GORD and Hiatus Hernia

Question 1

What are the risk factors for GORD?

Answer 1

Obesity
Alcohol
Smoking
Fhx GORD
Increasing age
Asthma
Psychological stress
Intake of specific foods e.g. coffee, mints, citrus fruits or fats

Question 2

How can GORD result in asthma?

Answer 2

Vagal stimulation caused by acid in the lower oesophagus may cause chronic coughing and throat clearing. Reflux induced asthma may be caused by chronic aspiration of the reflux contents and vasovagal bronchoconstriction

Question 3

Describe the. typical presentation of GORD?

Answer 3

Heartburn and regurgitation are the most reliable symptoms
These often occur after meals, especially large or fatty meals
Atypical symptoms include cough, laryngitis, asthma or dental erosion
Symptoms may be worse when the patient is lying down or bending over
Relief with antacids is typical

Question 4

What are alarm symptoms in the presentation of GORD?

Answer 4

Anaemia
Dysphagia
Haematemesis
Malaena
Persistent vomiting
Involuntary weight loss

Question 5

Routine testing for h.pylori infection is recommended by guidelines in GORD. T/F?

Answer 5

True

Question 6

Other than endoscopy, what investigations may be done for patients with GORD, particularly if symptoms are persistent?

Answer 6

Mannometry

Ambulatory 24-hour oesophageal pH

Question 7

What lifestyle measures should be used to treat GORD?

Answer 7

Weight loss
Smoking cessation
Avoidance of late-night eating

Question 8

What is the standard pharmacotherapy for GORD?

Answer 8

8 week treatment with PPIs - omeprazole

or H2 receptor antagonists

Question 9

What type of surgery is used for GORD?

Answer 9

Fundoplication

Question 10

Give an example of a H2 receptor antagonist?

Answer 10

Cimetidine and ranitidine

Question 11

List some of the complications of GORD?

Answer 11

Oesophagitis
Oesophageal ulcer
Oesophageal stricture
Barrett's oesophagus
Adenocarcinoma of the oesophagus
Iron deficiency anaemia

Question 12

What is Barrett’s oesophagus?

Answer 12

Metaplasia of the oesophageal epithelium which is considered to. be a premalignant lesion

Question 13

What is a hiatus hernia?

Answer 13

The protrusion of intra-abdominal contents through an enlarged oesophageal hiatus of the diaphragm

Question 14

What are the risk factors for a hiatus hernia?

Answer 14

Obesity
Male sex
Advanced age
Elevated intra-abdominal pressure
Structural abnormalities of the oesophagus

Question 15

Describe the difference between sliding and rolling hiatus hernia?

Answer 15

Sliding - the whole fundus of the stomach slides through the diaphragm and the lower oesophageal sphincter is no longer in contact with the diaphragm
Rolling - the fundus is pushed up through the gap in the diaphragm but the lower oesophageal sphincter remains in contact with the diaphragm

Question 16

Which type of hiatus hernia is more likely to cause symptoms?

Answer 16

Sliding hiatus hernia because the disruption of the lower oesophageal sphincter

Question 17

Which type of hiatus hernia is more likely to become strangulated?

Answer 17

Rolling hiatus hernia

Question 18

What are the symptoms of hiatus hernia?

Answer 18

Often asymptomatic
Same symptoms as GORD - heartburn, regurgitation
May also be: dysphagia, odynophagia, vomiting, GI bleeding, early satiety, bloating, hoarseness, wheeze

Question 19

How is hiatus hernia investigated?

Answer 19

CXR
Contrast upper GI series
Oesophago-gastroduodenoscopy
CT

Question 20

The Nissen fundoplication is the surgery used to treat hiatus hernia. Describe the principle of how this works/

Answer 20

The fundus is wrapped around the distal oesophagus which encourages the lower oesophageal sphincter to assume its correct position and also acts as an artificial sphincter

Question 21

What are the complications of surgery to repair hiatus hernia?

Answer 21

Gas bloat syndrome
Dysphagia
Dumping syndrome
Excessive scarring
Vagus nerve injury
Achalasia

Question 22

What findings would be seen on CXR when there is a hiatus hernia?

Answer 22

Retrocardiac air bubble

Question 23

Describe the management of hiatus hernia

Answer 23

Strangulation / obstruction -> emergency surgical repair
Symptomatic GORD -> PPI and lifestyle changes
Rolling hernia -> surgical repair +/- anti-reflux procedure

Question 24

What are the potential complications of hiatus hernia?

Answer 24

GI bleeding
Barrett’s oesophagus -> adenocarcinoma
Obstruction / strangulation
Gastric volvulus

Question 25

Describe the management of Barrett’s oesophagus

Answer 25

PPIs and surveillance
Endoscopic radio frequency ablation and/or anti-reflux surgery considered if GORD, required if dysphagia
If high-grade dysplasia is present then consider oesophagectomy