GORD

Question 1

What is gastro-oesophageal reflux disease (GORD)?

Answer 1

LOS dysfunction –> stomach acid reflux –> irritates oesophageal lining –> oesophagitis

Question 2

What type of lining does the

a. Oesophagus
b. Stomach have?

Answer 2

Oesophagus = squamous epithelial cell 
Stomach = columnar epithelial cell

Question 3

What are the oesophageal related symptoms of GORD?

Answer 3

Oesophageal: Dyspepsia related symptoms:

Heartburn - related to meals, worse lying down/ stooping, relieved by antacids
Acid regurgitation - acid brash/water brash
Bloating & belching
Odonophagia

Question 4

What are the extra-oesophageal symptoms of GORD?

Answer 4

Extra-oesophageal: 
Hoarse voice 
Chronic cough
Nocturnal asthma 
Laryngitis/ sinusitis

Question 5

Risk factors for GORD

Answer 5

Hiatus hernia 
Smoking 
Alcohol
Obesity
Pregnancy 
Drugs: anti-AChM, nitrates, CCBs, TCAs
Iatrogenic: Heller's myotomy

Question 6

Investigations for GORD

Answer 6

Isolated symptoms don't need Ix
Bloods: FBC
CXR: hiatus hernia may be seen
OGD if:
- over 55 years
- symptoms >4 weeks
- persistent symptoms despite Rx
- weight loss 
Ba swallow: hiatus hernia, dysmotility
24h pH testing +/- manometry
- ph <4 for > 4hrs

Question 7

OGD allows grading by which classification?

Answer 7

Los angeles classification

Question 8

Differentials of GORD

Answer 8

Oesophagitis 
- infection, CMV, candida
- IBD
- caustic substances, burns 
PUD
Oesophageal Ca

Question 9

Conservative management of GORD

Answer 9

Loss weight
Raise head of bed for sleep
Small regular meals more than three hours before bed
Stop smoking
Reduce alcohol intake
Avoid spicy food, caffeine
Stop drugs: NSAIDs, steroid, CCBs, nitrates

Question 10

Medical management of GORD

Answer 10

OTC antacids: Gaviscon/ Rennie/ Mg trisilicate

1. Full dose PPI for 1-2mo
   - Omeprazole PO 20mg OD
   - Lansoprazole PO 30mg OD
2. No response - double dose PPI BD
3. No response - add H2RA = Ranitidine 300mg nocte
   - neutralises stomach acid

Question 11

Surgical management of GORD

Answer 11

Nissen fundoplication if:
Severe symptoms
Refractory to medical rx
Confirmed reflux on pH monitoring

Question 12

Aim of Nissen fundoplication

Answer 12

Resolve symptoms - preventing reflux by repairing diaphragm
Usually laparoscopic approach
Mobilise gastric fundus and wrap around LOS
Close any diaphragmatic hiatus

Question 13

Complications of Nissen fundoplication

Answer 13

Bloating
Inability to belch/vomit
Dysphagia if wrapped too tight

Question 14

Complications of GORD

Answer 14

Oesophagitis - heartburn
Ulceration –> haematemesis (rarely), meleana, iron deficiency
Benign stricture: dysphagia
Barrett’s oesophagus - metaplasia of squamous epithelium –> dysplasia –> adenocarcinoma
Oesophageal adenocarcinoma

Question 15

What is Barrett’s oesophagus

Answer 15

Premalignant condition - where constant reflux of gastric contents causes metaplasia of the squamous epithelium of the oesophagus –> low grade dysplasia–> high grade dysplasia –> risk of adenocarcinoma
Patients report an improvement in their symptoms when this happens

Question 16

What is the risk of progression of Barrett’s to adenocarcinoma?

Answer 16

3-5% lifetime risk

Question 17

How are pts with Barrett’s oesophagus monitored

Answer 17

Regular endoscopy

Question 18

What is the management of Barrett’s oesophagus?

Answer 18

PPIs e.g. omeprazole

Some evidence that regular aspirin can prevent development of adenocarcinoma but this isn’t in guidelines yet

Question 19

What other treatment can be offered to patients with low-high grade dysplasia Barrett’s oesophagus

Answer 19

Ablation therapy - laser, photodynamic and cryotherapy during endoscopy
To change the epithelium to normal cells & prevent progression to cancer