-erosive reflux disease
    - symptoms without visible mucosal injury
18
Q

Name complications of GERD

A 
Esophagitis
Esophageal stricture
Barrett's esophagus
Progressive pulmonary fibrosis
Chronic laryngitis
19
Q

Which injurious fluids cause GERD complications?

A

Acid
Pepsin
Biliary
Pancreatic

20
Q

How is esophagitis graded?

A

Los Angeles Classification

21
Q

Define a mucosal break as per the Los Angeles classification

A

An area of slough adjacent to normal mucosa in the squamous epithelium w/wo overlying exudate

22
Q

Give the Los Angeles classification of esophagitis

A

Grade A - 1 or more mucosal breaks <5mm
Grade B - at least 1 mucosal break >5mm but not continuous between tops of adjacent mucosal folds
Grade C - at least 1 mucosal break that is continuous between tops of adjacent folds but not circumferential
Grade D - mucosal break that involves at least 3/4 of luminal circumference

23
Q

Define an esophageal stricture

A

A fibrotic mucosal ring located at the squamocolumnar junction
AKA “Schatzki ring”

24
Q

What is Barrett’s esophagitis?

A

End stage GERD

Tubular squamous epithelium -> columnar epithelium with intestinal metaplasia

25
Q

Name complications of Barett’s oesophagus

A

Adenocarcinoma
Ulceration
Strictures

26
Q

Name potential investigations in GERD

A 
Endoscopy
Barium swallow
24h ambulatory pH monitoring 
Esophageal high resolution manometry
Esophageal impedance testing 
Symptomatic (ECG, echo)
27
Q

Discuss the management of GERD

A
  1. Lifestyle modification
    - elevate head of bed
    - avoid tight clothes
    - small, frequent meals
    - no eating before bedtime
    - avoid certain foods
  2. Medical
    - 12w simple antacids
    - PPI lifelong
  3. Surgical
    - Nissen’s fundoplication
    - partial fundoplication
28
Q

Name indications for antireflux surgery

A

Failure of medical therapy
Young patient
Structural defects
Complications

29
Q

Which GERD presentations need to be managed before antireflux surgery

A
  1. Atypical symptoms that don’t resolve with PPI
  2. Barrett’s
  3. Stricture

MBChB Surgery (38 decks)

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