GORD and hiatus hernia Flashcards
Describe GORD?
- Oesophageal mucosa is exposed to gastroduodenal contents for prolonged periods of time, resulting in:
- Oesophagitis
- Benign oesophageal stricture
- Barrett’s oesophagus
What are the causes of GORD?
- Hiatus hernia
- Abnormalities of LOC
- Delayed gastric emptying
- Gastric acid hypersecretion
- Obesity, smoking, alcohol, Helicobacter pylori
What drugs can cause GORD?
- Nitrates
- Tricyclics
- Anticholinergics
What are the symptoms of GORD?
- Oesophageal
- Heartburn, belching, acid brash, odynophagia
- Extra-oesophageal
- Sinusitis
- Chronic cough
- Nocturnal asthma
Name some complications of GORD?
- Ulcers
- Oesophagitis
- Iron deficiency anaemia
- Barrets oesophagus: Metaplasia -> dysplasia -> neoplasia
Describe Barrett’s oesophagus?
- Distal oesophageal metaplasia
- Squamous to columnar epithelium
- Increases risk of adenocarcinoma development
Describe some investigations into GORD?
- Endoscopy if:
- Dysphagia OR
- >55yrs with alarm symptoms OR
- Treatment-refractory dyspepsia
- When endoscopy is normal:
- 24h oesophageal pH monitoring
Describe the treatment for GORD?
- Lifestyle
- Weight loss, smoking cessation, avoid fizzy drinks & spicy food
- Avoid eating <3h before bed
- Drugs
- Antacids: magnesium trisilicate + PPI
- H2 blocker for refractory symptoms
- Surgery
- Radiofrequency induced hypertrophy
- Aim is to increase the resting lower oesophageal sphincter pressure
- Radiofrequency induced hypertrophy
What drugs affect oesophageal motility?
What drugs damage oesophageal mucosa?
- Motility
- Nitrates, anticholinergics, CCBs
- Damage mucosa
- NSAIDs, K+ salts, bisphosphonates
Describe a sliding hiatus hernia?
- Most common
- The GO junction slides up into the chest
- Acid reflux happens as lower oesophageal sphincter is less competent
Describe a paraoesophageal (rolling) hiatus hernia?
- GO junction remains in abdomen, bulge of stomach herniates up into the chest alongside the oesophagus.
- GORD is less common in this case
What imaging can help diagnose a hiatus hernia?
- Upper GI endosccopy
- Can visualise the mucosa
- Cannot reliably exclude hiatus hernia
What is the treatment for a hiatus hernia?
- Lose weight
- Treat GORD
- Surgery is medical therapy fails
Describe the relevance of abnormalities of the lower oesophageal sphincter in GORD?
- Normally:
- LOS is tonically contracted, relaxing only for swallowing
- Patients with GORD:
- Reduced LOS tone which allows reflux when intra-abdominal pressure rises
- Sphincter tone is normal but reflux occurs due to episodes of inappropriate relaxation
Steps involved in reflux surgery?
- Reduction of the hiatus hernia
- Approximation of the crura around the hiatus hernia
- Fundoplication
Describe the relationship between GORD and hiatus hernia?
- Hiatus hernia causes reflux
- Pressure gradient between abdominal and thoracic cavities which normally pinches the hiatus is lost
- The oblique angle between the oesophagus and cardia is lost
Describe the relationship between environmental factors and the development of GORD?
- Dietary fat, coffee, tea, chocolate, alcohol
- Relax the LOS and may provoke symptoms
What are the important features of hiatus hernias?
- Herniation of stomach through the diaphragm into the chest
- Occurs in 30% of the population over 50
- Often asymptomatic
- Heartburn and regurgitation can occur
- Gastric volvulus may complicate large hernias
Draw the management diagram for GORD
Describe iron deficiency anaemia as a complication of GORD?
- Blood loss from chronic oesophagitis
- Patients have a large hiatus hernia
- Bleeding from erosions in the stomach neck - Cameron lesions
- Colorectal cancer must be ruled out
Describe the relationship between GORD and gastric volvulus?
- Massive intrathoracic hiatus hernia may twist on itself
- Leading to gastric volvulus
- Can cause gastric/oesophageal obstruction
- Severe chest pain, vomiting, dysphagia
Describe the diagnosis and management of gastric volvulus?
- Diagnosis
- CXR
- Air bubble in the chest
- Barium swallow
- CXR
- Management
- Most resolve spontaneosly
- Surgery after acute episode has been managed with NG decompression
Describe the results of 24h oesophageal pH monitoring?
pH <4 for more than 6% of time is diagnostic
Describe the use of H2 blockers?
- eg Ranitidine
- Blocks the action of histamine H2 receptors in gastric parietal cells which decreases the production of stomach acid
Describe the use of PPIs?
- eg Omeprazole
- Inhibit gastric H+-K+ATPase
- Responsible for H+ secretion into the gastric lumen
Consequences of long term PPI treatment?
- Reduced absorption of iron, B12 and magnesium
- Increased osteoporosis risk
- Predisposition to campylobacter and salmonella
What are the epithelium in the stomach?
Mucus secreting columnar cells
Complications of fundoplication surgery?
- Inability to belch
- Early satiety
- Increased flatus
Briefly describe fundoplication?
- Nissen fundoplication is most common
- The stomach fundus is wrapped around the lower oesophagus 360o
