GORD + Oesophageal Disorders Flashcards
What is GORD?
Gastro-oesophageal reflux diease
A common disease caused by reflux of the stomach contents (acid +/- bile) causing troublesome symptoms and/or complications
What is the pathophysiology of GORD?
Reflux occurs due to:
- More frequent Transient Lower Oesophageal Sphincter Relaxations (TLESRs)
- Failure of intra-abdominal segment of the oesophagus which acts as a flap valve
- Failure of mucosal rosette formed by folds of the gastric mucosa and the contraction of the crural diaphragm at the LOS
- Reduced oesophageal motility
What is the main cause of reflux in GORD?
LOS relaxes transiently independently of swallow after meals
What are oesophageal mucosal defence mechanisms?
- Mucus - traps bicarb which acts as a buffer
- Epithelium - structure limits diffusion of H+ into cells
- Sensory mechanisms - pain due to irritation by acid and contraction of longitudinal muscles
What are the main causes of GORD?
- LOS hypotension
- Hiatus hernia
- Oesophageal dysmotility
- Obesity
- Gastric acid hypersecretion
- Delayed gastric emptying
- Smoking
- Alcohol
- Pregnancy
- Drugs
What are the different types of hiatus hernia?
- Sliding hiatus hernia
- Rolling hiatus hernia
What is a sliding hiatus hernia?
The GO junction slides up into the chest. ACid reflux often happens as the LOS becomes less competent in many cases
What is a rolling hiatus hernia?
The GO junction remains in the abdomen but a bulge of stomach herniates up into the chest alongside the oesophagus. As the GO remains intact, GORD is less common
Which type of hiatus hernia is more commonly associated with GORD?
Sliding hiatus hernia
What lifestyle factors play a role in the development of GORD?
- Smoking
- Alcohol
- Obesity
- Hot beverages
- Caffeine together with patient age and gender.
What are symptoms of GORD?
- Dyspepsia
- Belching
- Acid brash
- Waterbrash
- Odynophagia
- Nocturnal asthma/Chronic cough
- Laryngitis
- Sinusitis
What is dyspepsia?
Burning, retrosternal discomfort after meals, lying down, stooping. It can be relieved by antacids
What is acid brash?
Acid or bile regurgitation
What is waterbrash?
Markedly increased salivation
What is adynophagia?
Painful swallowing - can be caused by oesophagitis or ulceration
What are complications of GORD?
- Oesophagitis
- Ulcers
- Benign stricture
- Iron-deficiency
- Barrett’s oesophagus
What might your differential diagnosis be for someone presenting with features of GORD?
- Oesophagitis from corrosives
- NSAIDs
- Duodenal/Gastric ulcers
- Gastric cancer
- Non-ulcer dyspepsia
- Oesophageal spasm
- Cardiac disease
If someone presented with features of GORD, what investigations would you consider doing?
Primarily clinical diagnosis. If dysphagia, or >55 yrs with alarm symptoms:
- Endoscopy
- 24-hr intramural pH monitoring/impedence +/- manometry
What can endoscopy show in someone with features of GORD?
- Oesophagitis
- Hiatus hernia
- Barrett’s oesophagus
What is involved in pH monitoring?
24-hour ambulatory monitoring uses a pH-sensitive probe positioned in the lower oesophagus and is used to identify acid reflux episodes (pH <4). Catheter and implantable sensors are available; both are insensitive to alkali.
pH is a valuable means of correlating episodes of acid reflux with patient’s symptoms.
What is involved in impedance monitoring?
Uses a catheter to measure the resistance to flow of ‘alternating current’ in the contents of the oesophagus. Combined with pH it allows assessment of acid, weakly acid, alkaline and gaseous reflux, which is helpful in understanding the symptoms that are produced by a non-acid reflux.
What is manometry?
Performed by passing a catheter through the nose into the oesophagus and measuring the pressures generated within the oesophagus.
It is used to assess oesophageal motor activity. It is not a primary investigation and should be performed only when the diagnosis has not been achieved by history, barium radiology or endoscopy.
What is defined as excessive reflux on pH testing?
pH < 4 for > 4% of the time + correlation with symptoms
What lifestyle factors would you address when managing someone with GORD?
