GORD and hiatus hernia Flashcards
1
Q
What is GORD?
A
- Gastric acid from stomach leaks into the oesophagus
- More common in men and in western countries
2
Q
Describe the pathophysiology of GORD?
A
- Lower oesophageal sphincter normally controls passage of contents from oesophagus to stomach
- In GORD, the sphincter is relaxed more frequently than normal
- Refluxed acidic contents than result in pain and mucosal damage
3
Q
Risk factor for GORD?
A
- Age
- Obesity
- Male gender
- Alcohol, smoking
- Caffeinated drinks, fatty/spicy foods
4
Q
What are the clinical features of GORD?
A
- Chest pain
- burning, retrosternal
- worse after meals, lying down, bending over or straining
- relieved by antacids
- Belching, odynophagia, chronic/nocturnal cough
- Red flags: dysphagia, weight loss, early satiety, malaise
5
Q
Describe a classification system for GORD?
A
- Los Angeles classification
- Based on mucosal breaks in distal oesophagus from endoscopy
- Grade A: breaks <= 5mm
- Grade B: breaks >5mm
- Grade C: breaks extending between tops of >=mucosal folds but <75% circumferance
- Grade D: circumferential breaks (>=75%)
6
Q
Name some differentials for GORD to consider?
A
- Malignancy (oesophageal or gastric)
- Peptic ulceration
- Oesophagitis
- Oesophageal motility disorders
7
Q
Name the invesitgations that should be performed for a suspected GORD?
A
- Clinical diagnosis from good history + resolution of symptoms with PPI
- Upper GI endoscopy
- Investigate malignancy and complications of reflux
- 24hr pH monitoring is gold standard for GORD diagnosis
- Combined with oesophageal manometry to exclude oesophageal dysmotility
8
Q
Describe pH monitoring studies?
A
- Assess:
- Amount of time acid is present in the oesophagus
- Correlation between acid presence and patients symptoms
- Produces a DeMeester score
- Can help determine patients symptom-reflux correlation
9
Q
Describe the management of GORD?
A
- Avoid known precipitants
- alcohol, smoking, coffee
- Encourage weight loss
- Medical and surgical interventions
10
Q
Describe the medical management of GORD?
A
- PPIs (first line for majority of patients)
- Likely to remain on them for life unless they undergo surgery
11
Q
What are the main indications for surgery in GORD?
A
- Failure to response to medical therapy
- Patient preference to avoid life-long medication
- Patients with complications of GORD (recurrent pneumonia or bronchiectasis)
12
Q
Describe the surgical management of GORD?
A
- Fundoplication
- The top part of the stomach is wrapped around the lower oesophagus
- Recreates a physiological lower oesophageal sphincter
13
Q
What are the main side effects of anti-reflux surgery?
A
- Dysphagia
- Bloating
- Inability to vomit
14
Q
Describe 2 new techinques for the management of GORD?
A
- Stretta
- Radio-frequency energy is delivered endoscopically to cause thickening of the lower oesophageal sphincter
- Linx
- String of magnetic beads is inserted laparoscopically around the lower oesophageal sphincter to tighten the LOS
15
Q
What are the main complications of GORD?
A
- Aspiration pneumonia
- Barret’s oesophagus
- Oesophagitis and oesophageal strictures
- Oesophageal cancer
16
Q
Immediately after surgery for severe oesophagitis, a patient reports difficulty belching, increased saliva, and abdominal pain. What is the likely cause of these symptoms?
A
The Nissen fundoplication procedure has wrapped the fundus of the stomach too tightly around the gastrooesophageal junction
17
Q
What is a hernia?
A
Protrusion of a whole/part of an organ through the a cavity wall into an abnormal position
18
Q
What is a hiatus hernia?
A
- Protrusion of an organ from the abdominal cavity into the thorax through the oesophageal hiatus
- Typicall the stomach
- Can also be small bowel, colon or mesentery
19
Q
What are main subtypes of hiatus hernia?
A
- Sliding hiatus hernia (80%)
- Rolling or Para-oesophageal hernia (20%)
20
Q
Describe a sliding hiatus hernia?
A
The GO junction, the abdominal part of the oesophagus and the cardia of the stomach slide upwards through the diaphragmatic hiatus into the thorax
21
Q
Describe a rolling or para-oesophageal hiatus hernia?
A
- Upward movement of the gastric fundus occurs to lie alongside a normally placed GO junction
- Creates a bubble of stomach in the thorax
- True hernia with a peritoneal sac
22
Q
What are the risk factors for hiatus hernias?
A
- Age
- Age-related loss of diaphragmatic tone
- Increasing intraabdominal pressures (repeated coughing)
- Increased size of diaphragmatic hiatus
- Pregnancy, obesity, ascites
23
Q
Clinical features of hiatus hernia?
A
- Majority are asymptomatic
- Vomiting, weight loss, bleeding, hiccups, palpitations
- Swallowing difficulties
24
Q
Name some differentials for hiatus hernia?
A
- Cardiac chest pain
- Gastrif or pancreatic cancer
- GORD
25
What investigations should be performed in someone where there is a clinical suspicion of hiatus hernia?
* Oesophagogastroduodenoscopy (OGD) is gold standard
* Shows upward displacement of GO junction (Z-line)
* Can be incidental diagnosis from CT or MRI
26
Describe the management of hiatus hernia?
* Weight loss, smoking cessation, reduced alcohol intake
* Medical
* PPIs eg omeprazole for symptom control
* Surgery may also be indicated
27
What are the indications for surgical management of hiatus hernia?
* Remaining symptomatic despite maximum medical therapy
* Increased risk of stranglation/volvulus
* Nutritional failure due to gastric outlet obstruction
28
Describe the surgical management of hiatus hernia?
1. Laparoscopic cruroplasty
* Hernia reduced from thorax into abdomen and is reapproximated to the appropriate size
* Any large defects require mesh to strength repair
2. Fundoplication to prevent further herniation
29
What are the complications of hiatus hernia surgery?
* Recurrence of hernia
* Abdominal blating due to inability to belch
* Dysphagia if fundoplication is too tight ot crural repair is too narrow
* Fundal necrosis if left gastric artery is damaged
30
Name some complications of a hiatus hernia?
* Incarceration and strangulation
* Gastric volvulus can also occur
31
What is a gastric volvulus?
* Stomach twists on itself 180o
* Leads to obstruction of gastric passage and tissue necrosis
32
What is the presentation of a gastric volvulus?
* Borchardt's triad:
* Severe epigastric pain
* Retching without vomiting
* Inability to pass an NG tube
33
What is the gold standard of diagnosis of a hiatus hernia?
Endoscopy
34
Which branch of the aorta supplies the majority of the stomach?
Coeliac trunk
35
Describe the presentation of a peptic stricture?
* Longer history of dysphagia, non-progressive
* Usually symptoms of GORD
* Lacks systemic features of malignancy
36
Describe dysmotility disorder of the oesophagus?
* Dysphagia which is episodic and non-progressive
* Retrosternal pain may accompany the episodes
37
Describe the presentation of a Mallory-Weiss tear?
* History of ovmiting following by vomiting with small amounts of blood
* Usually very little systemic disturbance
38
A 76-year-old man presents with a 5 week history of progressive dysphagia. An upper GI endoscopy is performed and the surgeon notices changes that are compatible with Barretts oesophagus. The oesophagus is filled with food debris that cannot be cleared and the endoscope encounters a resistance that cannot be passed.
What is the likely diagnosis?
Adenocarcinoma of the oesophagus
39
Hiatus hernia
40
