GORD Flashcards
Define GORD?
Reflux of stomach contents -> oesophagus
outline the aetiology of GORD?
Caused by disruption of mechanisms that prevent reflux
Mechanisms that prevent reflux:
- Lower oesophageal sphincter
- Acute angle of junction
- Mucosal rosette (less mucosal fold -> gastro-eosophageal junction)
- Intra-abdominal portion of oesophagus (diaphragm acts as a sphincter) e.g. obesity, pregnancy which cause pressure on stomache => hiatal hernia
Prolonged oesophageal acid clearance contributes to 50% of cases
Increased dietary fat
What are the risk factors for GORD?
FH of heartburn/ GORD
Obesity
Preg
Older age
Hiatus hernia
Drugs relaxing the smooth muscle in LOS e.g. antimusc, CCBs, nitrates and smoking
Summarise the epidemiology of GORD?
COMMON
10-20% of adults
What aggrevates the pain from GORD?
LYING SUPINE- how many pillows do you slep with
bending
large meals
drinking alcohol
what relives the pain from GORD?
Antacids
what are the presenting symptoms of GORD?
Substernal/epigastric burning discomfort or ‘heartburn’
Aggravated by:
- Lying supine – HOW MANY PILLOWS THEY SLEEP WITH AT NIGHT
- Bending
- Large meals
- Drinking alcohol
Pain is relieved by antacids
Waterbrash (regurgitation of an excessive accumulation of saliva from the lower part of the oesophagus often with some acid material from the stomach)
SIDE NOTE: acid brash is when the acid acc enters the mouth
Sour/ bitter taste in mouth, esp after meals
Aspiration - may result in hoarseness, laryngitis, nocturnal cough and wheeze +/- pneumonia (rare)
Dysphagia - caused by formation of peptic stricture after long-standing reflux
Stricture = narrowing of passage
Bloating – other causes like cancer/ stricture should be ruled out first
CAN GET SILENT REFLUX- ONLY SYMPTOM IS COUGH
What are the signs of GORD on physical examination?
Usually NORMAL
Occasionally - epigastric tenderness, wheeze on chest auscultation, dysphonia, halitosis (bad breath), enamel erosion, cough, dysphagia
what are the possible complications of GORD?
Oesophageal ulceration
Peptic stricture
Anaemia
Barrett’s oesophagus
Oesophageal adenocarcinoma
Associated with asthma and chronic laryngitis e.g. hoarseness etc
Summarise the prognosis of GORD
- 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
What are the appropriate investigations for GORD?
1st line: If suspected: a trial of PPI is given (+ urea breath test/ H.pylori stool test)
If GORD persists: upper GI endoscopy and biopsy (confirms presence of oesophagitis and can exclude malignancy – must exclude for all >55 years)
Other tests: 24h pH monitoring, manometry (measuring LES pressure as you swallow sips of water through a lubricated catheter passed through nose), barium swallow
Outline the conservative management of GORD?
Weight loss
Elevating head of bed
Avoid provoking factors
Stop smoking
Lower fat meals
Avoid fried meals and less tomatoes too
Avoid large meals late in the evening
Outline the medical management of GORD?
Proton pump inhibitors (e.g. lansoprazole, omeprazole) - 20mg
H2 antagonists (e.g. ranitidine) - may be needed as an adjunctant
Triple therapy if H pylori cause: PPI + 2 ABs (e.g. clarithromycin 500mg + amoxicillin 1g/metronidazole 400mg + omeprazole) - taken twice daily
Describe the use of endoscopy in the medical management of GORD?
Annual endoscopic surveillance - looking for Barrett’s Oesophagus
May be necessary for stricture dilation or stenting
Oesophagus perforation is possible complication and would need a CT with oral contrast to visualise
Describe the surgical management of GORD?
Antireflux surgery if refractory to medical treatment
Nissen Fundoplication: Fundus of the stomach is wrapped around the lower oesophagus - helps reduce the risk of hiatus hernia and reduce reflux
Magnetic sphincter augmentation with beads
