GORD Flashcards
Definition
Where acid from the stomach refluxes through the lower oesophageal sphincter + irritates the lining of the oesophagus = symptoms of oesophagitis
What are the two sphincter mechanisms at the gastroesophageal junction which usually prevent reflux
Lower oesophageal sphincter
Diaphragmatic sphincter
Epidemiology
Age: more common in elderly
Risk factors
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
Aetiology
Lower oesophageal sphincter tension
- smoking, alcohol
Increased intra-abdo pressure:
- Obesity, Pregnancy
Gastric acid hypersecretion/ Delayed gastric emptying
Hiatus hernia
Oesophageal dysmotility (e.g. systemic sclerosis)
Drugs: tricyclics, anticholinergics, nitrates
Helicobacter pylori
Physiology of stomach acid and LOS
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
Pathophysiology
GORD is caused by the following:
- 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
Signs
Examination is often normal unless there is evidence of dental erosions from severe GORD
Symptoms
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
Extra oesophageal symptoms
Chronic asthma
Nocturnal asthma
Hoarse voice
Laryngitis
Sinusitis
SYMPTOMS WORSE ON LYING DOWN
Diagnosis
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
Treatment
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)
Complications
Barret’s oesophagus
Oesophageal strictures
- 60 + Px
- progressively worsening dysphagia
- TX = Oesophageal dilation (endoscopic) + PPI
Red flag symptoms
Dysphagia (slow progressive onset)
> 55 years
weight loss
haematemesis (cough up blood)
upper Abdo pain
treatment resistant dyspepsia
palpable mass
