GORD

Question 1

Aetiology of GORD?

Answer 1

Disruption of mechanisms that prevent reflux (eg. Physiological LOS, mucosal rosette, acute angle of junction, intra abdo portion of oesophagus).
Prolonged oesophagus clearance contributes to 50% cases.
Raise in abdo pressure, eg pregnancy, constipation…
Factors such as cigarette smoking and certain drugs can cause relaxation of the LOS leading to reflux.

Question 2

Epidemiology of GORD?

Answer 2

Common.

Prevalence 5-10% adults.

Question 3

History of GORD?

Answer 3

Sub streak burning discomfort - heartburn - aggravated by lying supine, bending, large meals or alcohol.
Pain relieved by antacid.
Waterbrash
Aspiration could lead to voice hoarseness, laryngitis, nocturnal cough and wheeze. (Pneumonia = rare).
Dysphagia (from formation of peptic stricture post long standing reflux).

Question 4

What would be revealed on examination in a GORD px?

Answer 4

Usually normal.

Occasionally:
•epigastric tenderness,
•wheeze on chest auscultation,
•dysphonia.

Question 5

What examinations should be performed when suspecting GORD?

Answer 5

Upper GI endoscopy, biopsy and cytological brushings:
•To confirm the presence of oeso- phagitis
•Exclude the possibility of malignancy (all patients >45 years).

Barium swallow:
•To detect hiatus hernia, peptic stricture, extrinsic compression of the oesophagus can be visualized.

CXR: Not specifically for GORD.
•Incidental finding of hiatus hernia (gastric bubble behind cardiac shadow).

Twenty-four hour oesophageal pH monitoring:
•pH probe placed in lower oesophagus determines the temporal relationship between symptoms and oesophageal pH.

Question 6

Definition of GORD?

Answer 6

Inflammation of the oesophagus caused by reflux of gastric acid and/or bile.

Question 7

How to manage a patient with GORD?

Answer 7

Advice:
Lifestyle changes, weight loss, elevating head of bed, avoid provoking factors, stopping smoking, lower fat meals, avoiding large meals late in the evening.

Medical:
•Antacids and alginates, H2 antagonists (e.g. ranitidine) or proton pump inhibitors (e.g. lansoprazole) are sufficient for most patients.

Endoscopy:
•Annual endoscopic surveillance for Barrett’s oesophagus may be necessary for stricture dilation or stenting.

Surgery:
•Anti-reflux surgery for those with symptoms despite optimal medical management or in those intolerant of medication.

Nissen fundoplication
•(fundus of the stomach is wrapped around the lower oesophagus and held with seromuscular sutures)
•Helps reduce any hiatus hernia and reduce reflux.

Question 8

What are the possible complications of GORD?

Answer 8

Oesophageal ulceration
Peptic stricture
Anaemia
Barrett’s oesophagus 
Oesophageal adenocarcinoma

Associated with asthma and chronic laryngitis.

Question 9

What is the prognosis for GORD?

Answer 9

Fifty percent respond to lifestyle measures alone.

In patients who require drug therapy withdrawal is often associated with relapse.

Twenty percent of patients undergoing endoscopy for GORD have Barrett’s oesophagus*.

*NB: Barrett’s oesophagus is characterized by metaplasia of oesophageal squamous epithelium and replacement with columnar epithelium.
This is a premalignant condition with an increased risk of dysplasia and adenocarcinoma.