When I was just a second year, on my first clinical attachment, I had taken a history from a patient and I was in the student common room reading over the drug history. I got to o-mep-ra-zole. And a fifth year student says to me ‘you must be in second year’. I thought she was being a bit pretentious. Now I get it. Everyone is on omeprazole, or some similar PPI.
Gastro-Oesophageal Reflux Disease
Definition: when reflux of stomach contents (acid +/- bile) into the oesophagus causes troublesome symptoms (≥2 heartburn episodes/wk) and/or complications (mucosal injury)
Aetiology/ risk factors:
–lower oesophageal sphincter (LOS) hypotension
-loss of oesophageal peristaltic function
-gastric acid hypersecretion
-slow gastric emptying
-overeating (increased gastric volume)
-smoking (lowers LOS pressure)
-surgery for achalasia
-drugs: tricyclics, anticholinergics, nitrates
-possibly Helicobacter pylori
Epidemiology: Common; 10-20% of adults in Western societies experience heartburn and of these, about a third will have evidence of GORD.
-heartburn: burning, retrosternal or epigastric discomfort after large meals
aggravated by lying, stooping, straining
relieved by antacids
-acid brash (acid or bile regurgitation), waterbrash (increased salivation)
-odynophagia (painful swallowing e.g. from oesophagitis or ulceration
-nocturnal asthma (chronic wheeze)
-chronic cough, especially at night
-laryngitis (hoarseness, throat clearing)
-chest pain, back pain
-halitosis (bad breath)
-usually normal examination
-occasionally, epigastric tenderness, wheeze, dysphonia (hoarseness)
Endoscopy- often poor correlation between symptoms and endoscopic findings
May see changes such as- erythema, erosions, ulcers, mucosal breaks, strictures
Oesophagitis (seen in < 50% with typical GORD symptoms) severity is classified by the modified Savary-Millar classification or the Los Angeles classification.
Inflamed Oesophagus due to GORD
Barium swallow-may show hiatus hernia (cause) or strictures (complication)
24h oesophageal pH monitoring +/- manometry– helps to diagnose GORD when endoscopy is normal.
Manometry assesses oesophageal peristalsis and enables placement of the pH probe above the LOS. Significant reflux if pH <4 for >4.7% of the time.
-raise bed head
-small, regular meals; avoid eating < 3h before bed
-avoid provoking factors: e.g. hot drinks, alcohol, citrus fruits, tomatoes, onions, fizzy drinks, spicy foods, coffee, tea, chocolate
-avoid drugs that affects oesophageal motility: nitrates, anticholinergics, calcium channel blockers (these relax the oesophageal sphincter)
-avoid drugs that damage the mucosa: NSAIDs, bisphosphonates, potassium salts
–Antacids-e.g. magnesium trisilicate mixture (10mL/8h) or alginates e.g. Gaviscon Advance (10-20mL/8h) for symptom relief
–Proton pump inhibitor for oesophagitis e.g. lansoprazole (30mg/24h) or omeprazole. Twice daily if not responsive.
-aims to increase resting lower oesophageal sphincter pressure
-consider in severe GORD (confirm by pH monitoring/ manometry), resistant to drug treatment
Options include: Nissen fundoplication (fundus of stomach is wrapped 360º around lower oesophagus and held with seromuscular sutures), HALO or Stretta radiofrequency ablation of the gastro-oesophageal junction if high grade dysplasia
-oesophagitis, oesophageal ulceration
-benign oesophageal stricture
-iron deficiency (if bleeding)
-Barrett’s oesophagus ⇒ oesophageal adenocarcinoma (< 1/1000/yr risk of adenocarcinoma in GORD)
-reflux asthma, cough and laryngitis syndromes
From surgery: dysphagia (mostly temporary), difficulty belching, increased flatus, rarely oesophageal perforation, pneumothorax, splenic injury
Prognosis: 50% respond to lifestyle measures alone
Drug therapy is effective, but withdrawal is often associated to relapse.
Antireflux surgery offers effective symptom control in 85-90% of patients.
References: Cheese & Onion, Rapid Medicine