GORD

Question 1

GORD: What is it?

Answer 1

GORD= reflux of stomach contents and acid into the oesophagus, irritating the oesophageal squamous epithelial lining, due to weakening of the LES. The stomach has acolumnar epithelialliningthat is more protected against stomach acid

Question 2

GORD: Triggers

Answer 2

• Gastroparesis (increased gastric pressure)
• Hiatus Hernia
• Greasy and spicy foods
• Coffee and tea
• Alcohol
• Smoking
• Stress
• Obesity/Pregnancy
• Hiatus hernia
• Surgery in achalasia
• Non-steroidal anti-inflammatory drugs (aspirin)

Question 3

GORD: Symptoms

Answer 3

Symptoms associated with dyspepsia (indigestion):
- epigastric abdominal pain
- retrosternal chest pain/heart burn
- abdominal bloating (burbing + flatulence)
- nausea and vomiting
- acid reflux
- hoarse voice
- nocturnal cough

Symptoms of cancer (refer for 2-week wait referal for further investigations eg. endoscopy):
- age > 55
- Persistent symptoms > 4 weeks
- Treatment resistant dyspepsia
- Dysphagia(difficulty swallowing) at any age gets an immediate two week wait referral
- Upper abdominal mass on palpation
- Weight loss
- Upper GI bleed - melaena or coffee ground vomiting
- Low haemoglobin (anaemia)
- Raised platelet count (thrombocytosis- blood loss)

Question 4

GORD: Management

Answer 4

Management of gastro-oesophageal reflux disease can be split into:

• Lifestyle changes
• Reviewing medications(e.g., stop NSAIDs)
• Antacids(e.g., Gaviscon, Pepto-Bismol and Rennie) – short term only
• Proton pump inhibitors(e.g., omeprazole and lansoprazole)
• Histamine H2-receptor antagonists(e.g., famotidine)
• Surgery - laparoscopic fundoplication. This involves tying the fundus of the stomach around the lower oesophagus to narrow the lower oesophageal sphincter.

Lifestyle changesinclude:
- Reduce tea, coffee and alcohol
- Weight loss
- Avoid smoking
- Smaller, lighter meals
- Avoid heavy meals before bedtime
- Stay upright after meals rather than lying flat

Question 5

GORD: Investigations

Answer 5

• FBC to rule out anaemia and thrombocytosis
• 24hr oesophageal pH monitoring
• Upper GI endoscopy (OGD) to look for underlying cause or complications (malignancy, hiatus hernia oesophagitis, Barrett’s oesophagus)
• Oesophageal manometry/barium swallow meal to oesophageal dysmotility or dysphagia
• H-pylori tests (to exclude H-pylori as differential)

Question 6

PPIs

Answer 6

Proton pump inhibitors (PPI) cause irreversible blockade of H+/K+ ATPase of the gastric parietal cell.

Examples include omeprazole and lansoprazole.

Adverse effects
hyponatraemia, hypomagnasaemia
osteoporosis → increased risk of fractures
microscopic colitis
increased risk of C. difficile infections, especially when used with antibiotics

Question 7

GORD: Complications

Answer 7

oesophagitis
benign strictures (tissue scarring)
Barrett’s oesophagus
oesophageal carcinoma
ulcers
anaemia

Question 8

GORD in children

Answer 8

Risk factors
preterm delivery
neurological disorders

Features
typically develops before 8 weeks
vomiting/regurgitation
milky vomits after feeds
may occur after being laid flat
excessive crying, especially while feeding

Management (partly based on the 2015 NICE guidelines)
advise regarding position during feeds - 30 degree head-up
infants should sleep on their backs as per standard guidance to reduce the risk of cot death
ensure infant is not being overfed (as per their weight) and consider a trial of smaller and more frequent feeds
a trial of thickened formula (for example, containing rice starch, cornstarch, locust bean gum or carob bean gum)
a trial of alginate therapy e.g. Gaviscon. Alginates should not be used at the same time as thickening agents
NICE do not recommend a proton pump inhibitor (PPI) to treat overt regurgitation in infants and children occurring as an isolated symptom. A trial of one of these agents should be considered if 1 or more of the following apply:
unexplained feeding difficulties (for example, refusing feeds, gagging or choking)
distressed behaviour
faltering growth
prokinetic agents e.g. metoclopramide should only be used with specialist advice
If there are severe complications (e.g. failure to thrive) and medical treatment is ineffective then fundoplication may be considered

Complications
distress
failure to thrive
aspiration
frequent otitis media
in older children dental erosion may occur

Question 9

Suspected Cancer Referral

Answer 9

Urgent
- All patients who’ve got dysphagia
- All patients who’ve got an upper abdominal mass consistent with stomach cancer
- Patients aged >= 55 years who’ve got weight loss, AND upper abdominal pain/reflux/dyspepsia

Non-urgent
- Patients with haematemesis
- Patients aged >= 55 years who’ve got:
upper abdominal pain + low Hb
dyspepsia symptoms/weight loss + raised platelet
- dyspepsia symptoms + nausea or vomiting

This can be summarised at a step-wise approach
1. Review medications for possible causes of dyspepsia
2. Lifestyle advice
3. Trial of full-dose proton pump inhibitor for one month OR a ‘test and treat’ approach for H. pylori
if symptoms persist after either of the above approaches then the alternative approach should be tried

Testing for H. pylori infection
initial diagnosis: NICE recommend using a carbon-13 urea breath test or a stool antigen test, or laboratory-based serology ‘where its performance has been locally validated’
test of cure:
there is no need to check for H. pylori eradication if symptoms have resolved following test and treat
however, if repeat testing is required then a carbon-13 urea breath test should be used