Gastro-oesophageal Reflux Disease

Question 1

What is GORD?

Answer 1

Chronic condition in which stomach contents flows back into the oesophagus.

Question 2

What causes GORD?

Answer 2

1. Caused by disruption of mechanisms that prevent reflux
   Mechanisms that prevent reflux:
   - Lower oesophageal sphincter (transient relaxation of the LOS)
   - Acute angle of junction
   - Mucosal rosette
   - Intra-abdominal portion of oesophagus (diaphragm acts as a sphincter) e.g. obesity, pregnancy
2. Prolonged oesophageal acid clearance contributes to 50% of cases
3. Increased dietary fat

Question 3

What are the risk factors for GORD?

Answer 3

Smoking, Alcohol, Stress, Obesity, Pregnancy, Hiatus Hernia, Older Age

Question 4

Summarise the epidemiology of GORD

Answer 4

• COMMON
• 5-10% of adults

Question 5

What are the presenting symptoms/ signs of GORD?

Answer 5

• Heartburn (burning retrosternal pain) → burning sensation in the chest after meals, Can be worse after patient has been lying down or bending over
• Acid Regurgitation → reflux of acid into mouth, leaves sour/bitter taste in mouth, mainly after meals
• Halitosis → bad smelling breath
• Waterbrash → increased salivation
• Dysphagia & Dyspepsia (feeling of burning, pain, or discomfort in the stomach)

Question 6

What investigations are used to diagnose/ monitor GORD?

Answer 6

1. Resolution of symptoms after 8 week PPI Trial → Gold Standard, 1st order. Further tests (eg. endoscopy) are indicated if symptoms do not improve with therapeutic 8-week PPI trial, or if patients has alarm symptoms
2. Upper GI Endoscopy (if alarming features) → if age>55 years, symptoms >4 wks or not responding to treatment, dysphagia, relapsing symptoms, weight loss (red flag symptoms)
   - PPI’s should be stopped 2 weeks before upper GI endoscopy
3. Oesophageal Manometry with pH monitoring → if endoscopy negative
4. Barium Swallow

Question 7

How is GORD managed?

Answer 7

1. Lifestyle → weight loss, smoking cessation, small regular meals, avoid foods that may exacerbate (acidic fruits, coffee, alcohol)
2. Medical Therapy → continue PPI that was working before, consider adding H2 blocker (eg. ranitidine). Antacids may be useful for symptom relief.
   - PPI’s ⇒ can cause hyponatraemia (SIADH?), increase risk of c.diff infections, hypomagnesaemia and also risk of osteoporosis and fractures.
   - A H. pylori test (carbon 13 urea breath test) should be done before starting a proton pump inhibitor (PPI) because use of a PPI within 2 weeks of the test can lead to false negatives.
3. Surgery → Nissen fundoplication “In this procedure, the surgeon wraps the top of the stomach around the lower esophagus”. All forms of surgery aim to increase LOS pressure.
4. Monitoring → routine endoscopy to assess for disease progression

Question 8

What complications may arise following GORD?

Answer 8

oesophageal ulcer/perforation, oesophageal stricture, Barrett’s oesophagus (metaplasia, squamous → columnar epithelium, increases risk of oesophageal adenocarcinoma), Adenocarcinoma of the oesophagus, anaemia

Question 9

Summarise the prognosis of patients with GORD

Answer 9

• 50% respond to lifestyle measures alone
• In patients that require drug therapy, withdrawal is often associated with relapse
• 20% of patients undergoing endoscopy for GORD have Barrett’s oesophagus