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
Name some possible complications of GORD
