GORD and hiatus hernia

Question 1

Risk factors of GORD

Answer 1

• Hiatus hernia
• Smoking
• EtOH
• Obesity
• Pregnancy
• Drugs: antimuscarinics, nitrates, CCB, TCAs
• Iatrogenic: Heller’s myotomy

Question 2

Presentation of GORD

Answer 2

• Retrosternal pain
• heartburn related to meals
• Worse lying down especially at night
• Relieved by antacids
• Belching
• Regurgitation
• Odonophagia

Extra-oesophageal:
• Nocturnal asthma
• Chronic cough
• Laryngitis, sinusits

Question 3

Complications of GORD

Answer 3

• Oesophagitis
• Ulceration: rarely causing haematemesis or melaena
• Benign stricture: dysphagia
• Barrett’s oesophagus
- adenocarcinoma

• Aspiration pneumonia

Question 4

Barrett’s oesophagus

Answer 4

Intestinal metaplasia of squamous epithelium to stratified columnar which can lead to dysplasia and adenocarcinoma

Question 5

Investigations

Answer 5

• Bloods: FBC, Fe
• CXR: hiatus hernia may be seen
• OGD
• Ba swallow: hiatus hernia, dysmotility
• 24h pH testing (gold standard) 
- pH <4 for >4hrs
• manometry - dysmotility

Question 6

When to do OGD

Answer 6

• > 55yrs
• Persistent symptoms despite Tx
• Anaemia
• Loss of wt.
• Anorexia
• Recent onset progressive symptoms
• Melaena
• Swallowing difficulty

OGD allows grading by Los Angeles Classification

Question 7

Treatment of GORD

Answer 7

Medical:
• OTC antacids: Gaviscon

1: Full-dose PPI for 1-2mo
- Lansoprazole OD
2: No response → double dose PPI BD
3: No response: add an H2RA - Ranitidine

Surgical: Nissen Fundoplication

Question 8

When is Nissen fundoplication required

Answer 8

All 3 of:

• Severe symptoms
• Confirmed reflux (pH monitoring)
• Failure to respond to medical mx
• Patient preference
• complications

Question 9

Nissen fundoplication

Answer 9

Prevents reflux and repairs diaphragm

• laparoscopic
• Mobilise gastric fundus and wrap around lower
oesophagus
• Close any diaphragmatic hiatus

Question 10

Nissen fundoplication complications

Answer 10

Gas-bloat syndrome - inability to belch/vomit
- settle after 6 weeks

Dysphagia if wrap too tight

Bloating

Question 11

Risk factors for GORD

Answer 11

Age
Obesity
Male gender
Alcohol
Smoking
Caffeinated drinks
Fatty or spicy foods.

Question 12

Red flags for GORD

Answer 12

Dysphagia
Weight loss
Early satiety
Malaise 
Loss of appetite

Question 13

Grading of GORD

Answer 13

Los Angeles Classification of Reflux

Question 14

Conservative mx of GORD

Answer 14

• Lose weight
• Raise head of bed
• Small regular meals ≥ 3h before bed
• Stop smoking and ↓ EtOH
• Avoid hot drinks and spicy food

• Stop drugs: NSAIDs, antimuscarinics, nitrates, CCB, TCAs

Question 15

Contraindication to anti-reflux surgery

Answer 15

Oesophageal dysmotility