GORD

Question 1

GORD Definition

Answer 1

Reflux of gastric contents, especially acid, aborally (toward the mouth) rather than distally into duodenum

Question 2

GORD Aetiology

Answer 2

• inappropriate transient relaxations of lower esophageal sphincter (LES) - most common
  
  • low basal LES tone (especially in scleroderma)
  • intra-abdominal pressure
  • acid hypersecretion (rare) - Zollinger-Ellison syndrome (gastrin-secreting tumour)
  • contributing factors include: delayed esophageal clearance, delayed gastric emptying, increased
  • hiatus hernia worsens reflux, does not cause it

Question 3

GORD Clinical Features

Answer 3

• “heartburn” (pyrosis) and acid regurgitation (together are 80% sensitive and specific for reflux)
  
  • ± bitter regurgitation, water brash, sensation of a lump in the throat, frequent belching

Question 4

GORD Investigations

Answer 4

• Usually a clinical diagnosis based on symptom history and relief following a trial of pharmacotherapy (proton pump inhibitor (PPI): symptom relief 80% sensitive for reflux)
  • gastroscopy indications:
    
    • rule out conditions that mimic reflux (e.g. cancer, peptic ulcer, infective esophagitis)
    • distinguish between esophagitis (indicating aggressive treatment) and non-esophagitis reflux disease (NERD - sole goal of treatment is symptom relief)
    • diagnose Barrett’s esophagus (requires endoscopic surveillance for cancer)
  • esophageal manometry
    
    • diagnose abnormal peristalsis and/or decreased LES tone
    • surgical fundoplication more likely to be successful if lower oesophageal pressure is diminished; less likely to be successful if abnormal peristalsis
  • barium swallow:
    
    • to assess presence of strictures
  • 24-h pH monitoring:
    
    • most accurate test but rarely required
    • most useful if PPIs do not improve symptom

Question 5

GORD Management

Answer 5

• PPIs are most effective therapy, usually need to be continued on maintenance therapy
  * PPI SI: B12, Ca, Mg and Fe deficiency
  • on-demand: antacids (Mg(OHh, Al(OH)3, alginate), H2-blockers or PPis can be used for NERD
  • diet helps symptoms, not the disease; only beneficial lifestyle changes are weight loss (if obese) and elevating the head ofbed (ifnocturnal symptoms)

Question 6

GORD Complications

Answer 6

• oesophageal stricture disease- scarring can lead to dysphagia (solids)
  
  • ulcer
  • bleeding
  • Barrett’s esophagus and esophageal adenocarcinoma- gastroscopy is recommended for patients with chronic GERD or symptoms suggestive of complicated disease (e.g. anorexia, weight loss, bleeding, dysphagia)