- Weight loss
- Smoking cessation
- Small, regular meals
- Avoid eating < 3 hrs before bed
-
Reduce
- Hot drinks and alcohol
- Citrus fruits
- Spicy food
- Caffeine
- Chocolate
What medications would you consider givign someone who was suffering from GORD?
In order
- Antacids - Gaviscon, magnesium trisilicate mixture
- PPI - lansoprazole, omeprazole
- H2 blockers
What drugs would you want to avoid in someone with GORD?
Affecting oesophageal motility
- Nitrates
- Anticholinergics
- CCBs
Causing mucosal damage
- NSAIDs
- K+ Salts
- Bisphosphonates
What are examples of PPIs?
- Omeprazole
- Rabeprazole
- Lansoprazole
- Pantoprazole
- Esomeprazole
How do PPIs work?
Work by reducing the acid secretion of parietal cells in the stomach by inhibiting the proton pump. Normally the proton pump exchanges H+ ions in the parietal cells for K+ ions in the stomach lumen, thereby increasing the H+ in the stomach, which forms HCl. By inhibiting this pump, PPI’s reduce the HCl in the stomach.
What are indications for PPIs?
- Gastric and duodenal ulcers
- H.Pylori eradication
- Dspepsia
- GORD
- Pprevention and treatment of NSAID-associated ulcers
- Zollinger-Ellison syndrome.
What are side effects of PPIs?
- Nausea
- Vomiting
- Bloating
- Abdominal pain
- Diarrhoea or constipation
- Rarely hepatitis and interstitial nephritis can be seen
How do H2 antagonists work?
Paracrine cells in the stomach lining produce histamine in response to gastrin (stimulated by protein ingestion) or ACh (from vagal stimulation) which stimulates the parietal cells to produce gastric acid
H2-receptor antagonists block the receptors on the parietal cells thus inhibiting this action and decreasing acidity.
How would you manage someone the first time the presented with features of GORD?
- Lifestyle changes
- PPIs
If, when managing someone with PPIs and Lifestyle advice for GORD, they had an incomplete response to PPIs, how would you manage them?
- Higher dose PPIs
- H2 antagonists
- Further testing
When would you consider surgery in someone with GORD?
Surgery (open or laparoscopic fundoplication) reserved mainly for:
- Good response to proton-pump inhibitors (PPIs) but who do not wish to take long-term medical treatment
- Refractory GORD
- Complications of GORD
What surgical procedure is used to treat GORD?
Open/Laproscopic Nissen fundoplication - aim to increase resting LOS pressure
What is barrett’s oesophagus?
A condition in which part of the normal oesophageal squamous epithelium is replaced by metaplastic columnar mucosa to form a segment of ‘columnar-lined oesophagus’ (CLO). It is a complication of gastro-oesophageal reflux disease and there is almost always a hiatus hernia present.
What are risk factors for the development of barrett’s oesophagus?
- >50 years old
- Obesity
- Male
- Caucasian
- FH of Barrett’s oesophagus
How would you investigate for barrett’s oesophagus?
Endoscopy + Biopsy
How is barrett’s oesophagus classified?
Prague classification:
- Length of circumferential CLO (C measurement)
- Maximum length (M measurement) - the distance from the top of the gastric folds to the most proximal tongue of the columnar mucosa.
What would you look for on endoscopic investigation in someone with barrett’s oesophagus?
- Proximal displacement of the squamocolumnar mucosal junction
- Biopsies demonstrating columnar lining above the proximal gastric folds
How would you manage a patient with confirmed barrett’s oesophagus?
Screening
- Dysplasia < 3cm oesophagus - discharge
- Dysplasia > 3 cm - 2-3 yearly endoscopy
Dysplasia detercted
- Low grade - examine again after 6 months
- High grade dysplasia/intramural carcinoma - consider endoscopic resection/radiofrequency ablation
What is achalasia?
An oesophageal motor disorder of unknown aetiology, characterised by oesophageal aperistalsis and insufficient lower oesophageal sphincter (LOS) relaxation in response to swallowing.
