GORD - Upper GI Flashcards
What is GORD?
symptoms or complications resulting from the reflux of gastric contents into the:
- oesophagus or beyond OR
- oral cavity (including larynx) OR
- lung
Summarise the aetiology of GORD
Physiology
- lower oesophageal sphincter regulates food passage from: oesophagus to the stomach
- lower oesophageal sphincter contains both: intrinsic smooth muscle and skeletal muscle.
- Transient lower oesophageal sphincter relaxation is more common after meals and is stimulated by fat in the duodenum.
Pathophysiology
- Episodes of transient lower oesophageal sphincter relaxation occur more frequently in GORD
- –> reflux of gastric contents into the oesophagus.
- It is more likely to occur if there is a hiatal sac containing acid.
- Patients with severe reflux often have:
- a hiatus hernia AND
- decreased resting lower oesophageal sphincter pressure.
- However, pressure can be high in mild to moderate reflux
- What can occur pathologically alongside GORD?
- What is GORD classified into if there
- are erosions?
- are no erosions?
- GORD may occur with or without oesophageal inflammation (oesophagitis).
- if erosions are present on endoscopic examination, the condition is called erosive reflux disease (ERD
- if there are no erosions, it is called non-erosive reflux disease (NERD)
What are the risk factors for GORD?
- family history of heartburn or GORD
- obesity
- older age
- hiatus hernia
weak:
-
lower oesophageal sphincter (LOS) tone-reducing drugs
- nitrates, calcium channel blockers, alpha- and beta-adrenergic agonists, theophylline, and anticholinergics
- NSAIDs
- psychological stress
- asthma
- smoking
- alcohol
-
per-oral endoscopic myotomy (POEM)
- (Tx for achalasia)
-
dietary factors
- i.e. caffeinated foods or drinks, carbonated drinks, chocolate, citrus, and spicy foods.
Summarise the epidemiology of GORD
- affects between 10% and 30% of people in developed countries
- all age groups
- risk factors
What are the presenting symptoms of GORD?
oesophageal
- dysphagia
- globus
-
heartburn/indigestion (dyspepsia)
- worse after the patient has been lying down or bending over
-
acid regurgitation
- –> sour or bitter taste after meals
- bloating
- early satiety
extra-oesophageal
- cough
- laryngitis
- asthma
- dental erosion
What are some other causes of dysphagia that must be excluded with ?GORD
- motility disorder
- stricture
- ring
- malignancy
Name some atypical symptoms of GORD
- dyspepsia
- epigastric pain
- nausea
- bloating
- belching
What are the alarm symptoms for ?GORD
- weight loss
- haemoptysis
- anaemia
What are the signs of GORD O/E?
Usually NORMAL
Occasionally:
- epigastric tenderness
- dysphonia
extra-oesophageal
- dental erosion
- wheeze on O/A
What are the primary investigations for ?GORD?
-
PPI trial
- Further tests are indicated if:
- symptoms do not improve with therapeutic 8-week trial of a PPI
- OR if patient has alarm symptoms
- should see symptom improvement if GORD
- Further tests are indicated if:
Name some possible secondary investigations for ?GORD?
-
oesophagogastroduodenoscopy (OGD)
- is indicated to evaluate for complications;
- for pts w
- atypical, persistent, or relapsing symptoms;
- or for alarm features
- may show oesophagitis (erosion, ulcerations, strictures) or Barrett’s oesophagus
- (helps exclude Barratett’s)
-
oesophageal manometry
- for pts with persistent symptoms on therapy with twice-daily PPIs
- evaluates oesophageal contractions and lower oesophageal sphincter function
- It may detect subtle presentations of oesophageal motility disorders such as achalasia or diffuse oesophageal spasm
-
ambulatory pH monitoring
- can demonstrate abnormal exposure to oesophageal acid in the absence of oesophagitis
-
There are two types of pH monitoring:
- naso-oesophageal catheter
- wireless radiotelemetry capsule monitoring.
