GORD Flashcards
What is GORD?
A condition where gastric acid from the stomach leaks up into the oesophagus
Epidemilogy
Affecting around a quarter of the western population.
Around 4% of primary care appointments
M 2:1 Women
Pathophysiology
The lower oesophageal sphincter (LOS) controls passage of food form oesophagus to stomach.
It is normal for episodic LOS relaxation to occur, however in GORD the episodes become more frequent and there is reflux of gastric content.
The acidic gastric content result in pain and mucosal damage in oesophagus.
Risk factors
Age
Obesity
Male gender
Alcohol
Smoking
Caffeinated drinks
Fatty and spicy foods
Clinical features
Chest pain usually described as burning retrosternal sensation
Worse after meal, lying down, bending over or straining.
The pain is usually relieved by antacids.
There might also be belching, odynophagia, chronic cough or a nocturnal cough.
Red flags of GORD
Dysphagia
Weight loss
Early satiety
Malaise
Loss of appetite
These red flags symptoms indicates there might be underlying malignancy.
Examination findings
Typically unremarkable
What classification is used for GORD?
Los Angeles classification
Explain Los Angeles classification of reflux.
Used to grade reflux oesophagitis based on severity from the endoscopic findings of mucosal breaks in the distal oesophagus.
Grade A - breaks 5 mm or less
Grade B - >5 mm
Grade C - Breaks extending between the tops of 2 or more mucosal folds but <75 of circumference
Grade D - Circumferential breaks (75% or more)
Dx
Malignancy
Peptic ulceration
Oesophageal motility disorders
Oesophagitis
Cardiac/Biliary disease
Ix
Clinical diagnosis with good history and resolution of symptoms after a trial of PPi.
When should urgent endoscopy be done?
Suspecting upper GI malignancy in…
Patients with dysphagia
Any patient >55yo with weight loss and upper abdo pai, dyspepsia or reflux.
When should an upper GI endoscopy be done?
Exclude malignancy and investigate complications of reflux such as oesophagitis, stricturing and Barrett’s.
Red flags of GI malignancy
New onset symptoms or worsening despite PPis.
What is the gold standard in diagnosing GORD.
24h pH monitoring.
This is required for patients in whom medical treatment fails and surgery is being considered.
It should be combined with oesophageal manometry to exclude oesophageal dysmotility.
Explain pH monitoring studies.
The amount of time acid is present in the oesophagus
Correlation between the presence of acid and the patient’s symptoms
This produces an algorithmic score called DeMeester score
General management of GORD
Avoiding known precipitants like alcohol, coffee, fatty foods
Weight loss
Smoking cessation
Medical management
PPis in addition to lifestyle changes are first line.
Patient’s are likely to remain on them life-long unless they proceed to surgery.
Indications for surgical management
Failure to respond to medical therapy
Patient preference to avoid life-long medication
Patients with complications of GORD like recurrent pneumonia or bronchiectasis.
Pros of surgery
More effective than medical treatment in terms of…
Symptom relief
QOL improvement
Cost
Although due to associated side effects a lot of patients are reluctant to accept surgery.
Does surgery reduce cancer risk from Barrett’s oesophagus?
No evidence suggest that it does
Types of surgery
Fundoplication
Stretta
Linx
What is the main surgical management?
Fundoplication
Explain fundoplication
The gastro-oesophageal junction and hiatus are dissected.
The fundus is then wrapped around the GOJ to create a new LOS.
Give specific examples of fundoplication
They usually differ in direction and completeness of the wrap.
Nissen’s = posterior 360 fundoplication
Partial anterior approach
Main side effects of fundoplication
Dysphagia
Bloating
Inability to vomit
These side effects usually settle after 6 weeks
Explain Stretta
Uses radio-frequency energy by endoscopy to cause thickening of LOS
Explain Linx
String of magnetic beads is inserted around LOS laparoscopically to tighten LOS.
Main complications of GORD
Aspiration pneumonia
Barrett’s
Oesophagitis
Oesophageal strictures
Oesophageal cancer
