GORD

Question 1

define GORD

Answer 1

chronic condition in whichh stomach contents flow back into the oesophagus, causing irritation to the mucosa
reflux is primary caused by an inappropriate, transient relaxtion of the lower eosophageal sphincter

Question 2

endoscopic finding associated with GORD

Answer 2

reflux oesophagitis is associated with oesophageal mucosal injury
individuals may have classic GORD symptoms without eosophageal injury

Question 3

NERD

Answer 3

non erosive reflux disease
50-70% of GORD patients
characteristic reflux disease in the absense of oesophageal injury such as reflux oesophagitis

Question 4

transient lower oesophageal sphincter relaxations

Answer 4

normal - allow venting of accumulated gases to prevent distension of the stomach
in GORD, frequency of relaxtions increases andd two thirds of relaxations are accompanied by reflux of gastric content
this is thought to be due to delayed gastric emptying

Question 5

imbalance between intragstric and lower oesophageal sphincter pressures

Answer 5

reflux occurs when the intragastric pressure in higher than that created by the lower oesophageal sphicter

Question 6

lower oesophageal sphincter tone is decreased by

Answer 6

caffiene, nitroglycerin
conditions that cause denervation of the muscle layer, such as scleroderma

Question 7

intragastric pressure is increased by

Answer 7

pregnancy, delayed gastric emptying and obesity

Question 8

mechanisms of GORD

Answer 8

gastroeosophageal junction dysfunction caused by
- increased frequency of transient lower oesophageal sphincter relaxations
- imbalance between intragastric and lower oesophageal pshincter pressures
- anatomic abnormalities of the gastrooesophageal junction

and impaired oesophageal acid clearance

Question 9

impaired oesophageal acid clearance

Answer 9

acid reflux should be neutralised by salivary bicarbonate and evacuated back to the stomach via oesophageal peristalsis
clearance may be disrupted by reduced salivation (eg. due to smoking) and/or decreased peristalsis eg. due to inflammation

Question 10

why are smoking, caffiene and alcohhol risk factors

Answer 10

smoking, caffiene and alcohol - these all decrease LES tone
alcohol and caffiene also stiulte gastric acid secretion

Question 11

why is pregnancy a risk factor for GORD

Answer 11

present in up to 80% of pregnancies
pathophysiology is due to increased abdominal pressure, decreased LES tone (due to high oestrogen and progesterone levels during pregnancy), and prolonged gastric emptying as a result of reduced gastric motility

Question 12

the angle of His

Answer 12

the angle that is formed between the oesophagus and the gastric fundus
in healthy adults, it is 50-60º

Question 13

why do children have more reflux than adults

Answer 13

infants usually have an underdeveloped, flat angle of His
regurgitation of stomach contents after meals is a common finding during the first 12 months of life and is not considered pathological

Question 14

other risk factors for GORD

Answer 14

smoking, caffiene, and alcohol
stress
obesity
pregnancy
angle of His enlargement >60º
iatrogenic eg. after gastroscopy
inadequate oesophageal protective factors ie. saliva, peristalsis
gastrointestinal malformations and tumours
sclroderma
sliding hiatal hernia
asthma

Question 15

typical symptoms of GORD

Answer 15

retrosternal burning pain
regurgitation
dyspagia, odynophagia
water brash

these symptoms can also be associated with oesophagitis or oesophageal cancer

Question 16

water brash

Answer 16

a symptoms of excessive salivation triggered by refluxing of stomach acid

Question 17

atypical symptoms of GORD

Answer 17

pressure sensation in the chest/noncardiac chest pain
belching/bloating
dyspepsia
nausea
halitosis

Question 18

halitosis

Answer 18

unpleaseant odour to breath

Question 19

extraoesophageal symptoms of GORD

Answer 19

chronic non productive cough and nighttime cough
hoarseness
bronchospasm
dental erosion

Question 20

aggrevating factors

Answer 20

lying down after meals
cartain foods/beverages = dependant on the individual

Question 21

red flags in GORD

Answer 21

dysphagia, odynophagia - these patients should be evaluated for eosophagitis and oesophageal cancer
anaemia and/or evidence of GI bleeding
unintentional weight loss
vomiting
signs of GI bleeding
presence of >1 risk factor for barretts oesophagus

Question 22

oesophagitis

Answer 22

• infectious oesophigits
• drug induced oesophigitis
• eosinophilic eosophigitis

Question 23

gold standard test for GORD

Answer 23

there is no gold standard test for diagnosis
diagnosis is based on clinical presentation, endoscopic evaluation, reflux assessment and therapuetic response

Question 24

appoach for typical symptoms without red flags in GORD

Answer 24

initiate treatment with empiric one daily PPI trial
if there is relief after 8 weeks, GORD is likley, you can discontinue the PPI
if symptoms persist on PPI or recur after discontinuing PPi, refer for endoscopy

Question 25

is testing fro H pylori required

Answer 25

not recommended in the workup of typical GORD in patients without dyspepsia in whom neither PUD nor gastritis is suspected

Question 26

approach for red flags in GORD

Answer 26

refer to gastroenterology for endoscopy before initiating treatment

Question 27

risk factors for barretts

Answer 27

male
european descent
age >50
obese
symptoms >5 years

Question 28

indications for endoscopy

Answer 28

red flags in GORD
risk factors for barretts
no imporvement after PPI trial
red flags for dyspepsia

Question 29

supportive findings on endoscopy

Answer 29

typically in the lowest third of the oesophagus
erythema, edema, friability
erosions, mucosal breaks, ulcerations
peptic strictures and rings
salmon pink mucosa (suggestive of barrett oesophagus)
proximal migration of the Z line

Question 30

what is salmon pink mucosa suggestive

Answer 30

barrett oesophagus

Question 31

what is needed to diagnose eosinophillic oesophagitis

Answer 31

eosophageal biopsy

Question 32

eosophageal pH monitoring indications

Answer 32

refractory GORD symptoms despite PPI therapy
confirmation of suspected NERD

Question 33

when to use barium swallow

Answer 33

not routinely indicated for GORD bu can be considered if the main symptom is dysphagia or if there is suspicion of structural abnormalitiies eg. oesophageal rings or webs or motility disorders

Question 34

when to use eosophageal manometry

Answer 34

consider is achalasia or oesopageal hypermotility is suspected

Question 35

oeosphageal manometry

Answer 35

a diagnostic test that is used to evaluate the peristaltic functuon of the oesophagus during swallowing
the propagation, speed and vigor are the peristaltic wave is measured via an oesophageal catheter fitted with pressure sensors every 3-6cm
may be used to investigated dysphasia due to oesophageal motility disorders

Question 36

pharmacological therapy

Answer 36

PPIs - once daily 30-60 minutes before a meal
H2 receptor antagonists

Question 37

dietary recommendations

Answer 37

small portions
avoid eatiing at least 2-3 hours before bed time
avoid foods and beverages that appear to trigger symptoms

Question 38

lifestyle recommendations

Answer 38

weight loss in patients with obesity
elevate the head of the bed 10-20cm for patients with nighttime symptoms

Question 39

medications that may worsen symtopms

Answer 39

calcium channel blockers
diazepam

Question 40

surgical therapy

Answer 40

should only be considered in select cases eg. patients wo develop complications despite recieving optimal medical therapy