GORD Flashcards

1
Q

What is GORD?

A

Gastro-Oesophageal Reflux Disease

A condition whereby gastric acid from the stomach leaks up into the oesophagus

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2
Q

How common is GORD?

A

Very common - affects around a quarter of the population in Western countries

Represents approximately 4% of primary care appointments

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3
Q

What is the pathophysiology of GORD?

A

In GORD, the episodic relaxation of the lower oesophageal sphincter (that is part of it’s normal function) becomes more frequent & allows reflux of gastric contents into the oeophagus.

The refluxed acidic gastric contents / alkaline bile results in pain & mucosal damage.

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4
Q

What is the normal function of the lower oesophageal sphincter?

A

Controls the passage of contents from the oesophagus to the stomach.

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5
Q

What are the risk factors for GORD?

A
  • Age
  • Obesity
  • Male gender (2:1)
  • Alcohol
  • Smoking
  • Caffeinated drinks
  • Fatty / spicy foods.
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6
Q

What are symptoms of GORD?

A
  • Chest pain
    • Burning retrosternal sensation
    • Worse after meals, lying down, bending over, or straining
    • Relieved (at least partially) by antacids.
  • Excessive belching
  • Odynophagia
  • Chronic cough / nocturnal cough
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7
Q

What red flag symptoms should you always check for when someone presents with symptoms of GORD?

A

Signs of underlying malignancy:

  • Dysphagia
  • Weight loss
  • Early satiety
  • Malaise
  • Loss of appetite
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8
Q

What signs are typically found on examination?

A

Examination is typically unremarkable

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9
Q

What tool can be used to grade reflux oesophagitis based on severity from the endoscopic findings of mucosal breaks in the distal oesophagus?

A

The Los Angeles Classification of Reflux

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10
Q

What are important differentials to consider for GORD?

A
  • Malignancy (oesophageal or gastric)
  • Peptic ulceration
  • Oesophageal motility disorders
  • Oesophagitis

Also important not to miss key cardiac or biliary disease! Coronary artery disease and biliary colic can commonly mimic episodic reflux disease

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11
Q

What investigations may be useful for a patient presenting with symptoms of GORD?

A
  1. Urgent endoscopy

For patients with red flag symptoms for upper GI malignancy & those with new onset / worsening symptoms despite PPI

  • To exclude malignancy & look for complications of reflux (oesophagitis, stricturing, or Barrett’s oesophagus)
    2. 24hr pH monitoring (Gold standard diagnostic investigation)
  • For patients in whom medical treatment fails and surgery is being considered.
    3. Oesophageal manometry (Always done w/ pH monitoring)
  • To exclude oesophageal dysmotility (which would cause many surgeons to tailor their operative approach or avoid surgery).
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12
Q

What red-flag symptoms do the NICE guidelines state indicate urgent endoscopy?

A

NICE guidance states the red-flag symptoms for a suspected upper GI malignancy requiring urgent endoscopy are:

  • Patients with dysphagia
  • Any patient >55yrs with weight loss and upper abdominal pain, dyspepsia, or reflux
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13
Q

How do pH monitoring studies work?

A

They assess various criteria (e.g. amount of time acid is present in the oesophagus & the correlation between the presence of acid and the patient’s symptoms)

Produces an algorithmic score called the DeMeester score which can help determine a patient’s symptom / reflux correlation.

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14
Q

What conservative steps should be advised to all patients with GORD?

A
  • Avoiding known precipitants
    • Alcohol, coffee, fatty foods
  • weight loss
  • Smoking cessation.
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15
Q

What is the medical management of GORD?

A
  1. Proton pump inhibitors (1st line, alongside lifestyle changes)

Symptoms tend to recur rapidly after ceasing to take PPIs and so many patients are likely to remain on them life-long unless they proceed to surgery

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16
Q

What are the main 3 indications for surgery to treat GORD?

A
  1. Failure to respond / partial response to medical therapy
  2. Patient preference to avoid life-long medication
  3. Patients with complications of GORD (particularly respiratory complications, e.g. recurrent pneumonia / bronchiectasis)
17
Q

What is the surgical management of GORD?

A
  1. Fundoplication

Gastro-oesophageal junction and hiatus are dissected and the fundus wrapped around the GOJ, recreating a physiological lower oesophageal sphincter.

18
Q

How does the surgical management compare to the medical management of GORD?

A

Surgery has been shown to be more effective than medical treatment in terms of :

  • Symptom relief
  • Quality of life improvement
  • Cost.

However, due to associated complications and side-effects, many patients refuse surgery.

19
Q

What are the side effects of fundoplication?

A
  • Dysphagia
  • Bloating
  • Inability to vomit

Often settle after 6 weeks in most patients, as the post-operative swelling and inflammation recedes.

20
Q

What are the main complications of GORD?

A
  • Aspiration pneumonia
  • Barrett’s oesophagus
  • Oesophagitis
  • Oesophageal strictures
  • Oesophageal cancer
  • Ulcers
  • Anaemia
  • Benign strictures