GORD

Question 1

Define Gastro-Oesophageal Reflux Disease

Answer 1

symptoms or complications resulting from the reflux of gastric contents into the oesophagus or beyond, into the oral cavity (including larynx) or lung

Question 2

Explain the aetiology/risk factors of GORD

Answer 2

RISK FACTORS:

• Family history of GORD/Heartburn
• Hiatus Hernia (reducing competence of the gastro-oesophageal junction and inhibiting clearance of oesophageal acid post-reflux)
• Obesity

AETIOLOGY/PATHOPHYSIOLOGY

• Episodes of transient lower oesophageal sphincter relaxation are a normal phenomenon, but they occur more frequently in GORD, causing reflux of gastric contents into the oesophagus.
• Transient lower oesophageal sphincter relaxation is more common after meals and is stimulated by fat in the duodenum.
• Patients with severe reflux often have a hiatus hernia and decreased resting lower oesophageal sphincter pressure.
• The duration of contact with gastric contents depends on the number of episodes of reflux, the efficacy of oesophageal peristalsis, and the neutralisation of acid by saliva

Question 3

Summarise the epidemiology of gastro-oesophageal reflux disease

Answer 3

• COMMON
• 5-10% of adults

Question 4

Recognise the presenting symptoms of gastro-oesophageal reflux disease

Answer 4

• Substernal/epigastric burning discomfort or ‘heartburn’ that is ggravated by:
  
  • Lying supine
  • Bending
  • After Large meals (esp. fatty & spicy)
  • Drinking alcohol
  • Pain is relieved by antacids
• Sour/bitter taste in mouth
• Waterbrash (regurgitation of an excessive accumulation of saliva from the lower part of the oesophagus often mixed with some acid material from the stomach)
• Dysphagia - caused by the formation of peptic stricture after long-standing reflux
• Chronic dry cough

Question 5

Recognise the signs of GORD on physical examination

Answer 5

• Usually NORMAL
• Occasionally - epigastric tenderness, wheeze on chest auscultation, dysphonia

Question 6

Identify appropriate investigations for GORD and interpret the results

Answer 6

• Often a CLINICAL diagnosis
• If suspected: a trial of PPI is given
• If GORD persists: upper GI endoscopy and biopsy (confirms presence of oesophagitis and can exclude malignancy – must exclude for all >55 years)
• Other tests: 24h pH monitoring, manometry, barium swallow X-Ray

Question 7

Generate a management plan for GORD

Answer 7

• Advice:
  
  • Weight loss
  • Elevating head of bed
  • Avoid provoking factors (Lower fat meals, Avoid large meals late in the evening)
  • Stop smoking
• Medical:
  
  • Antacids/Alginates (e.g. Gaviscon)
  • H2 antagonists (e.g. ranitidine)
  • PPI (e.g. lansoprazole, omeprazole)
• Endoscopy:
  
  • Annual endoscopic surveillance - looking for Barrett’s Oesophagus
  • May be necessary for stricture dilation or stenting
• Surgery:
• Nissen Fundoplication:
  
  • Fundus of the stomach is wrapped around the lower oesophagus - helps reduce the risk of hiatus hernia and reduce reflux

Question 8

Identify the possible complications of gastro-oesophageal reflux disease and its management

Answer 8

• Oesophageal ulceration
• Peptic stricture
• Anaemia
• Barrett’s oesophagus
• Oesophageal adenocarcinoma (rare)
• Associated with asthma and chronic laryngitis

Question 9

Summarise the prognosis for patients with gastro-oesophageal reflux disease

Answer 9

• 50% respond to lifestyle measures alone
• In patients that require drug therapy, withdrawal is often associated with relapse
• 20% of patients undergoing endoscopy for GORD have Barrett’s oesophagus