GORD Es notes Flashcards
GORD causes
LOS hypotension Hiatus hernia (likely sliding) Oesophageal dysmotility (e.g. systemic sclerosis) Obesity Gastric acid hypersecretion Delayed gastric emptying Smoking Alcohol Pregnancy Drugs- TCAs, anticholinergics, nitrates H Pylori
Hiatus hernia- Sliding
80%
Gastro-oesophageal junction slides up into the chest
Acid reflux often happens as the LOS becomes less competent in many cases
Hiatus hernia- Paraoesophageal (rolling hernia)
20%
Gastro-oesophageal junction remains in the abdomen but a bulge of stomach herniates up into the chest alongside the oesophagus
Hiatus Hernias clinical features
Common: 30% of patients >50 years, especially obese women
Although most small hernias are asymptomatic, patients with large hernias may develop GORD
Hiatus hernia imaging
Upper GI endoscopy visualises the mucosa (?oesophagitis) but cannot reliably exclude a hiatus hernia
Hiatus hernia treatment
Lose weight
Treat GORD
Surgery indications- intractable symptoms despite aggressive medical therapy, complications
Rolling hiatus hernias may strangulate but the risk drops dramatically after 65
Prophylactic repair is only undertaken in those considered at high risk, due to operative mortality (1-2%)
Oesophageal GORD symptoms
Heartburn (dyspepsia)= burning, retrosternal discomfort after meals, lying, stooping or straining, relieved by antacids
Belching
Acid brash= acid or bile regurgitation
Water brash= increased salivation
Odynophogia (e.g. from oesophagitis or ulceration)
Extra-Oesophageal GORD symptoms
Nocturnal asthma
Chronic cough
Laryngitis (hoarseness, throat clearing)
Sinusitis
GORD complications
Oesophagitis Ulcers Benign stricture Iron deficiency Barrett's oesophagus
GORD- Barrett’s
Metaplasia –> dysplasia –>neoplasia
Distal oesophageal epithelium undergoes metaplasia from squamous to columnar
0.1-0.4%/yr of those with Barrett’s progress to oesophageal cancer (higher if dysplasia is present)
Dysplasia on biopsy in Barrett’s oesophagus requires endoscopic mucosal therapy
GORD differential diagnosis
Oesophagitis from corrosives, NSAIDs, herpes or Candida Duodenal or gastric ulers or cancers Non-ulcer dyspepsia Oesophageal spasm Cardiac disease
GORD investigations
Endoscopy- 1) if dysphagia or 2) if >55 with alarm symptoms or 3) if treatment-refractory dyspepsia
24hr oesophageal pH monitoring +/- manometry help diagnose GORD when endoscopy is normal
GORD management- lifestyle
Weight loss Smoking cessation Small, regular meals Reduce: hot drinks, alcohol, citrus fruits, tomatoes, fizzy drinks, spicy foods, caffeine, chocolate Avoid eating >3 hrs before bed Raisethe bed head
GORD management- drugs
Antacids (e.g. magnesium trisilicate mixture 10ml/8h) or alginates (e.g. Gaviscon 102-ml/8h PO) to relieve symptoms Add PPI (e.g. lansoprazole 30mg/24h PO) For refractory symptoms, add H2 blocker and/or try twice-daily PPI Avoid drugs affecting oesophageal motility- nitrates, anticholinergics, CCBs (relax oesophageal sphincter)- or that damage the mucosa- NSAIDs, K+ salts, biphosphates
GORD management- surgery
Aim to increase resting LOS pressure Consider in severe GORD (confirm by pH-monitoring/manometry) if drugs are not working Atypical symptoms (cough, laryngitis) are less likely to improve with surgery compared to patients with typical symptoms
