GORD Flashcards
GOR DEDINITION
Normal physiological event transient lower oesphageal sphincter relaxation (TLESR). Allows passages of gastric contents into the oesphagus occurs several times per day in infants/children/ adults
Duration <3mins post prandial
GORD
Pathological process TLESR that has symptoms and +/- complications
GORD there is increased freq of TLESR
There is increased amouth of reflux matter
There is increased duration of TLESR
Hiatus hernia
Decreased LES pressure
There is increased strain assoc with the reflux
HH delays the Oesphageal clearance
HH changes the angle and pulls open the LES
The bigger the hernia the greater the degree of dysfunction of the LES
Conditions predispose to GORD
Obesity
Neuromuscular disease eg congenital myopathy
Neurological disease eg CP
Genetics conditions eg downs s, CHARGE Sx
Congenital diaphragmatic hernia
Severe prematurity
CF
Chronic lung disease eg Bronchiectasis, CLD
Sceroderma
Previous oesph caustic injury eg chemotherapy
How do you diagnose GORD
In infants there are no signs and symptoms that diagnose GORD
No evidence to support a trial of acid suppression in infants
Clinical diagnosis in children <8-12
After 8-12 years children may complain of heartburn /chest pain
Regurgitate, vomiting. Irritability are common in kids without GORD
Typical symptoms in an infant are V,irritability, regurgitate
Older child heartburn chest pain
Atypical symptoms dental erosion
Anaemia
Cough intermittent strider harness aponea
Should you give a trial of PPIs in an infant with ?GORD. T/F
False
No EBM to support the trial of acid suppression in infants with irritability crying and sleep disturbance
What investigations in GORD and why Ix
Diagnosis of pathological reflu and exclude other DD
Ix for GORD
Barium swallow not justified mostly
A modified Ba swallow may help to rule out aspiration
Tracheo- oesph fistula, malrotation, HH, Pyloric Stensosis(USS)
2 24 hour ph monitoring LIMITATIONS
Misses non acid reflux
Misses GOR related resp symptoms
Can have GORD and have a normal 24hours ph monitor
24 hour impedance monitoring
This is the GOLD standard for GORD
Records movement and acidity of reflux up and down the O
Acid Reflex ph<4
Non AR weak acidic or alkaline reflux
Detects acid and non acid reflux
Precise temporal association of all reflux sympt and events
Determines the extent of the GOR
Evaluate GOR in a pt with continuous feeds and on acid suppression treatment
Indications for 24hours ph impedance testcin
Pt with atypical discrete extra O symptoms eg chest pain, choking
Aponea intermittent strider
Correlation between symptoms and GOR events in a pt not responding to treatment
Continuous feeding
Endoscopy in GOR
Allows you to visualize and Biopsy the oesphagus
Look for strictures. HH/ Barrett’s oesphagus
2. Eosinophilia oesphagus is
3 presence of normal mucosa doesn’t exclude GORD
Causes of oesphagitis
GORD Eosinophilia oesphagitis Infection C alb, HSV Crohn’s disease Vomiting /eating disorder Bulimia CT disease Radiation/chemotherpay Lymphoma
Oesphageal manometry
Gives you info about peristalsis
NOT used to diagnose GORD
Role in chest pain dysphasia, odynophagia
Useful in Achalasia /Ruminaiton
Treatment of GORD
Lifestyle
Phamacological
Lifestyle
Thickened fluids Decrease visible regurgitate BUT DONT decrease acid GOR or freq of the reflux episodes
Prone position/lateral side associated with increased risk of SIDS
Avoid coffee.choclate/spicy IF produce GORD symptoms
LOSE Wt
Avoid overfeeding
Drugs in GORD
Antacids caution avoid prolonged use
Al/Mg risk of Al toxicity osteopenia Ricketts microcytic anaemia neurotoxicity
Ca Carobonate based antacids HyperCa++/renal failure/Alkalosis
Gaviscon temporary relief no EBM marginal help of reflux
3 Histamine H2 receptor antagonists Well tolerated Don’t work as well as PPIs Tachphlaxasis 6/52 Side effects rare head banging/ headache/irritability
PPIs
Bind to and inhibit gastric PP in the patient cell
Inhibit the amount of acid secretion reduce
Keep working don’t lose potency over time
P450 enzyme system hepatic metabolism clinical response can differ
Children may need higher doses than adults
Usually given as a single dose can be given as a BD dose if nocturnal symptom
Trail of ceasing and withdrawal /tapering as GORD not all chronic and relapsing
WEAN gradually or can risk rebound hyperacidity
PPI side effects
Mild 14% headache/ Diarrhoea/Constipation/nausea
Idiosyncratic
Drug to drug
RARE serious pneumonia C Difficule
Parietal cell hyperplasia
Osteopenia hypomagnesium
B12 vit C def
Prokinetic therapy for GORD
NO role in simple GORD used by gastroenterologist OCCASIONALLY
Erythromycin No EBM
Domperidone No EBM
Maxolon extrapyrimadial side effects
Fludoplication
Failed medical therapy persistent oesphagitis on endoscopy
Failed medical therapy recurrent chest infections ( aspiration)
Life threatening complications of GORD
? Role in life long treatment medically
? Role if non adherence to medical treatment
Complications of fundoplication
Gas bloated syndrome
Dumping syndrome
Early satiety
Post prandial rethching gagging
