GORD Flashcards
define GORD
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
endoscopic finding associated with GORD
reflux oesophagitis is associated with oesophageal mucosal injury
individuals may have classic GORD symptoms without eosophageal injury
NERD
non erosive reflux disease
50-70% of GORD patients
characteristic reflux disease in the absense of oesophageal injury such as reflux oesophagitis
transient lower oesophageal sphincter relaxations
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
imbalance between intragstric and lower oesophageal sphincter pressures
reflux occurs when the intragastric pressure in higher than that created by the lower oesophageal sphicter
lower oesophageal sphincter tone is decreased by
caffiene, nitroglycerin
conditions that cause denervation of the muscle layer, such as scleroderma
intragastric pressure is increased by
pregnancy, delayed gastric emptying and obesity
mechanisms of GORD
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
impaired oesophageal acid clearance
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
why are smoking, caffiene and alcohhol risk factors
smoking, caffiene and alcohol - these all decrease LES tone
alcohol and caffiene also stiulte gastric acid secretion
why is pregnancy a risk factor for GORD
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
the angle of His
the angle that is formed between the oesophagus and the gastric fundus
in healthy adults, it is 50-60º
why do children have more reflux than adults
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
other risk factors for GORD
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
typical symptoms of GORD
retrosternal burning pain
regurgitation
dyspagia, odynophagia
water brash
these symptoms can also be associated with oesophagitis or oesophageal cancer
water brash
a symptoms of excessive salivation triggered by refluxing of stomach acid
atypical symptoms of GORD
pressure sensation in the chest/noncardiac chest pain
belching/bloating
dyspepsia
nausea
halitosis
halitosis
unpleaseant odour to breath
extraoesophageal symptoms of GORD
chronic non productive cough and nighttime cough
hoarseness
bronchospasm
dental erosion
aggrevating factors
lying down after meals
cartain foods/beverages = dependant on the individual
red flags in GORD
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
oesophagitis
- infectious oesophigits
- drug induced oesophigitis
- eosinophilic eosophigitis
gold standard test for GORD
there is no gold standard test for diagnosis
diagnosis is based on clinical presentation, endoscopic evaluation, reflux assessment and therapuetic response
appoach for typical symptoms without red flags in GORD
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
is testing fro H pylori required
not recommended in the workup of typical GORD in patients without dyspepsia in whom neither PUD nor gastritis is suspected
approach for red flags in GORD
refer to gastroenterology for endoscopy before initiating treatment
risk factors for barretts
male
european descent
age >50
obese
symptoms >5 years
indications for endoscopy
red flags in GORD
risk factors for barretts
no imporvement after PPI trial
red flags for dyspepsia
supportive findings on endoscopy
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
what is salmon pink mucosa suggestive
barrett oesophagus
what is needed to diagnose eosinophillic oesophagitis
eosophageal biopsy
eosophageal pH monitoring indications
refractory GORD symptoms despite PPI therapy
confirmation of suspected NERD
when to use barium swallow
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
when to use eosophageal manometry
consider is achalasia or oesopageal hypermotility is suspected
oeosphageal manometry
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
pharmacological therapy
PPIs - once daily 30-60 minutes before a meal
H2 receptor antagonists
dietary recommendations
small portions
avoid eatiing at least 2-3 hours before bed time
avoid foods and beverages that appear to trigger symptoms
lifestyle recommendations
weight loss in patients with obesity
elevate the head of the bed 10-20cm for patients with nighttime symptoms
medications that may worsen symtopms
calcium channel blockers
diazepam
surgical therapy
should only be considered in select cases eg. patients wo develop complications despite recieving optimal medical therapy
