GORD, Eosinophilic oesophagitis Flashcards
What is GORD (6)
- Gastro Oesophageal Reflux Disease (GORD)
- persistent and progressive heartburn caused by stomach contents returning past the sphincter back to oesophagus.
- Endoscopically negative reflux disease- no oesophageal injury
- Endoscopically proven oesophagitis- confirmed oesophageal injury
- More common in older patients and women
- Can lead to an abnormality of the cells in the lining of the oesophagus (Barrett’s), the most important risk factor for oesophageal cancer
What are the causes leading to reduced competence of the lower oesophageal sphincter (4)
- hiatus hernia
- Physical
- Diet and smoking
- Drug-related
What is the hiatus hernia cause to reduced competence of the lower oesophageal sphincter (3)
- Part of the stomach moves above diaphragm into chest
- 10-20% prevalence
- More common if >50, pregnant or overweight
What is the physical cause to reduced competence of the lower oesophageal sphincter (4)
- Excessive pressure overcomes the sphincter
- Obesity (link poor)
- Pregnancy
- Excursion
What is the diet/smoking cause to reduced competence of the lower oesophageal sphincter (3)
- Fatty foods and chocolate lubricate mucosa of LOS
- Excessive caffeine relaxes smooth muscle of the LOS
- Excessive alcohol consumption and smoking
What is the drug related cause to reduced competence of the lower oesophageal sphincter (3)
- Anticholinergic drugs relax smooth muscle of the LOS
- Drugs that slow down gastric emptying
- Immunosuppressed patient with recurrent candidiasis
What are the signs and symptoms of GORD (8)
Progression from:
- Heart burn
- Pain (can resemble heart attack pain)
- Acid regurgitation
- Dysphagia
- Cough (particularly when lying down), hoarse voice
- Aspiration pneumonia
- Can lead to ulcerations and strictures
- Barret’s oesophagus
What is the course of action for GORD (8)
- Very similar presentation to dyspepsia
- Including same red flags and referral points
- Once referred → endoscopy or oesophago-gastro duodenoscopy (OGD)
- Narrow tube with camera swallowed to view: Oesophagus, Stomach, Proximal duodenum
- Allows biopsy
- Low morbidity (1/200)
- Low mortality (1/2000)
- 4% referrals lead to cancer diagnosis
what drugs should be avoided for GORD (3)
- Diazepam
- Antimuscarinics
- Tricyclic antidepressants
What intervention is there for post-endoscopy - endoscope negative (no oesophagitis)
Full dose PPI for 4-8 weeks.
If full dose of PPI for 4-8 weeks for post-endoscopy - endoscope negative (no oesophagitis) is effective (2)
- If symptoms recur (20-30% patients), offer a PPI at the lowest dose possible to control symptoms
- Discuss self management with “when needed” treatment
If full dose of PPI for 4-8 weeks for post-endoscopy - endoscope negative (no oesophagitis) is not effective (2)
- Switch to a different PPI at Full dose
- Add in H2 antagonist to above
What intervention is there for post-endoscopy - endoscope positive (with oesophagitis)
Full dose PPI for 8 weeks: healing treatment
If full dose of PPI for 4-8 weeks for post-endoscopy - endoscope positive (with oesophagitis) is effective
Continue treatment at full dose
If full dose of PPI for 4-8 weeks for post-endoscopy - endoscope positive (with oesophagitis) is not effective (3)
- Switch to another PPI at full or high dose, or change to high dose of current PPI
- Consider referral to specialist: Surgery, electrical stimulation and also other pharmacotherapies…
- treat underlying cause
What are the GORD mucosal protectors (3)
- Bismuth subsalicylate (antacid) - 525mg 4 times a day for 7 days
- Sucralfate (sucrose-aluminium complex) - 2g twice daily or 1g 4 times daily for 4-6 weeks
- Misoprostol (synthetic prostaglandin E2, useful to counter NSAIDs) - 400mg twice daily or 200mg 4 times daily for at least 4 weeks
What are GORD sphincter strengtheners and prokinetics (2)
- Strengtheners: Improve tone of lower oesophagus sphincter muscle - dopamine antagonists & metoclopramide
- Prokinetics: Speed up transit of stomach contents - dopamine antagonists, metoclopramide & erythromycin
What is Eosinophilic oesophagitis (2)
- Eosinophils infiltrate and cause inflammation in the oesophagus
- Also called ‘allergic oesophagitis’
What are the symptoms of Eosinophilic oesophagitis (5)
- Pain after certain food types
- Swallowing difficulty
- Food impaction
- Vomiting
- Heartburn that doesn’t respond to PPIs
What is the pathophysiology of eosinophilic oesophagitis (3)
- Infiltration of eosinophils into the epithelial lining of the oesophagus
- Allergic reaction against ingested food
- Eosinophils are inflammatory cells that release a variety of chemical signals which inflame the surrounding oesophageal tissue
What happens during asthma of the oesophagus (7)
- Allergen detected
- Eosinophils invade the epithelium
- Immune response activated: Type 2 helper cells activated
- Release cytokines:
- Interleukin 5
- Interleukin 13
- Eotaxin-3
What are the treatments to eosinophilic oesophagitis (3)
- dietary changes - six food elimination diet
- Swallowed corticosteroids - soluble beclomethasone tablets
- oesophageal dilation
What is the six-food elimination diet (SFED) (6)
- Dairy
- Soya
- Eggs
- Wheat
- Peanuts
- Fish/shellfish
