GORD and Barrett's Oesophagus

Question 1

What is GORD?

Answer 1

Reflux of stomach contents into the oesophagus causing troublesome symptoms due to acid injuring the squamous epithelium lining of the oesophagus.

Question 2

What are the typical symptoms of GORD?

Answer 2

Heartburn and acid regurgitation

Question 3

What are the causes of GORD?

Answer 3

1. Lower oesophageal sphincter hypotension
2. Gastric acid hypersecretion
3. Delayed gastric emptying
4. Smoking and alcohol (decreases LOS tone)
5. Pregnancy
6. Drugs

Question 4

Which medications can cause GORD?

Answer 4

Calcium channel blockers, nitrates, bisphosphonates, steroids.

Question 5

What are the risk factors for GORD?

Answer 5

Hiatus hernia, obesity (increased intra abdominal pressure), old age, family history.

Question 6

What is this a presentation of?

Heartburn especially after meals, lying down. Relieved by antacids. Belching, acid or bile regurgitation, odynophagia.

Answer 6

GORD

Question 7

What is odynophagia?

Answer 7

Painful swallowing

Question 8

What are the red flag signs in dyspepsia?

Answer 8

ALARMS
A - anaemia
L - loss of weight
A - anorexia
R - recent onset/progressive symptoms
M - melaena/haematemesis
S - swallowing difficulty

Question 9

What are the indications for upper GI endoscopy in dyspepsia?

Answer 9

1. Dysphagia
2. > 55 and red flags (ALARM S)
3. Refractory to medical treatment

Question 10

What invasive investigation should you perform in all ulcers and what are you trying to exclude?

Answer 10

Biopsy to exclude malignancy

Question 11

What are the differentials for dyspepsia?

Answer 11

1. Peptic ulcer disease
2. GORD, gastritis, oesophagitis, hernia
3. Malignancy
4. Biliary causes
5. Other epigastric pain - AAA, angina, MSK, pancreatitis

Question 12

What are the steps for investigating dyspepsia?

Answer 12

1. Review medication
2. Lifestyle advice
3. 8-week PPI trial (omeprazole 20mg OD)
4. If no improvement after PPI trial, consider testing for H. pylori.

Question 13

What is the pre-procedure, procedure, and post-procedure management for an upper GI endoscopy?

Answer 13

1. Stop PPIs two weeks prior (masks pathology)
2. NBM 6hr prior
3. Do not drive for 24-hours if sedation used
4. Sedation optional for the procedure

Question 14

What are the complications of an upper GI endoscopy?

Answer 14

Sore throat, amnesia from sedation, perforation, bleeding.

Question 15

What are the complications of GORD?

Answer 15

1. Oesophagitis
2. Peptic ulcers which may bleed
3. Benign structures causing progressive dysphagia
4. Barrett’s oesophagus which may lead to oesophageal cancer (metaplasia, dysplasia, neoplasia)

Question 16

What is the underlying cellular pathology in Barrett’s oesophagus?

Answer 16

Metaplasia of normal stratified squamous epithelium of the distal oesophagus to glandular columnar epithelium.

Question 17

Which groups of patients are screened with endoscopy for Barrett’s oesophagus?

Answer 17

Chronic GORD and multiple risk factors (obese, >50yrs, male, white, family history) every 2 to 5 years.

Question 18

How is Barrett’s oesophagus diagnosed?

Answer 18

Biopsy of endoscopically visible columnarisation for histology.

Question 19

What is the management for Barrett’s oesophagus?

Answer 19

1. Detect and prevent oesophageal adenocarcinoma
2. Endoscopic assessment every 2-years for those with extensive disease.
3. High grade dysplasia - endoscopic resection or mucosal radiofrequency ablation

Question 20

What are the two types of hiatus hernia?

Answer 20

Sliding (80%) and rolling (20%)

Question 21

What is this describing?
Gastroesophageal junction slides up into the chest, acid reflux occurs as the lower oesophageal sphincter becomes less competent over time.

Answer 21

Sliding hiatus hernia

Question 22

What is this describing?
Gastroesophageal Junction remains in the abdomen but a bulge of the stomach hernia Eights up into the chest alongside the oesophagus.

Answer 22

Rolling hiatus hernia

Question 23

In which patient groups are hiatus hernias more common?

Answer 23

Obese women >50 years old

Question 24

How is a hiatus hernia diagnosed?

Answer 24

Upper GI endoscopy visualises mucosa but cannot reliably exclude hernia, chest x-ray may show air bubble in the thorax.

Question 25

What is the treatment for a hiatus hernia?

Answer 25

Lose weight and treat the GORD, surgery for intractable symptoms despite aggressive medical treatment.