GI - GORD

Question 1

What is the pathophysiology of GORD?

Answer 1

-LOS dysfunction leads to reflux of gastric contents and oesophagitis

Question 2

What are risk factors for GORD?

Answer 2

• Hiatus hernia
• Smoking
• EtOH
• Obesity
• Pregnancy
• Drugs: anti-AChM, nitrates, CCBs, TCAs

Question 3

GORD: symptoms

Answer 3

• Retrosternal pain: heartburn (worse lying down, related to meals, relieved by antacids)
• Belching
• Regurgigation
• Odonophagia
• Extra esophageal: nocturnal asthma, chronic cough, laryngitis/sinusitis

Question 4

GORD: complications

Answer 4

• Oesophagitis
• Benign stricture: dysphagia
• Barrett’s oesophagus (intestinal meta plasma of squamous epithelium - dysplasia - adenocarcinoma)

Question 5

GORD: differential

Answer 5

• oesophagitis (IBD, infection [CMV, candida], caustic substances/burns)
• PUD
• oesophageal Ca

Question 6

GORD: Ix

Answer 6

• If pt has isolated symptoms, don’t need Ix
• Bloods: check FBC
• CXR: might see hiatus hernia
• Do OGD if: pt>55ya, persistent symptoms, Anaemia, Loss of wt, Anorexia, Recent onset progressive symptoms, Malayan, Swallowing difficulty
• Do manometry to exclude dysmotility problems

Question 7

GORD: conservative Rx

Answer 7

• Lose wt
• raise head
• small regular meals
• stop smoking/alcohol intake
• avoid hot drinks/spicy foods
• Stop: NSAIDs, anti-AChM, nitrates, CCB, TCAs

Question 8

GORD: medical Rx (GP Mx)

Answer 8

• Over the counter antacids: gaviscon
  1. Full dose PPI for 1-2 mo: lansoprazole 30mg OD
  2. No response: double PPI dose (can go up to 60mg BD, but that is for Zollinger Ellison)
  3. No response: add an H2RA - Ranitidine 300mg

Question 9

GORD: surgical Rx

Answer 9

• Do surgical Rx if have severe symptoms, refractory to medical Rx and confirmed reflux (with pH monitoring)
• Do Nissan fundoplication bu mobilising gastric fungus and wrapping it around lower oesophagus

Question 10

Hiatus hernia: sliding vs rolling

Answer 10

• Sliding (80%): Gastro-oesophageal junction slides up into chest and often associated with GORD
• Rolling (15%): gastro-oesophageal junction remains in abdo but bulge of stomach rolls into chest alongside oesophagus. LOS remains intact so GORD uncommon but can strangulate
• 5% are mixed

Question 11

Hiatus hernia: Ix

Answer 11

• CXR: gas bubble and fluid level in chest
• Ba swallow: diagnostic
• OGD: assess for oesophagitis
• 24h pH and manometry: exclude Achalasia or dysmotility

Question 12

Hiatus hernia Rx

Answer 12

• Lose wt
• Rx for reflux
• Surgery if intractable symptoms despite medical Rx
• Should repair rolling hernia even if asymptomatic b/c these can strangulate