GORD and hiatus hernia

Question 1

Describe GORD?

Answer 1

• Oesophageal mucosa is exposed to gastroduodenal contents for prolonged periods of time, resulting in:
  
  • Oesophagitis
  • Benign oesophageal stricture
  • Barrett’s oesophagus

Question 2

What are the causes of GORD?

Answer 2

• Hiatus hernia
• Abnormalities of LOC
• Delayed gastric emptying
• Gastric acid hypersecretion
• Obesity, smoking, alcohol, Helicobacter pylori

Question 3

What drugs can cause GORD?

Answer 3

• Nitrates
• Tricyclics
• Anticholinergics

Question 4

What are the symptoms of GORD?

Answer 4

• Oesophageal
  
  • Heartburn, belching, acid brash, odynophagia
• Extra-oesophageal
  
  • Sinusitis
  • Chronic cough
  • Nocturnal asthma

Question 5

Name some complications of GORD?

Answer 5

• Ulcers
• Oesophagitis
• Iron deficiency anaemia
• Barrets oesophagus: Metaplasia -> dysplasia -> neoplasia

Question 6

Describe Barrett’s oesophagus?

Answer 6

• Distal oesophageal metaplasia
  
  • Squamous to columnar epithelium
• Increases risk of adenocarcinoma development

Question 7

Describe some investigations into GORD?

Answer 7

• Endoscopy if:
  
  • Dysphagia OR
  • >55yrs with alarm symptoms OR
  • Treatment-refractory dyspepsia
• When endoscopy is normal:
  
  • 24h oesophageal pH monitoring

Question 8

Describe the treatment for GORD?

Answer 8

• 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

Question 9

What drugs affect oesophageal motility?

What drugs damage oesophageal mucosa?

Answer 9

• Motility
  
  • Nitrates, anticholinergics, CCBs
• Damage mucosa
  
  • NSAIDs, K+ salts, bisphosphonates

Question 10

Describe a sliding hiatus hernia?

Answer 10

• Most common
• The GO junction slides up into the chest
• Acid reflux happens as lower oesophageal sphincter is less competent

Question 11

Describe a paraoesophageal (rolling) hiatus hernia?

Answer 11

• GO junction remains in abdomen, bulge of stomach herniates up into the chest alongside the oesophagus.
• GORD is less common in this case

Question 12

What imaging can help diagnose a hiatus hernia?

Answer 12

• Upper GI endosccopy
  
  • Can visualise the mucosa
  • Cannot reliably exclude hiatus hernia

Question 13

What is the treatment for a hiatus hernia?

Answer 13

• Lose weight
• Treat GORD
• Surgery is medical therapy fails

Question 14

Describe the relevance of abnormalities of the lower oesophageal sphincter in GORD?

Answer 14

• Normally:
  
  • LOS is tonically contracted, relaxing only for swallowing
• Patients with GORD:
  
  1. Reduced LOS tone which allows reflux when intra-abdominal pressure rises
  2. Sphincter tone is normal but reflux occurs due to episodes of inappropriate relaxation

Question 15

Steps involved in reflux surgery?

Answer 15

• Reduction of the hiatus hernia
• Approximation of the crura around the hiatus hernia
• Fundoplication

Question 16

Describe the relationship between GORD and hiatus hernia?

Answer 16

• 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

Question 17

Describe the relationship between environmental factors and the development of GORD?

Answer 17

• Dietary fat, coffee, tea, chocolate, alcohol
• Relax the LOS and may provoke symptoms

Question 18

What are the important features of hiatus hernias?

Answer 18

• 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

Question 19

Draw the management diagram for GORD

Answer 19

Question 20

Describe iron deficiency anaemia as a complication of GORD?

Answer 20

• 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

Question 21

Describe the relationship between GORD and gastric volvulus?

Answer 21

• Massive intrathoracic hiatus hernia may twist on itself
  
  • Leading to gastric volvulus
• Can cause gastric/oesophageal obstruction
  
  • Severe chest pain, vomiting, dysphagia

Question 22

Describe the diagnosis and management of gastric volvulus?

Answer 22

• Diagnosis
  
  • CXR
    
    • Air bubble in the chest
  • Barium swallow
• Management
  
  • Most resolve spontaneosly
  • Surgery after acute episode has been managed with NG decompression

Question 23

Describe the results of 24h oesophageal pH monitoring?

Answer 23

pH <4 for more than 6% of time is diagnostic

Question 24

Describe the use of H2 blockers?

Answer 24

• eg Ranitidine
• Blocks the action of histamine H2 receptors in gastric parietal cells which decreases the production of stomach acid

Question 25

Describe the use of PPIs?

Answer 25

• eg Omeprazole
• Inhibit gastric H+-K+ATPase
  
  • Responsible for H+ secretion into the gastric lumen

Question 26

Consequences of long term PPI treatment?

Answer 26

• Reduced absorption of iron, B12 and magnesium
• Increased osteoporosis risk
• Predisposition to campylobacter and salmonella

Question 27

What are the epithelium in the stomach?

Answer 27

Mucus secreting columnar cells

Question 28

Complications of fundoplication surgery?

Answer 28

• Inability to belch
• Early satiety
• Increased flatus

Question 29

Briefly describe fundoplication?

Answer 29

• Nissen fundoplication is most common
• The stomach fundus is wrapped around the lower oesophagus 360^o