Gastro-oesophageal reflux disease (GORD)

Question 1

Define Gastro-oesophageal reflux disease (GORD)

Answer 1

A condition which develops when the reflux of the stomach contents cuses troublesome symptoms (ie at least two heartburn episodes per week) and/or complications

Question 2

What may predispose you to GORD?

Answer 2

• Lower oesophageal sphincter hypotension
• Hiatus hernia
• Loss of oesophageal peristaltic function
• Abdominal obesity
• Gastric acid hypersecretion
• Delayed gastric emptying
• Overeating
• Smoking
• Alcohol
• Pregnancy
• Surgery in achalasia
• Drugs (tricyclics, anticholinergics, nitrates)
• Systemic sclerosis
• Helocobacter pylori??

Question 3

What are the symptoms of GORD?

Answer 3

Oesophageal;

• Heartburn Iburning, retrosternal discomfort related to meals, lying down, stooping & straining, relieved by antacids)
• Belching
• Acid brash (acid or bile regurgitation)
• Waterbrash (excessive salivation)
• Odynophagia (painful swalling, eg from oesophagitis or ulceration)

Extra-oesophageal;

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

Question 4

What are complications of GORD?

Answer 4

• Oesophagitis
• Ulcers
• Benign stricture
• Barrett’s oesophagus (the epithelium of the distal oesophagus undergoes metaplasia from squamous to columnar type. Endoscopic appearance is ‘velvety’ epithelium)
• Oesophageal adenocarcinoma
• Iron-deficiency anaemia (rare)

Question 5

What, therefor, are some differential diagnosis of GORD?

Answer 5

• Oesophagitis (corrosives, NSAID)
• Infection (CMV, herpes, Candida)
• Dudodenal/ gastric ulcers or cancer
• Non-ulcer dyspepsia

Question 6

What investigations would you perform to diagnose GORD?

Answer 6

• Upper GI endoscopy, if;
  
  • >55yrs
  • Symptoms >4weeks
  • Dysphagia
  • Persistent symptoms despite treatment
  • Relapsing symptoms
  • Weight loss
• Barium swalling may show hiatus hernia
• 24hr oesophageal pH monitoring +/- manometry (if endoscope is normal)

Question 7

How would you treat GORD?

Answer 7

Lifestyles;

• Encourage weight loss, Xsmoking, raise head in bed, small/regular meals
• Avoid hot drinks, alcohol, citrus fruits, tomatoes, onions, carbonated beverages, spicy foods, coffee, tea, chocolate & eating <3hrs before bed
• Avoid drugs
  
  • Red. oseophageal motility; nitrates, anticholinergics, tricyclic antidepressants, calcium channel blockers
  • Damage mucosa; NSAIDs, K⁺ salts, biphosphonates

Drugs;

• Antacids (magnesium trisilicate mixture)
• Alginates (Gavicon Advance)
• Oesophagitis; PPI (lansoprazole)

Surgery;

• Nissen fundoplication (wrap stomach around oesophagus so when it contracts it closes oesophagus preventing acid reflux)
• Only if severe

Question 8

Outline the Los Angeles (LA) classification of GORD

Answer 8

There are 4 grades;

1. >=1 mucosal break/s <5mm long not extending beyond 2 mucosal fold tops
2. Mucosal break >5mm long limited to the space between 2 mucosal fold tops
3. Mucosal break continuous between the tops of 2 or more mucosal folds but which involves less than 75% of the oesophageal circumference
4. Mucosal break involving >=75% of the oesophageal circumference