GORD + (hiatus hernia)

Question 1

What is GORD?

Answer 1

Gastro-oesophageal reflux disease (GORD) is where acid from the stomach refluxes through the lower oesophageal sphincter and irritates the lining of the oesophagus.

Question 2

What epithelium does the oesophagus have?

Answer 2

The oesophagus has a squamous epithelial lining making it more sensitive to the effects of stomach acid.

Question 3

What epithelium does the stomach have?

Answer 3

The stomach has a columnar epithelial lining that is more protected against stomach acid.

Question 4

What is dyspepsia?

Answer 4

Dyspepsia is a non-specific term used to describe indigestion

Question 5

what encompasses dyspepsia?

Answer 5

Heartburn
•Acid regurgitation
•Retrosternal or epigastric pain
•Bloating
•Nocturnal cough
•Hoarse voice

Question 6

What can endoscopy be used for?

Answer 6

Endoscopy can be used to assess for peptic ulcers, oesophageal or gastric malignancy if there are concerning features.

Question 7

What requires an urgent endoscopy?

Answer 7

Patients with evidence of a GI bleed (i.e. meleana or coffee ground vomiting)

Question 8

What do patients who have symptoms consistent with cancer receive?

Answer 8

Patients with symptoms suspcious of cancer should have a two-week-wait referral so that endoscopy is performed within 2 weeks

Question 9

What are the red flag symptoms?

Answer 9

Dysphagia (difficulty swallowing) at any age gets a two week wait referral
•Aged over 55 (this is generally the cut off for urgent versus routine referrals)
•Weight loss
•Upper abdominal pain / reflux
•Treatment resistant dyspepsia
•Nausea and vomiting
•Low haemoglobin
•Raised platelet count

Question 10

What lifestyle advice for GORD?

Answer 10

Reduce tea, coffee and alcohol
•Weight loss
•Avoid smoking
•Smaller, lighter meals
•Avoid heavy meals before bed time 
•Stay upright after meals rather than lying flat

Question 11

What medication?

Answer 11

acid-neutralising meds
Gaviscon
•Rennie

Proton pump inhibitors (reduce acid secretion in the stomach)
•Omeprazole
•Lansoprazole

Ranitidine
•This is an alternative to PPIs
•H2 receptor antagonist (antihistamine)
•Reduces stomach acid

Question 12

What surgical intervention?

Answer 12

Surgery for reflux is called laparoscopic fundoplication. This involves tying the fundus of the stomach around the lower oesophagus to narrow the lower oesophageal sphincter.

Question 13

What is H.Pylori?

Answer 13

H. pylori is a gram negative aerobic bacteria

Question 14

How does H.Pylori thrive?

Answer 14

t avoids the acidic environment by forcing its way into the gastric mucosa. The breaks it creates in the mucosa exposes the epithelial cells underneath to acid.

It also produces ammonia to neutralise the stomach acid. The ammonia directly damages the epithelial cells. Other chemicals produced by the bacteria also damage the epithelial lining.

Question 15

When to test for H.pylori?

Answer 15

test for H. pylori to anyone with dyspepsia. They need 2 weeks without using a PPI before testing for H. pylori for an accurate result.

Question 16

What tests can be done?

Answer 16

Urea breath test using radiolabelled carbon 13
•Stool antigen test
•Rapid urease test can be performed during endoscopy.

Question 17

Describe a rapid urease test?

Answer 17

A rapid urease test is also known as a CLO test (Campylobacter-like organism test). It is performed during endoscopy and involves taking a small biopsy of the stomach mucosa. Urea is added to this sample. If H. pylori are present, they produce urease enzymes that converts the urea to ammonia. The ammonia makes the solution more alkali giving a positive result on when the pH is tested.

Question 18

How is H.pylori treated?

Answer 18

The eradication regime involves triple therapy with a proton pump inhibitor (e.g. omeprazole) plus 2 antibiotics (e.g. amoxicillin and clarithromycin) for 7 days.

The urea breath test can be used as a test of eradication after treatment. This is not routinely necessary.

Question 19

What is Barret’s Oesophagus?

Answer 19

metaplasia from a squamous to a columnar epithelium.

Question 20

What do patients experience with Barret’s oesophagus occurs?

Answer 20

When this change happens patients typically get an improvement in reflux symptoms.

Question 21

Barret’s oesophagus and malignancy

Answer 21

Barretts oesophagus is considered a “premalignant” condition and is a risk factor for the development of adenocarcinoma of the oesophagus (3-5% lifetime risk with Barretts). Patients identified as having Barretts oesophagus are monitored for adenocarcinoma by regular endoscopy.

Question 22

Barret’s Oesophagus

Answer 22

Treatment of Barretts oesophagus is with proton pump inhibitors (e.g. omeprazole).

Ablation treatment during endoscopy using photodynamic therapy, laser therapy or cryotherapy is used to destroy the epithelium so that it is replaced with normal cells

Question 23

What is a hiatus hernia?

Answer 23

•This refers to herniation of the stomach through the diaphragm

Question 24

Where should the diaphragm be and how does this prevent hiatus hernia?

Answer 24

• The diaphragm opening should be at the level of the lower oesophageal sphincter and should be fixed in place
• The opening helps to maintain a narrow sphincter that stops acid and stomach contents refluxing into the oesophagus

Question 25

What happens in herniation?

Answer 25

•When there is herniation and broadening of the diaphragm opening, this allows contents to reflux up into the oesophagus and give reflux symptoms

Question 26

What is a sliding hernia?

Answer 26

◦The stomach slides up along with the oesophagus through the diaphragm

Question 27

What is a rolling hernia?

Answer 27

◦A separate portion of the stomach (i.e. the fundus), folds around and enters through the diaphragm opening along with the oesophagus

Question 28

Treatment of hiatus hernia?

Answer 28

•Treatment is either conservative (with medical treatment of reflux) or surgical repair if high risk of complication or causing severe symptoms