GORD + (hiatus hernia) Flashcards
What is GORD?
Gastro-oesophageal reflux disease (GORD) is where acid from the stomach refluxes through the lower oesophageal sphincter and irritates the lining of the oesophagus.
What epithelium does the oesophagus have?
The oesophagus has a squamous epithelial lining making it more sensitive to the effects of stomach acid.
What epithelium does the stomach have?
The stomach has a columnar epithelial lining that is more protected against stomach acid.
What is dyspepsia?
Dyspepsia is a non-specific term used to describe indigestion
what encompasses dyspepsia?
Heartburn •Acid regurgitation •Retrosternal or epigastric pain •Bloating •Nocturnal cough •Hoarse voice
What can endoscopy be used for?
Endoscopy can be used to assess for peptic ulcers, oesophageal or gastric malignancy if there are concerning features.
What requires an urgent endoscopy?
Patients with evidence of a GI bleed (i.e. meleana or coffee ground vomiting)
What do patients who have symptoms consistent with cancer receive?
Patients with symptoms suspcious of cancer should have a two-week-wait referral so that endoscopy is performed within 2 weeks
What are the red flag symptoms?
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
What lifestyle advice for GORD?
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
What medication?
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
What surgical intervention?
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.
What is H.Pylori?
H. pylori is a gram negative aerobic bacteria
How does H.Pylori thrive?
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.
When to test for H.pylori?
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.
What tests can be done?
Urea breath test using radiolabelled carbon 13
•Stool antigen test
•Rapid urease test can be performed during endoscopy.
Describe a rapid urease test?
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.
How is H.pylori treated?
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.
What is Barret’s Oesophagus?
metaplasia from a squamous to a columnar epithelium.
What do patients experience with Barret’s oesophagus occurs?
When this change happens patients typically get an improvement in reflux symptoms.
Barret’s oesophagus and malignancy
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.
Barret’s Oesophagus
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
What is a hiatus hernia?
•This refers to herniation of the stomach through the diaphragm
Where should the diaphragm be and how does this prevent hiatus hernia?
- 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
What happens in herniation?
•When there is herniation and broadening of the diaphragm opening, this allows contents to reflux up into the oesophagus and give reflux symptoms
What is a sliding hernia?
◦The stomach slides up along with the oesophagus through the diaphragm
What is a rolling hernia?
◦A separate portion of the stomach (i.e. the fundus), folds around and enters through the diaphragm opening along with the oesophagus
Treatment of hiatus hernia?
•Treatment is either conservative (with medical treatment of reflux) or surgical repair if high risk of complication or causing severe symptoms