What is the pathophysiology of achalasia?
Inflammatory destruction of inhibitory nitrinergic neurons in the oesophageal myenteric (Auerbach) plexus results in loss of peristalsis and incomplete lower oesophageal sphincter relaxation. The exact cause of this inflammatory process is unknown
Histopathology shows inflammation of the myenteric plexus of the oesophagus with reduction of ganglion cell numbers. Cholinergic innervation appears to be preserved.
What are symptoms of achalasia?
Tend to be slow, progressive symptoms:
- Dysphagia - solids and liquids
- Regurgitation
- Dyspespia
- Weight loss
- Chest pain
- Chest infections
Why do individuals with achalasia get recurrent chest infections?
Aspiration caused by regurgitation
If you suspected achalasia, what investigations would you do?
- Upper GI endoscopy
- Barium swallow
- Manometry
- X-ray
- CT
Why would you perform upper GI endoscopy in someone presenting with symptoms of achalasia?
To exclude malignancy - should be done for any cause of new onset dysphagia
What might you find on Barium swallow in someone with Achalasia?
- Loss of peristalsis and delayed oesophageal emptying
- Dilated oesophagus that tapers to a beak-like narrowing at GOJ
What might be found on investigation using manometry when investigating for achalasia?
- Incomplete relaxation of the LOS with wet swallows and oesophageal aperistalsis - most important diagnostically
- High resting LO pressure
- Swallows followed by simultaneous contraction waves, typically low-amplitude
Why might you do a CT in someone with achalasia?
Check for malignancy
Why might you do a CXR in someone with suspected achalasia?
Look for oseophageal dilatation
How would you manage someone with achalasia?
- Initial management -> Medications -> Nitrates, CCBs
-
Surgical fitness assessment
- Fit for surgery - Pneumatic dilatation, Lapro cardiomyotomy
- Not fit for surgery - Nitrates, CCB, Botulinum toxin A, Gastrostomy
What is involved in pneumatic dilatation?
It involves the mechanical dilation of the lower oesophageal sphincter using a balloon with a sufficiently forceful mechanical stretch to rupture the muscle fibres. The balloon is inserted endoscopically or by a combined endoscopic-radiological approach.
What is involved in a laproscopic cardiomyotomy?
The abdominal approach involves sequentially, division of the peritoneum over the oesophagus, mobilization of the right and left margins of the oesophagus, and exposure of 5cm of oesophagus below the phreno-oesophageal membrane.
After identification of the anterior vagus nerve, a vertical myotomy is performed lateral to it along the oesophagus.
What are complications of achalasia?
- Aspiration pneumonia and lung disease
- Increased risk of oesophageal SCC
What is diffuse oesophageal spasm?
A severe form of oesophageal dysmotility that can sometimes produce retrosternal chest pain and dysphagia. It can accompany GORD
What is the most common cause of oesophageal stricture?
Benign stricture secondary to reflux
What can cause benign oesophageal strictures?
- Reflux
- Ingestion of corrosives
- After radiotherapy
- After sclerosis of varices
- Following prolonged nasogastric intubation.
What organisms most commonly cause oesophageal infection?
- Candida
- Herpes simplex
- Cytomegalovirus
- Tuberculosis.
Where can oesophageal diverticula occur?
- Immediately above the UOS - pharyngeal pouch
- Near the middle of the oesophagus
- Just above the LOS - epiphrenic diverticulum
What is a mallory-Weiss tear?
This is a linear mucosal tear occurring at the oesophagogastric junction and produced by a sudden increase in intra-abdominal pressure. It often occurs after a bout of coughing or retching and is classically seen after alcoholic ‘dry heaves’.
What are causes of oesophageal rupture?
- Iatrogenic - endoscopy/biopsy/dilatation
- Trauma - penetrating/foreign body
- Carcinoma
- Boerhaave syndrome
- Corrosive ingestion
What is Boerhaave syndrome?
Rupture due to violent vomiting
What are features of oesophageal rupture?
- Odynophagia
- Tachypnoea
- Dyspnoea
- Shock
- Surgical emphysema
What surgical option is used to treat achalasia?
Heller’s cardiomyotomy
