Gastro-oesophageal reflux disease

Question 1

Define Gastro-oesophageal reflux disease

Answer 1

Inflammation of the oesophagus caused by reflux of gastric acid and/or bile

Question 2

Aetiology of Gastro-oesophageal reflux disease

Answer 2

The lower oesophageal sphincter contains intrinsic smooth muscles and skeletal muscle, and transient relaxation is normal, but it occurs more frequently in GORD to cause reflux
Transient lower oesophageal sphincter relaxation is more common after meals and is stimulated by fat in the duodenum
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
Disruption of mechanisms that prevent reflux (physiological, mucosal rosette, acute angle)

Question 3

Risk factors of Gastro-oesophageal reflux disease

Answer 3

Family history
Older age
Hiatus hernia
Obesity
Intake of specific foods (coffee, mints, citrus fruits, fats)
Psychological stress
Asthma
NSAIDs
Alcohol use
Smoking
Drugs that reduce oesophageal sphincter pressure e.g. CCBs

Question 4

Symptoms of Gastro-oesophageal reflux disease

Answer 4

Heartburn
- Typically after meals or after alcohol intake
- Can worsen when lying down or bending over
- Can occur at night
- Not usually exertional
Acid regurgitation
- Sour or bitter taste mainly after meals
Dysphagia (due to peptic stricture formation after long-standing reflux)
Bloating/early satiety
Globus
Halitosis
Dyspepsia
Aspiration: voice hoarseness, laryngitis, nocturnal cough, wheeze

Question 5

Signs of Gastro-oesophageal reflux disease

Answer 5

Usually normal
Epigastric tenderness
Wheeze on chest auscultation (aspiration)
Dysphonia (aspiration

Question 6

Investigations for Gastro-oesophageal reflux disease

Answer 6

H. pylori urea breath test (must not be on PPIs): rule out peptic ulcers → if negative →
PPI trial for 8 weeks

Serology
FBC
U&Es
LFTs
CRP
Amylase

OGD + Biopsy: oesophagitis (erosion, ulceration, strictures) ± Barrett’s
Ambulatory pH monitoring 24h: pH <4 >4% of the time
Oesophageal manometry: ?achalasia, spasm
Barium swallow: oesophagitis
CXR: ?hiatus hernia

Question 7

What necessitates 2WW OGD

Answer 7

Dysphagia
Upper abdominal mass (? stomach cancer)
Age ≥55yo AND weight loss AND (any of):
- Dyspepsia
- Reflux / GORD
- Upper abdominal pain

Question 8

What necessitates non-urgent OGD

Answer 8

Haematemesis
Age ≥55yo AND (any of):
- Treatment-resistant dyspepsia
- Upper abdominal pain with low Hb
- N&V + reflux, WL, dyspepsia or upper abdo pain
- Raised platelets + N&V, WL, reflux, dyspepsia or upper abdo pain

Question 9

Management for Gastro-oesophageal reflux disease

Answer 9

No OGD →
1st: review medications for possible causes of dyspepsia + lifestyle advice
2nd: trial PPI 4w (omeprazole 20mg once daily) OR ‘test and treat’ for H. pylori (Carbon-13 breath test + CAP (clarithromycin, amoxicillin, PPI))
3rd: the other management of the above (wait 2w after trial PPI before testing for H. pylori)
4th: “treatment-resistant dyspepsia” → non-urgent OGD

Endoscopically proven oesophagitis (± (if severe) annual review
1st: PPI (for 1 month → for another 1 month → for another 1 month at double dose)
2nd: add H2-RA

+ lifestyle changes:
Weight loss
Head-of bed elevation
Avoidance of late-night eating
Specific food eliminations e.g. coffee, chocolate, alcohol, acidic foods
Avoid smoking

Question 10

Second line management for Gastro-oesophageal reflux disease after medical management

Answer 10

Surgery: Nissen fundoplication (For those with good response to PPI but are non-adherent or wish not to take it)

fundus of stomach is wrapped around the lower oesophagus and held with seromuscular sutures to reduce hiatus hernia and reflux

Indication: refractory GORD, hiatus hernia
Cx: gas-bloat syndrome (can’t belch/vomit), dysphagia (if the wrap is too tight)

Question 11

Complications for Gastro-oesophageal reflux disease

Answer 11

Oesophageal ulceration (haemorrhage, perforation)
Peptic stricture
Anaemia
Barrett’s oesophagus
Adenocarcinoma

Question 12

Prognosis for Gastro-oesophageal reflux disease

Answer 12

Most patients respond to PPI treatment
Maintenance therapy is recommended for those who have symptoms when PPI is discontinued
Most patients relapse off PPI, but there are risks associated with long-term use
Adenocarcinoma may be a serious (but rare) complication
When stricture, Barrett’s metaplasia or adenocarcinoma are absent in healed mucosa at initial endoscopy, risk of development of adenocarcinoma I 0/1% at 7 years’ follow up