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Flashcards in FN: GORD Deck (17):
1

Pathophysiology

􏰀 LOS dysfunction → reflux of gastric contents → oesophagitis.

2

RF

􏰀 Hiatus hernia
􏰀 Smoking
􏰀 EtOH
􏰀 Obesity
􏰀 Pregnancy
􏰀 Drugs: anti-AChM, nitrates, CCB, TCAs
􏰀 Iatrogenic: Heller’s myotomy

3

symptoms Oesophageal

􏰀 Heartburn
􏰁 Related to meals
􏰁 Worse lying down / stooping
􏰁 Relieved by antacids
􏰀 Belching
􏰀 Acid brash, water brash
􏰀 Odonophagia

4

Extra-oesophageal symptoms

􏰀 Nocturnal asthma
􏰀 Chronic cough
􏰀 Laryngitis, sinusitis

5

Complications

􏰀 Oesophagitis: heartburn
􏰀 Ulceration: rarely → haematemesis, melaena, ↓Fe
􏰀 Benign stricture: dysphagia
􏰀 Barrett’s oesophagus
􏰁 Intestinal metaplasia of squamous epithelium
􏰁 Metaplasia → dysplasia → adenocarcinoma
􏰀 Oesophageal adenocarcinoma

6

Differential Dx

Oesophagitis
􏰁 Infection:
- CMV, candida
- 􏰁 IBD
- 􏰁 Caustic substances / burns
PUD Oesophageal Ca

7

Ix

1. Isolated symptoms don’t need Ix
2. Bloods: FBC
3. CXR: hiatus hernia may be seen
4. OGD if:
􏰁 - >55yrs
􏰁 - Symptoms >4wks
􏰁- Dysphagia
-􏰁 Persistent symptoms despite Rx
􏰁 - Wt. loss
􏰁- OGD allows grading by Los Angeles
Classification
5. Ba swallow: hiatus hernia, dysmotility
6. 24h pH testing ± manometry
􏰁 pH <4 for >4hrs

8

Conservative Rx

􏰀 Lose wt.
􏰀 Raise head of bed
􏰀 Small regular meals ≥ 3h before bed
􏰀 Stop smoking and ↓ EtOH
􏰀 Avoid hot drinks and spicy food
􏰀 Stop drugs: NSAIDs, steroids, CCBs, nitrates

9

Medical Rx

􏰀 OTC antacids: Gaviscon, Mg trisilicate
􏰀 1: Full-dose PPI for 1-2mo
􏰁 Lansoprazole 30mg OD
􏰀 2: No response → double dose PPI BD
􏰀 3: No response: add an H2RA
􏰁 Ranitidine 300mg nocte
􏰀 Control: low-dose acid suppression PRN

10

Surgical Mx

Nissen Fundoplication
􏰀 Indications: all 3 of:
􏰁 Severe symptoms
􏰁 Refractory to medical therapy
􏰁 Confirmed reflux (pH monitoring)

11


Nissen Fundoplication

􏰀 Aim: prevent reflux, repair diaphragm
􏰀 Usually laparoscopic approach
􏰀 Mobilise gastric fundus and wrap around lower
oesophagus
􏰀 Close any diaphragmatic hiatus
􏰀 Complications:
􏰁 Gas-bloat syn.: inability to belch / vomit 􏰁 Dysphagia if wrap too tight

12

Hiatus Hernia classification

sliding
Rolling
Mixed

13

Hiatus Hernia Sliding

80%
Gastro-oesophageal junction slides up into chest
􏰀 Often assoc. ̄c GORD

14

Hiatus Hernia Rolling

􏰀 15%
Gastro-oesophageal junction remains in abdomen but a bulge of stomach rolls into chest alongside the oesophagus
􏰀 LOS remains intact so GORD uncommon 􏰀 Can → strangulation

15

Hiatus Hernia Mixed

5%

16

Hiatus Hernia Ix

􏰀 CXR: gas bubble and fluid level in chest
􏰀 Ba swallow: diagnostic
􏰀 OGD: visualises the mucosa but can’t exclude hernia
􏰀 24h pH + manometry: exclude dysmotility or achalsia

17

Hiatus Hernia Rx

􏰀 Lose wt.
􏰀 Rx reflux
􏰀 Surgery if intractable symptoms despite medical Rx.
􏰁 Should repair rolling hernia (even if asympto) as it may strangulate.

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