Gastro-oesophageal reflux disease

Question 1

Causes of GORD

Answer 1

Lower oesophageal sphincter hypotension
Hiatus hernia
Oesophageal dysmotility (e.g. systemic sclerosis)
Obesity
Gastric acid hyper secretion
Delayed gastric emptying
Smoking
Alcohol
Pregnancy
Drugs: tricyclics, anticholinergics, nitrates
Helicobacter pylori (controversial)

Question 2

Oesophageal symptoms of GORD

Answer 2

Heartburn (burning, retrosternal discomfort after meals, lying, stooping or straining, relieved by antacids)
Belching
Acid brash (acid or bile regurgitation)
Waterbrash (increased salivation: “my mouth fills with saliva”)
Odynophagia (painful swallowing, e.g. from oesophagitis or ulceration)

Question 3

Extraoesophageal symptoms of GORD

Answer 3

Nocturnal asthma
Chronic cough
Laryngitis (hoarseness, throat clearing)
Sinusitis

Question 4

Complications of GORD

Answer 4

Oesophagitis
Ulcers
Benign stricture
Iron deficiency
Metaplasia --> dysplasia --> neoplasia: GORD may lead to Barrett's oesophagus (distal oesophageal epithelium undergoes metaplasia from squamous to columnar). 0.1-0.4%/yr of those with Barrett's progress to oesophageal cancer (higher if dysplasia is present).

Question 5

Differential diagnosis of GORD

Answer 5

Oesophagitis from corrosives
NSAIDs
Herpes
Candida
Duodenal or gastric ulcers or cancers
Non-ulcer dyspepsia
Oesophageal spasm
Cardiac disease

Question 6

Tests for GORD

Answer 6

Endoscopy if dysphagia, or if >55yrs old with alarm symptoms or with treatment refractory dyspepsia.
24h oesophageal pH monitoring +/- manometry help diagnose GORD when endoscopy is normal.

Question 7

Treatment of GORD: lifestyle

Answer 7

Weight loss.
Smoking cessation.
Small, regular meals.
Reduce hot drinks, alcohol, citrus fruits, tomatoes, onions, fizzy drinks, spicy foods, caffeine and chocolate.
Avoid eating <3h before bed.
Raise the bed head.

Question 8

Treatment of GORD: drugs

Answer 8

Antacids, e.g. magnesium trisilicate mixture (10mL/8h), or alginates, e.g. Gaviscon (10-20mL/8h PO) relieve symptoms.
Add a PPI, e.g. lansoprazole 30mg/24h PO.
For refractory symptoms, add an H2 receptor blocker and/or try twice daily PPI.
Avoid drugs affecting oesophageal motility (nitrates, anticholinergics, Ca2+ channel blockers- relax the low oesophageal sphincter) or that damage mucosa (NSAIDs, K+ salts, bisphosphonates).

Question 9

Treatment of GORD: surgery

Answer 9

e.g. laparoscopic Nissen fundoplication, or novel options including laparoscopic insertion of a magnetic bead band or radiofrequency-induced hypertrophy.
These all aim to raise resting lower oesophageal sphincter pressure.
Consider in severe GORD (confirm by pH monitoring/ manometry) if drugs are not working.
Atypical symptoms (cough, laryngitis) are less likely to improve with surgery compared to patients with typical symptoms.