GORD

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:

Causes:

lower oesophageal sphincter (LOS) hypotension

-hiatus hernia

-loss of oesophageal peristaltic function

-abdominal obesity

-gastric acid hypersecretion

-slow gastric emptying

-overeating (increased gastric volume)

-smoking (lowers LOS pressure)

-alcohol

-pregnancy

-surgery for achalasia

-drugs: tricyclics, anticholinergics, nitrates

-systemic sclerosis

-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.

Symptoms:

-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)

-belching

-odynophagia (painful swallowing e.g. from oesophagitis or ulceration

 

Atypical symptoms:

-nocturnal asthma (chronic wheeze)

-chronic cough, especially at night

-laryngitis (hoarseness, throat clearing)

-sinusitis

-chest pain, back pain

-halitosis (bad breath)

Signs:

-usually normal examination

-occasionally, epigastric tenderness, wheeze, dysphonia (hoarseness)

Investigations:

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.

 

Image result for gastro gord

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.

 

Management:

Conservative

-raise bed head

-weight loss

-smoking cessation

-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

 

Pharmacological

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.

 

Surgical

-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

Image result for nissen fundoplication

 

Complications:

-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

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