GORD (Gastro-oesophageal reflux disease) Flashcards
What is GORD?
The reflux of gastric contents into the oesophagus caused by a defective lower oesophageal sphincter
What is the epidemiology of GORD?
≈5% adults have symptoms daily.
Three times more common in males than females
What are the lifestyle factors of GORD?
- Obesity
- Alcohol use
- Smoking
- Intake of specific foods (e.g. coffee, citrus foods, spicy foods, fat)
What are some previous medical risk factors of GORD?
- Hiatus hernia
- Lower oesophageal sphincter hypotension
- Loss of oesophageal peristaltic function
- Gastric acid hypersecretion
- Delayed gastric emptying
- Systemic sclerosis
- Pregnancy (raised intra-abdominal pressure, hormonal smooth muscle relaxation)
- Surgery for achalasia (failure of lower oesophageal sphincter to relax due to degeneration of the myenteric plexus)
- Pyloric stenosis (increased gastric contents volume-projectile vomiting)
Drugs (tri-cyclic anti-depressants, anticholinergics, nitrates, alendronate)
Why is obesity a risk factor?
It raises the intra-abdominal pressure
Why is smoking a risk factor?
It may cause a faulty oesophageal sphincter
Why is eating fatty foods a risk factor?
Raised intra-abdominal sphincter
What is the pathophysiology of GORD?
- Extent of mucosal damage depends on: duration of contact, type of gastric content and resistance of epithelia
- Severe reflux= involves oesophagus and inability to contract and clear contents
- Intermittent pharyngeal reflux= symptoms are experienced during sleep when the upper oesophageal junction relaxes
- Reflux induced asthma= caused by aspiration of gastric contents
What are the symptoms of GORD?
- Dyspepsia- Heartburn-(worse at night→ when lying down, stooping or bending) retrosternal burning
- Sensation of acid regurgitation
- Halitosis
- Belching
- N+V
- Epigastric pain
- Globus sensation- persistent sensation of lump in throat
- Onset relating to meals (pain when drinking alcohol or hot liquids)
- Symptoms relieved by antacids
- Odynophagia- pain on swallowing (oesophagitis or ulceration)
What are the alarming features of GORD?
weight loss, anaemia, dysphagia, haeamatemesis, melaena, persistent vomiting
What are some differential diagnoses of GORD?
- Oesophagitis- (caused by corrosive substances & NSAIDS)
- Infection- CMV, HSV, Candida
- Duodenal ulcers
- Gastric ulcers/ cancers
- Dyspepsia
- Heart burn (crushing, radiating to left arm)
What are some investigations used for GORD?
- Trial of PPI therapy
- Endoscopy- used if lifestyle and PPI didn’t work, aged 55 or over with treatment-resistant dyspepsia get it
- OGD if alarm features
- Oesophageal manometry
- Hiatus hernia barium swallow
What is the management of GORD?
- Encourage: weight loss, smoking cessation, raise head rest when sleeping, small/regular meals
- Avoid: Hot drinks, alcohol, eating before sleep
What is the treatment for GORDS?
- PPI (recommended first line) (Lansoprazole/Omeprazole)- inhibits gastric acid secretion by inhibiting H/K ATPase
- Antacids (Gaviscon/ Magnesium Trisilicate)- neutralises gastric acid
- H2-receptor antagonist (Ranitidine)- inhibits gastric acid secretion
- Prokinetic agents- (Metoclopramide)- aids gastric emptying
- Nissen Fundoplication- performed when medical treatment fails → gastric fundus is wrapped around the lower oesophagus→ reinforcing closure of the oesophageal sphincter
What is the prognosis for GORD?
- Most patients respond well to treatment (maintenance PPI treatment is recommended)
- Patients do higher risk of developing Barrett’s Oesophagus or Oesophageal Adenocarcinoma
What are the complications of GORD?
- Peptic strictures- may require endoscopic dilation and long-term PPI
- Barrett’s Oesophagus- metaplasia from squamous → columnar cells
- Oesophageal adenocarcinoma
- Oesophagitis or Ulcers
How can GORD appear in clinical examination?
Usually NORMAL
BUT red flag symptoms are upper abdominal mass, dysphagia, age >55yrs and weight loss
What should be done if there is an upper abdominal mass and GORD features?
Endoscopy and pH monitoring
Consider oeseophagogastroduodenoscopy, barium swallow
What is the acute management of GORD?
ACUTE:
1st LINE: standard-dose PPI e.g. omeprazole 20mg orally once daily
PLUS: lifestyle changes, weight loss, head of bed elevation, avoidance of late night eating
What is the ongoing first-line management/treatment for GORD?
1ST LINE: continued standard-dose PPI
What is the ongoing second-line management/treatment for GORD?
2nd LINE: surgery – reserved for those who have a good response to PPIs but do not wish to take long-term medical treatment
How should you manage GORD with incomplete response to PPI?
1ST LINE: high-dose PPI + futher testing – dosing is twice daily, before breakfast and dinner
WITH NOCTURNAL COMPONENT: add a H2-anatognist
