GORD Flashcards
What is gastro-oesophageal reflux disease (GORD)?
Gastro-oesophageal reflux disease (GORD) is a condition whereby gastric acid from the stomach leaks up into the oesophagus.
How common is GORD?
It is a very common problem, affecting around a quarter of the population in Western countries and represents approximately 4% of primary care appointments. It is twice as common in men compared to women.
Briefly describe the pathophysiology of GORD
The lower oesophageal sphincter controls the passage of contents from the oesophagus to the stomach.
As part of its normal function, episodic sphincter relaxation is expected, yet in GORD these episodes become more frequent and allow the reflux of gastric contents into the oesophagus.
The refluxed acidic gastric contents (or rarely alkaline bile) result in pain and mucosal damage in the oesophagus.
What are the risk factors for GORD?
The risk factors for gastro-oesophageal reflux disease include age, obesity, male gender, alcohol, smoking, caffeinated drinks and fatty or spicy foods.
What are the clinical features of GORD?
The main symptom of gastro-oesophageal reflux disease is chest pain. This is classically a burning retrosternal sensation, worse after meals, lying down, bending over or straining. Typically, it is relieved (at least partially) by antacids.
Additional symptoms may include excessive belching, odynophagia, a chronic cough, or a nocturnal cough.
Examination is typically unremarkable.
What are the red flag symptoms for GORD?
Always check for red flag symptoms (dysphagia, weight loss, early satiety, malaise and loss of appetite) for any underlying malignancy.
Briefly describe The Los Angeles Classification
The Los Angeles classification can be used to grade reflux oesophagitis based on severity from the endoscopic findings of mucosal breaks in the distal oesophagus:
- Grade A – breaks ≤5mm
- Grade B – breaks >5mm
- Grade C – breaks extending between the tops of ≥2 mucosal folds, but<75% of circumference
- Grade D – circumferential breaks (≥75%)
Which patients presenting with red flag symptoms require 2 week wait referrel for endoscopy?
NICE guidance states the red-flag symptoms for a suspected upper GI malignancy requiring urgent endoscopy are:
- Patients with dysphagia
- Any patient >55yrs with weight loss and upper abdominal pain, dyspepsia or reflux
What investigations should be ordered for GORD?
Note: imaging
The main role of upper GI endoscopy is to exclude malignancy and investigate for complications of reflux (oesophagitis, stricturing, or Barrett’s oesophagus). It is not required in the majority of patients.
However, if the symptoms are new onset (particularly in older patients) or worsening despite PPI, patients should be referred for an endoscopy.
24hr pH monitoring is the gold standard in the diagnosis of GORD and is required for patients in whom medical treatment fails and surgery is being considered. It should be combined with oesophageal manometry to exclude oesophageal dysmotility.
What is the role of 24hr pH monitoring for GORD?
pH monitoring studies assess various criteria such as the amount of time acid is present in the oesophagus and the correlation between the presence of acid and the patient’s symptoms.
This produces an algorithmic score called the DeMeester score and can help determine a patient’s symptom / reflux correlation.
What is the conservative management of GORD?
All patients with gastro-oesophageal reflux disease should be advised to take conservative steps in its management, including avoiding known precipitants (alcohol, coffee, fatty foods), weight loss and smoking cessation.
What is the medical management of GORD?
Proton pump inhibitors (in addition to lifestyle changes) are the first-line treatment and are very effective for the majority of patients.
Symptoms tend to recur rapidly after ceasing to take PPIs and so many patients are likely to remain on them life-long (unless they proceed to surgery).
When is surgical management for GORD indicated?
There are three main indications for surgery in gastro-oesophageal reflux disease:
- Failure to respond (or only a partial response) to medical therapy
- Patient preference to avoid life-long medication
- Patients with complications of GORD (in particular respiratory complications such as recurrent pneumonia or bronchiectasis)
Surgery has been shown to be more effective than medical treatment in terms of symptom relief, quality of life improvement, and cost. However, due to associated complications and side-effects, many patients are understandably reluctant to accept it.
What is the main surgical management offered to patients for GORD?
A fundoplication.
Briefly describe fundoplication
The main surgical intervention that can be offered for patients with GORD is a fundoplication, whereby the gastro-oesophageal junction and hiatus are dissected and the fundus wrapped around the GOJ, recreating a physiological lower oesophageal sphincter.
Several different approaches to the procedure have been described, differing in direction and completeness of the wrap (such as the posterior 360 (Nissen’s) approach or the partial anterior).
