GORD

Question 1

Definition

Answer 1

Where acid from the stomach refluxes through the lower oesophageal sphincter + irritates the lining of the oesophagus = symptoms of oesophagitis

Question 2

What are the two sphincter mechanisms at the gastroesophageal junction which usually prevent reflux

Answer 2

Lower oesophageal sphincter
Diaphragmatic sphincter

Question 3

Epidemiology

Answer 3

Age: more common in elderly

Question 4

Risk factors

Answer 4

Family history
Obesity: raised iatrogenic pressure
Pregnancy: raised iatrogenic pressure
Hiatus hernia: disrupts anatomy at the GOJ
Smoking and alcohol
Drugs: that decrease LOS pressure e.g. nitrates, caffeine, calcium channel blockers
Fatty foods: delays gastric emptying

Question 5

Physiology of stomach acid and LOS

Answer 5

The oesophagus has squamous epithelium = more sensitive to stomach acid
Stomach has columnar epithelial lining which dive into laminar propria forming gastric pits including secretory cells
- G cells = secrete gastrin
- Parietal cells = secrete HCl + intrinsic factor
- Chief cells = secrete pepsinogen which is cleaved into pepsin by HCl
- Foveolar cells (aka surface mucous cells) = secrete mucus to protect the gastric mucosa from HCl
The LOS relaxes to allow passage of food + contracts to close in between meals
- Primary peristalsis is contraction of the oesophagus which propels food down to the stomach
- Secondary peristalsis occurs shortly after swallowing to propel any reflux back into stomach

Question 6

Aetiology

Answer 6

• Increased sphincter relaxation (normally relax transiently to allow exit of accumulated gases
• Raised intragastric pressure = higher than that which can be tolerated by sphincter mechanisms = pregnancy + obesity
• Reduced sphincter tone = this allows intragastric pressure to overcome the sphincter mechanisms more easily (drugs; nitrates, and CCBs, reduce tone)
• Anatomical abnormalities of the GOJ = disrupts the functioning of the sphincter e.g. hiatus hernia
• Oesophageal dysmotility - impaired oesophageal peristalsis the ability of the oesophagus to clear acid

Question 7

Signs

Answer 7

Examination is often normal unless there is evidence of dental erosions from severe GORD

Question 8

Symptoms

Answer 8

Dyspepsia = non specific term use to describe indigestion
- Heartburn (retrosternal burning pain)
- Sour bitter taste of acid at the back of the mouth
- Acid regurgitation
- Retrosternal or epigastric pain
- Bloating
- Nocturnal cough
- Hoarse voice

Question 9

Extra oesophageal symptoms

Answer 9

Chronic asthma
Nocturnal asthma
Hoarse voice
Laryngitis
Sinusitis
SYMPTOMS WORSE ON LYING DOWN

Question 10

Diagnosis

Answer 10

FIRST LINE = Therapeutic challenge = Give PPI for 8 weeks
= total investigation basically
GOLD STANDARD =
- Done in red flag Px (wt. loss, dysphagia, haematemesis)
- Oesophageal manometry + 24 hour pH monitoring = measure LOS pressure + pH
- a pH < 4 more than 4% of the time is abnormal
ENDOSCOPY = oesophagitis, or Barrett’s oesophagus

Question 11

Treatment

Answer 11

Conservative lifestyle =
- stop smoking
- stop alcohol
- weight loss, smaller meals + 3hrs before bed)
- change sleeping position
FIRST LINE = PPI for 8 weeks
- Omeprazole
- H2RA = ranitidine if PPI CI
Ant-acids (SE = diarrhoea)
Alginates = Gaviscon (SYMPTOMATIC)
LAST RESORT = NISSEN FUNDOPLICATION (surgical tightening of LOS)

Question 12

Complications

Answer 12

Barret’s oesophagus
Oesophageal strictures
- 60 + Px
- progressively worsening dysphagia
- TX = Oesophageal dilation (endoscopic) + PPI

Question 13

Red flag symptoms

Answer 13

Dysphagia (slow progressive onset)
> 55 years
weight loss
haematemesis (cough up blood)
upper Abdo pain
treatment resistant dyspepsia
palpable mass