- Wireless radiotelemetry allows monitoring for 48 hours without a naso-oesophageal catheter, which results in less discomfort and fewer interruptions of daily activities*
- result = pH <4 more than 4% of the time is abnormal
- should be conducted after ODG & manometry
-
combined impedance-pH testing
- Can quantify exposure to oesophageal acid and identify reflux events regardless of acidic content to assess correlation with symptoms
- may detect acid or non-acid reflux events
-
barium swallow
- useful in patients with dysphagia for whom endoscopy is contraindicated or unavailable, or as a complement to endoscopy
- helpful in the diagnosis and evaluation of oesophagitis
- helps to exclued other causes of dysphagia
-
oesophageal capsule endoscopy
- Involves swallowing a capsule endoscope to visualise the oesophagus.
- Capsule endoscopy does not require sedation
- safer alternative to ODG
- contraindicated in the presence of suspected (e.g., presence of dysphagia) or known stricture or adhesions
- may show oesophagitis or Barrett’s oesophagus
Create a management plan for GORD
main goals of Tx are to:
- control symptoms
- prevent complications
basis of Tx is acid suppression
conservative Tx = lifestyle changes
- weight loss for overweight people
- smoking cessation for tobacco smokers
- head-of-bed-elevation
- avoidance of late-night eating if nocturnal symptoms are present
medical Tx
- PPIs
- BUT attempts to stop or reduce the dose to the minimum necessary to maintain symptomatic control should always be pursued (risks of LT therapy with PPIs)*
For patients <40 years old who present with typical, regular heartburn and no alarm symptoms, treatment should be started with standard-dose PPIs for about 8 weeks and lifestyle changes
How would the management plan change if there was an inadequate response to initial therapy for GORD (refractory)?
- high-dose PPI OR switch PPI
- endoscopy
–> if endoscopy fails to show erosive oesophagitis or Barrett’s oesophagus
–> further diagnostic testing
Reasons for lack of response to therapy should be sought. These may include:
- Functional GORD/hypersensitivity (patient does not have GORD by standard pH definition)
- Non-adherence to treatment
- Non-acidic reflux
- Inadequate acid control, or
- Zollinger-Ellison syndrome or individuals with polymorphisms in cytochrome P450 2C19 (CYP2C19) resulting in rapid metabolism of PPIs
Which GORD patients require long term therapy with PPIs?
Those who:
- Who have symptoms when the PPI is discontinued
- With erosive oesophagitis and Barrett’s oesophagus
Most patients relapse off PPI therapy
BUT there risks associated with long-term use of these drugs;
- –> attempts to stop or reduce the dose to the minimum necessary to maintain symptomatic control should always be pursued
What is the management plan for pts that present with complicated or atypical GORD (e.g. dysphagia or evidence of GI bleeding)?
immediate endoscopy
- What is the surgical management for GORD
- Which pts is this reserved for?
- Surgery (open or laparoscopic fundoplication)
- good response to PPIs AND
- are non-adherent to therapy / do not wish to take long-term medical treatment (e.g., due to adverse effects)
What is the recommended Tx of non-erosive reflux disease (NERD)?
- on-demand PPI therapy OR
- intermittent PPI therapy
Will pts who do not respond to PPI therapy benefit from surgical Tx?
NO
What are the risks of taking PPIs long term?
- risk factor for Clostridium difficile-associated diarrhoea
- increased risk of bone fracture or, with short-term use, CAP
- decreased efficacy of clopidogrel and possible adverse outcomes when clopidogrel is used concomitantly with a PPI
- hypomagnesaemia
- association between PPI use and CKD
Name some possible complications of GORD
Summarise the prognosis of GORD
- Most patients respond to treatment with proton-pump inhibitors (PPIs). Maintenance PPI therapy is recommended for those who have symptoms when the PPI is discontinued, as well as for those with erosive oesophagitis and Barrett’s oesophagus.
- Most patients relapse off PPI therapy. However, there are risks associated with long-term use of these drugs; therefore, attempts to stop or reduce the dose to the minimum necessary to maintain symptomatic control should always be pursued.
- Oesophageal adenocarcinoma may be a serious though rare complication of GORD. When stricture, Barrett’s metaplasia, or adenocarcinoma are absent in the setting of a healed mucosa at initial endoscopy, the risk for development of adenocarcinoma is about 0.1% at 7 years’ follow-up
