Gord long answer

Question 1

What is GORD

Answer 1

Gastro-oesophageal reflux disease

Persistent reflux of gastric contents into oesophagus, provoking symptoms and impairing quality of life

Question 2

Etiology

Answer 2

Caused by a weak, incompetent cardiac sphincter

Risk factors:

-hiatus hernia - when cardiac sphincter is in thoracic cavity, it is under less pressure as there are less organs and no cruer muscles exerting pressure on it- less pressure allows contents to escape

peptic ulcers/diabetes - insufficent drainage of stomach forces sphincter open

obesity - +abdominal fat decreases angle of His, eliminating flap valve - no extra line of defence

Pregnancy - foetus has same effect as fat, and progesterone weakens cardiac sphincter

Poor diet:
fat slows drainage, carbonated drinks distend stomach, stretching and reducing pressure on gastro-oesophageal junction

Question 3

Pathophysiology

Answer 3

the risk factors mentioned above mean that the cardiac sphincter doesn’t fully close (hypertonia), or transiently relaxes, due to the weakened pressure on the sphincter or increased pressure on the oesophagus

In GORD, the stomach contents are pushed into the oesophagus

oesophagus doesn’t have a mucous lining to protect against acid

epithelium irritated by acidic stomach contents

epithelium erodes
causes pain, & bleeding

chronic reflux can lead to oesophageal cancer

Question 4

Signs and symptoms

Answer 4

Epigastric/retrosternal pain

• burning
• radiating to back
• occurs after eating
• eased when upright
• worsened when flat -nocturnal
• tender on palpation
• can be confused with angina

Respiratory symptoms:

• Cough - acid inflames lungs
• wheeze
• hoarsenss - acid inflames vocal chords
• SOB

Haematemisis

Question 5

Management

Answer 5

Acute:
encourage pt to take their own meds:
-Antacids (magnesium hydrochloride) neutralise the stomach, reducing irritation
-PPI (omeprazole) inhibit acid production
-H2-receptor antagonists (ranitidine) inhibit histamine, reducing acid formation

Sit pt up - gravity prevents reflux
advise pt to avoid bending - increases intra-abdo pressure

Pain relief - paracetamol for mild pain - not ibuprofen as can further irritate GI tract

Severe pain - can consider entonox if pt has opened bowels recently + bowel sounds present

morphine good choice, potent analgesic + increases pressure on cardiac sphincter, reducing reflux

Monitor and reassure pt

consider other differentials- similar presentations to MI, AAA, Mallory-weiss tear, cholycystitis.