GORD Flashcards
is GORD acute or chronic
usually chronic
what is it
reflux of gastric contents (acid, bile, pepsin) back into oesophagus
symptoms
heartburn
acid regurgitation
less common symptoms, may happen if acid reflux reaches oropharynx/respiratory tract
chest pain
hoarseness
wheezing
cough
asthma
dental erosions
what is non erosive GORD
symptoms of GORD but endoscopy is normal i.e. oesophagus unharmed by stomach acid
what is erosive oesophagitis
oesophageal inflammation and mucosal erosions seen at endoscopy
risk factors for developing GORD
- trigger and fatty foods
- pregnancy
- hiatus hernia
- FHx
- increased intra gastric pressure from straining and coughing
- stress
- anxiety
- obesity
- drug SE
- smoking
- alcohol
complications of GORD
○ Oesophagitis (oesophageal inflammation)
○ Ulceration
○ Haemorrhage and stricture formation
○ Anaemia due to chronic blood loss
○ Aspiration pneumonia
○ Barrett’s oesophagus
non drug treatment
- healthy eating
- weight loss if appropriate
- avoiding trigger food
- eating smaller meals
- evening meal 3-4h before going to bed
- raising head of bed
- smoking cessation
- reducing alcohol consumption
- stress and anxiety can exacerbate
red flags - urgent endoscopy required
- Dysphasia
- Significant acute GI bleeding
- 55 and over with unexplained weight loss & symptoms of upper abdominal pain, reflux or dyspepsia
what is Barrett’s oesophagus and diagnosis
some cells in the lining of the oesophagus have started to change, in some people these cells can develop into oesophageal cancer
consider endoscopy if pt has GORD
take into account pt preg and individual RF
initial management - review drugs that can cause or exacerbate symptoms
○ Alpha blockers e.g. doxazosin, tamsulosin, alfuzosin, prazosin etc
○ Anticholinergics e.g. amitriptyline, olanzapine, oxybutynin, paroxetine, solifenacin etc
○ Benzodiazepines e.g. diazepam, chlordiazepoxide, lorazepam
○ Beta blockers e.g. atenolol, bisoprolol, carvedilol
○ Bisphosphonates e.g. alendronate, risendronate
○ CCBs e.g. amlodipine, nifedipine, verapamil, diltiazem
○ CCs e.g. prednisolone, dexamethasone, betamethasone,
○ NSAIDs e.g. ibuprofen, naproxen, diclofenac
○ Nitrates e.g. GTN, isosorbide mononitrate
○ Theophylline, aminophylline
○ TCAs e.g. amitriptyline, dosulepin, lofepramine, nortriptyline
is long term continuous use of antacids recommended?
no
pt with uninvestigated symptoms suggesting GORD should be managed as ….
uninvestigated dyspepsia
In patients with endoscopy confirmed diagnosis of GORD, the following treatment should be offered… (+ severe oesophagitis)
○ PPI for 4 or 8 weeks
○ No response, then offer H2 receptor antagonist e.g. ranitidine, famotidine, nizatidine, cimetidine
- Severe esophagitis ○ PPI for 8 weeks ○ Consider pt pref and underlying heath conditions and drug interactions
follow up management - what if the pt has refractory GORD
new alarm symptoms should be assessed and alternate diagnosis’ considered
- Other options include
○ Prescribing a further course of the initial PPI dose for one month
○ Double initial PPI dose for 1 month
○ Add a H2 receptor antagonist at bedtime for nocturnal symptoms or for short term use - Also check patient’s adherence to initial management and reinforce lifestyle advice
follow up management - for pt diagnosed with GORD whose symptoms recur after initial treatment
give a PPI at the lowest dose that can achieve symptom control and self management on PRN basis
follow up management - what to do if treatment for severe oesophagitis fails
Use a higher dose of the same PPI or switch to another PPI taking into account patient preference tolerability, underlying health conditions and drug interactions
For patients with severe oesophagitis that failed to respond to long term maintenance PPI therapy, consider a clinical review and switching to another PPI and/or seeking specialist advice
Patients with severe oesophagitis or who have had dilatation of an oesophageal stricture should remain on long term PPI therapy (taking into consideration the aforementioned factors)
GORD in pregnancy - symptoms, 1st line treatment, and alternatives
- Heartburn and acid reflux are symptoms of dyspepsia in pregnancy, commonly caused by GORD
- 1st line: dietary and lifestyle advise
- If this fails to control symptoms, offer an antacid or alginate
- If ineffective or if symptoms are severe, omeprazole or ranitidine (unlicensed) may help control symptoms
What is the recommended drug treatment for someone with diagnosed GORD?
- PPI for 4 or 8 weeks
- E.g. omeprazole 20mg OD for 4 or 8 weeks
What is the recommended drug treatment for someone with severe oesophagitis?
Omeprazole 40mg OD for 8 weeks, continue as maintenance is appropriate
What is the recommended drug treatment for someone with severe oesophagitis, refractory to initial treatment
Omeprazole 40mg BD
How should someone with suspected GORD be managed
For undiagnosed GORD, manage the patient as uninvestigated dyspepsia
When should drug treatment be commenced in pregnancy, and what would you offer?
- 1st line pregnancy: lifestyle and dietary advice
- If inadequate, try antacid or alginate e.g.
- If inadequate, offer
○ omeprazole 20mg OD for 4 to 8 weeks OR
○ ranitidine 150mg BD for up to 8 weeks or if necessary 12 weeks, alternatively 300mg OD for up to 8 weeks or if necessary 12 weeks DOSE TO BE TAKEN AT NIGHT
