GORD

Question 1

What is GORD?

Answer 1

Reflux of gastric contents into oesophagus results in symptoms and/or complications.

Clinical diagnosis

Question 2

How can symptoms of GORD be categorised?

Answer 2

Typical (ie: heartburn and acid regurg)

Extra-oesophageal (ie: laryngitis)

Atypical (ie: bloating and dyspepsia).

Question 3

Aetiology of GORD?

Answer 3

Increased episodes of transient LOS relaxation leading to reflux of gastric contents

Transient LOS relaxation more common after meals and stimulated by fat in duodenum

Patients w severe reflux often have hiatus hernia

Question 4

Risk factors of GORD?

Answer 4

Strong:
- Fam Hx heartburn/ GORD
- Older age
- Hiatus hernia - same management
- Obesity
- LOS tone reduction

Weak:
- Meds that reduce tone (nitrates, anticholinergics, TCAs)
- Smoking, alcohol
- Increased intra-abdo pressure (i.e: pregnancy)

Question 5

Signs and symptoms of GORD?

Answer 5

• Heartburn (retrosternal)
• Acid regurg.
• NB: will be relieved by antacids
• Water brash: excessive saliva production
• Odynophagia
• Laryngitis
• Dyspepsia

Question 6

Key differentials for GORD?

Answer 6

MI, Pancreatitis, PUD

Question 7

Investigations for GORD?

Answer 7

• 8 week trial of PPIs - diagnostic (clinical)
• OGD - if not resolved/atypical - excl. malignancy
• LOS manometry - achalasia
• CXR - incidental hiatus hernia finding (gastric bubble behind heart)

Question 8

First-line management of GORD?

Answer 8

• Lifestyle: lose weight, reduce alcohol + fatty meals
• PPIs (standard dose, 8w)
  
  • Omeprazole/ esomeprazole/ rabeprazole
• Consider test and treat for H pylori

Question 9

Second-line management of GORD (if ongoing and PPI responsive)?

Answer 9

Nissen fundoplication
-Wrap top of stomach around lower esophagus. Reinforces lower esophageal sphincter reducing chance of reflux

Question 10

How is H pylori tested for?

Answer 10

Carbon 13 urea breath test
Blood serology
Endoscopic biopsy

Question 11

How does carbon 13 urea breath test work?

Answer 11

• Naturally-occurring gastric urea made up of 99% carbon isotope12C and 1% carbon isotope13C.
• Patients first drink sachet of orange juice, which rapidly closes duodenal sphincter to contain stomach contents. Patient then blows into glass tube w screw cap= baseline sample.
• Then consume drink containingenriched urea and after repeat= post-dose sample.
• Analyse both samples by mass spectrometry.
• Level of13C in baseline sample: normal.
• Increased levels in post-dose sample:H pylori. (Enriched urea has been broken down to produce high levels of13C; implies the presence ofH pyloriwhich excretes urease.)

Question 12

Treatment for H pylori?

Answer 12

PPI + amoxicillin/ clarithromycin/ metronidazole

Usually given a course of at least 2 antibiotics at once

Question 13

Potential complications of GORD? (4)

Answer 13

• Barret’s oesophagus
• Oesophageal ulceration
• Adenocarcinoma
• Peptic stricture