GORD and Hiatus Hernia

Question 1

What is GORD?

Answer 1

Reflux of gastric contents into the oesophagus due to a defective lower oesophageal sphincter

Question 2

What are some factors which are associated with GORD?

Answer 2

Anything which increases intra-abdominal pressure eg, obesity, pregnancy.
Alcohol, smoking and coffee.
Drugs which relax the LOS - tricyclics, anticholinergics, nitrates, CCBs, NSAIDs.
Overeating,
Hiatus hernia,
Tight clothes,
Surgery for achalasia

Question 3

What are the signs and symptoms of GORD?

Answer 3

Typical: Dyspepsia, sensation of acid regurgitation.
Atypical: Epigastric/chest pain, nausea, bloating, belching, globus, laryngitis, tooth erosion.

Question 4

What are the alarm symptoms in GORD?

Answer 4

Weight loss, anaemia, dysphagia, haematemesis, melaena, persistent vomiting

Question 5

What are the differential diagnosis for GORD?

Answer 5

Gastric ulcer, oesophageal cancer, oesophagitis, functional dyspepsia.

Question 6

What are the investigations for GORD?

Answer 6

Trial of standard dose PPI,
Oesophagogastroduodenoscopy if alarm features, atypical or persistent disease.
Oesophageal mamometry
24hr oesophageal pH monitoring (gold standard).

Question 7

What are the indications of an OGD in GORD?

Answer 7

Age >55,
Symptoms > 4 weeks or persisting despite treatment.
Dysphagia,
Relapsing symptoms,
Weight loss

Question 8

What are the types of hiatus hernia?

Answer 8

Sliding - GOJ above diaphragm (more common)
Rolling/paraoesphageal - GOJ remains below diaphragm and separate part of stomach herniates through

Question 9

What are the risk factors for a hiatus hernia?

Answer 9

Obesity and increased intra-abdominal pressure eg, ascites or multiparity.

Question 10

What are the features of a hiatus hernia?

Answer 10

Heartburn, dysphagia, regurgitation, chest pain

Question 11

What are the investigations for a hiatus hernia?

Answer 11

Barrium swallow is most sensitive however due to nature of symptoms most are diagnosied via OGD

Question 12

What is the management of a hiatus hernia?

Answer 12

Conservative management for all.
Medical management: 4-8 weeks of PPI
Surgical management: For rolling hernias. Involves Nussen’s fundoplication

Question 13

What are the lifestyle measurements for hiatus hernias and GORD?

Answer 13

Reduce tea, coffee, and alcohol.
Weight loss,
Avoid smoking,
Smaller and lighter meals.
Avoid heavy meals before bed.
Stay upright after meals

Question 14

WHat is the management of GORD?

Answer 14

Initially - 8 weeks of PPI eg, omeprazole 20mg OD.
If fails to respond then give high dose PPI and endoscopy.
If responds then give lowest dose possible which still controls symptoms

Question 15

What are the indications for surgery in GORD?

Answer 15

Failure to respond to medical therapy,
Patient preference to avoid long term medication.
Complications with GORD

Question 16

What is the management of endoscopically proven oesophagitis?

Answer 16

PPI for 1-2 months.
If responds then low dose treatment as required.
If no response then double dose for 1 months

Question 17

What are the complications of GORD?

Answer 17

Oesophagitis,
Ulcers,
Anaemia,
Benign strictures,
Barret’s oesophagus,
Oesophageal carcinoma

Question 18

Which patients should get an urgent cancer referral for endoscopy?

Answer 18

All patients with dysphagia,
Patients with upper abdo mass suspicious og gastric cancer.
Pagents >=55 years with weight loss AND any of: upper abdo mass, reflux or dyspepsia

Question 19

What are the investigations for H.pylori?

Answer 19

Initial - Urea breath test (not a rapid urease test) or stool antigen testing.
Test of cure - not indicated if symptoms have resolved however if persist then do urea breath test (need to be 4 weeks free of antimicrobials and 2 weeks free of PPIs).

Question 20

What are other possible investigations for H. pylori?

Answer 20

Stool antigen testing,
Urea breath test,
H pylori antibody testing,
Rapid urease test performed during endoscopy (CLO test)

Question 21

What is Zollinger Ellison Syndrome?

Answer 21

Condition where a duodenal or pancreatic tumour secretes gastrin. Gastrin is a hormone which stimulates acid secretion.

Question 22

What is dyspepsia?

Answer 22

Pain/discomfort in upper abdomen