GORD

Question 1

Pathophysiology of GORD

Answer 1

acid from the stomach refluxed through the lower oesophageal sphincter and irritates the lining of the oesophagus.

Question 2

risk factors: GORD

Answer 2

Helicobacter pylori

gram negative aerobic bacteria. It lives in the stomach. It causes damage the epithelial lining of the stomach resulting in gastritis, ulcers and increasing the risk of stomach cancer. It avoids the acidic environment by forcing its way into thegastric mucosa. The breaks it creates in the mucosa exposes theepithelial cellsunderneath to acid.

It also producesammoniato neutralise the stomach acid. Theammonia directly damages theepithelial cells. Other chemicals produced by the bacteria also damage the epithelial lining.

We offer a test forH.pylorito anyone with dyspepsia. They need 2 weeks without using a PPI before testing for H. pylori for an accurate result.

Question 3

Tests?

Answer 3

• Urea breath test using radiolabelled carbon 13
• Stool antigen test
• Rapid urease test can be performed during endoscopy.

Arapid urease testis also known as aCLO test(Campylobacter-like organism test). It is performedduring endoscopyand involves taking a small biopsy of the stomachmucosa.Ureais added to this sample. IfH. pyloriare present, they produceurease enzymesthat converts theureatoammonia. The ammonia makes the solution more alkali giving a positive result on when the pH is tested.

Question 4

Clinical presentation

Answer 4

Dyspepsia is a non-specific term used to describe indigestion. it covers the symptoms of GORD:

• heartburn
• acid regurgitation
• retrosternal or epigastric pain
• bloating
• nocturnal cough
• hoarse voice

Question 5

Treatment + management

Answer 5

Lifestyle advice:
- reduce tea, coffee and alcohol
- weight loss
- avoid smoking
- small, lighter meals
- avoid heavy meals before bed time
- stay upright after meals rather than lying flat

Acid neutralising medication when required:
- gaviscon
- Rennie

PPI (reduce acid secretion in the stomach)
- omeprazole
- lansoprazole

Ranitidine
- this is an alternative to PPIs
- H2 receptor antagonist (antihistamine)
- reduces stomach acid

Surgery for reflux is called laparoscopic fundoplication

• involves tying the fundus of the stomach around the lower oesophagus to narrow the lower oesophageal sphincter

Question 6

Important for treatment of dyspepsia? (approach)

Answer 6

When treating dyspepsia, if either a PPI or ‘test and treat’ approach has failed then the other approach should be tried next

NICE guidelines state:

‘Offer one of the following strategies to manage uninvestigated dyspepsia symptoms, depending on clinical judgement:

• Prescribe a full-dose proton pump inhibitor (PPI) for 1 month
• Test for Helicobacter pylori infection if the person’s status is not known or uncertain. If the person tests positive for H. pylori infection, prescribe first-line eradication therapy.If symptoms persist or recur following initial management, switch to the alternative strategy (for example, offer a full-dose PPI for 1 month if the person has been tested for H. pylori infection and vice versa).’

Question 7

Complications of GORD

Answer 7

Barretts Oesophagus

• constant reflux of acid results in the lower oesophageal epithelium metaplasia from squamous to a columnar epithelium.
• when this change happens patients typically get an improvement in reflux symptoms

barretts oesophagus considered a ‘premalignant’ condition and is a risk factor for the development of adenocarcinoma of the oesphagus (3-5% lifetime risk with barretts)

In some patients there is a progression from Barretts oesophagus (columnar epithelium) with no dysplasia tolow grade dysplasia tohigh grade dysplasia and then toadenocarcinoma.