GORD

Question 1

Why is the oesophagus more prone to damage from stomach acid than the stomach mucosa?

Answer 1

Oesophagus has squamous epithelial lining where as stomach as columnar epithelial and mucous-bicarbonate barrier, which provides more protection

Question 2

What happens in GORD?

Answer 2

Stomach acid is refluxed through the lower oesophageal sphincter causing irritating of the oesophagus

Question 3

What can cause GORD?

Answer 3

Weakening of LOS

Hiatus hernia
-GORD is more common in sliding hiatus hernia compared with rolling hiatus hernia due to sliding hiatus hernia leading to LOS become less competent (remains intact in rolling hiatus hernia)

Obesity

Gastric acid hypersecretion

Delayed gastric emptying

Smoking

Alcohol

Pregnancy

Certain drugs= TCA and nitrates

Helicobacter pylori

Question 4

Why is H pylori associated with development of GORD?

Answer 4

It can damage the epithelial lining of the stomach and might cause damage to the epithelial lining of the oesophagus
I.e. breaks in the epithelial lining leads to increased risk of damage to the underlying tissue if gastric acid infiltrates

Question 5

How might someone with GORD present?

Answer 5

Heartburn= retrosternal discomfort (may describe as chest pain)
-worsen after eating, stooping forward or lying down I.e. due to either increasing the producing of acid or due to the position exacerbating the incompetence of the LOS

Epigastric or retrosternal pain

Bloating

Belching

Water brash= excessive saliva production
I.e. patient says that mouth fills with saliva

Chronic nocturnal cough + hoarse voice due to acid irritating the vocal cords and upper oesophagus

Question 6

What can occur as a complication of GORD?

Answer 6

Oesophagitis

Ulcers

Benigns strictures= can leads to problems with swallowing

Barretts metaplasia
-distal oesophageal epithelium undergoes metaplasia where it changes from squamous to columnar epithelium

Question 7

What is Barrettes oesophagus? How is it managed and why is it important to detect early?

Answer 7

Metaplasia from squamous epithelium to columnar epithelium as a result of chronic GORD
NOTE: can present with improvement of reflux symptoms

Premalignant condition= patient at risk of developing adenocarcinoma

PPI and regular endoscopies to monitoring changes so can identify if has progressed to adenocarcinoma

Question 8

When is endoscopy indicated in GORD? What is

Answer 8

With dysphagia

Px >55 with ALARMS symptoms

• Anaemia (IDA)
• Loss of weight
• Anorexia
• Recent or progressive symptoms
• Melaena/haematemesis
• Swallowing difficulty

Treatment resistant/refractory dyspepsia

Question 9

How can GORD be managed?

Answer 9

Conservative:

• weight loss
• smoking cessation
• small regular meals
• reduce alcohol intake
• diet changes= decreased citrus intake, tomatoes, fizzy drinks, spicy foods and caffeine
• raise head in bed

Medical

• Antacids i.e. Magnesium trisilicate
• Alignates i.e. Gaviscon
• PPI i.e. Lansoprazole or omeprazole
• Ranitidine i.e. H2 receptor antagonist to reduce stomach acid production

Drugs to avoid:
-drugs effecting oesophageal motility or causing relaxation of LOS
I.e. nitrates, anticholinergics, Ca2+ channel blockers
-drugs damaging mucosa i.e. NSAIDs, bisphosphonates, K+ salts

Surgery:
-Laparoscopic fundoplication i.e. tying fundus of stomach around lower oesophagus to narrow the lower oesophageal sphincter