GORD Flashcards
What is GORD?
GORD is a broad group of conditions characterized by reflux of gastric contents (Acid and Bile) into the oesophagus causing pain and inflammation of its lining (Reflux Oesophagitis). A small amount of reflux is physiological abut it should not cause symptoms. This reflux can be due to lifestyle factors (smoking, obesity etc) or due to a physiological problem with the lower oesophageal sphincter.
Patients with GORD are at an increased risk of Barret’s oesophagus (metaplasia of the lower third of the oesophageal epithelium from normal stratified squamous epithelium to simple columnar epithelium with goblet cells in response to regurgitated acid). Barret’s Oesophagus predisposes patients to adenocarcinoma of the oesophagus
GORD is associated with Hiatus Hernia’s, there are 2 types (Sliding and Rolling): In a sliding hernia (80% of Hiatus Hernias), the gastro-oesophageal junction herniates up into the thoracic cavity, while in a rolling hernia, a different part of the stomach or a different abdominal organ (e.g. Small intestine, spleen, pancreas) protrudes through the diaphragm next to the oesophagus.
What will you find on a history of GORD?
Symptoms:
Dyspepsia (Heartburn) - S (Retrosternal) Q(Burning) T (Relieved by eating – Food lower pH of stomach), A (Worse when lying) R(Antacids)
Dysphagia/Odynophagia (Only as a result of oesophagitis)
Others - Acid regurgitation, Hyper-salivation, Bloating/Belching/Bad Breath, Cough, Laryngitis (hoarse voice/saw throat)
Risk Factors:
Smoking
Male
Pregnancy
Obesity
Alcohol
Certain Trigger Foods
Drugs affecting oesophageal motility (nitrates, anticholinergics, tricyclic antidepressants)
Drugs that damage the mucosa (NSAIDs, potassium salts, alendronate)
Risk Factors for a Hiatus hernia – Raised Intra-abdominal pressure (Pregnancy, Obesity, Heavy lifting, Chronic Cough), Age,
Systemic sclerosis – Reduces motility of the oesophagus
Specific Questions to ask: Diet - Specific foods like coffee, chocolate and alcohol weaken the oesophageal sphincter. Fatty foods take longer to digest, increasing stomach acidity Ask about ALARM signs: Anaemia/Age>55 Loss of weight - Adenocarcinoma of the Oesophagus increased risk in GORD Anorexia Recent onset/progressive worsening Melaena/Haematemesis Swallowing problems - Solids vs Liquids
Differentials:
Angina - Worse with exercise and not affected by eating, may need to be differentiated by ECG exercise test
Other causes of Oesophagitis - NSAIDS, Corrosives, Ulcers
Non-Ulcer dyspepsia - At least 3 months of recurrent upper abdominal pain, bloating, and nausea, with no obvious structural cause seen on endoscopy.
Gastric Ulcer – Epigastric Pain (not retrosternal), worse after eating
Duodenal Ulcer - Epigastric pain that radiates to the back and is relieved by a meal but worse 2-5 hours after a meal.
Biliary Colic - Right upper quadrant or epigastric colicky pain usually increasing in intensity and lasting several hours.
Achalasia - Unable to eat solids or liquids
Malignancy - Weight loss, progressive dysphagia
What will you find on examination of a patients with suspected GORD?
Examination: Normally nothing to find
Look for signs of anaemia/Malnutrition – Indicating underlying GI pathology
Feel for any tenderness – Epigastric pain may indicate an ulcer
What investigations will you order in GORD?
Investigations: GORD is a Clinical diagnosis and so no tests are needed unless re flags or treatment resistance
Bedside:
If treatment resistant to trail of PPI – H. Pylori Testing with 13C urea breath test
Imaging:
If red flags or treatment resistant and negative H. Pylori Testing – Upper GI endoscopy
24hr oesophageal pH monitoring and manometry - assess if treatment is working or if symptoms are present with pH drops if no underlying cause can be found on OGD. This will also help to decide if surgery for the Lower oesophageal sphincter will be helpful
Looking for Hiatus Hernia – An Upper GI endoscopy will be unable to see a hiatus hernia, and so a plan CXR, Barium Swallow or manometry testing may be used in treatment resistant GORD where a hiatus hernia is suspected
What is the treatment of GORD?
What is the treatment:
Lifestyle:
Weight Loss
Smoking cessation
Small/regular meals and don’t eat <3 hours before bed
Less hot drinks/alcohol/acid/fatty foods Don’t eat <3 hours before bed
Raise the head in bed if nocturnal symptoms
Encourage relaxation strategies if stress, anxiety or depression – These can worsen symptoms
Adjust medication - Remove any medication that are risk factors if possible
Medical:
Oral PPI trailed for 4 weeks, with Antacids (Gaviscon)
If needed increase PPI dose but titrate down to lowest required dose when stable
H2 receptor antagonist - 2nd line or can double PPI dose
Avoid drugs that predispose to GORD – E.g. NSAIDS
Surgical:
Consider in severe manometry confirmed GORD that is resistant to treatment
Laparoscopic Nissen Fundoplication (The gastric fundus is wrapped around the lower oesophagus and stitched in place) or Laparoscopic Magnetic bead application (artificial sphincter) to increase LOS resting tone.
If there is evidence of a hiatus hernia in treatment resistant GORD then consider surgery for it
What is the treatment of Barrett’s Oesophagus?
Endoscopic screening (looking for red epithelia not white) can be offered to patients with chronic GORD symptoms and multiple risk factors (at least three of age 50 years or older, white race, male sex, obesity).
If Barret’s is found on educate the patient on red flag symptoms to watch out for and surveillance every 2-3 years.
If the Barret’s progresses to dysplastic cells then endoscopic treatment (resection, Ablation) may be used to remove them, Oesophagectomy may be required for adenocarcinoma or dysplastic cells that are not superficial
What is the treatment of a hiatus hernia?
Most patients with a hiatus hernia do not require any treatment other than management of GORD
Surgical repair - Laparoscopic Curoplasty (Hernia reduction plus possible support with mesh) followed by Nissen Fundoplication
Treatment of a sliding hiatus hernia is not required if it is not causing any symptoms. However, in a rolling hernia, treatment would be considered even if asymptomatic due to the chance of severe complication e.g. Obstruction, weighing up the risks of surgery against the risk of complication.
Treatment is required in any strangulated/obstructed hernia
