Gastro-Oesophageal Reflux Disease (GORD)

Gastro-Oesophageal Reflux Disease (GORD)

·        Includes reflux oesophagitis

·        An acid and motility disease

·        Mechanisms for reflux:

o   Lowered sphincter pressure/incompetence: Aggravated by large meals, acidic (e.g. citrus), fatty food, chocolate, smoking, peppermint, caffeine

o   ­Abdominal pressure: effects right crus of diaphragm which acts like an external LOS: aggravated by obesity, straining, pregnancy, bending over

·        Presentation:

o   Heart burn

o   Dyspepsia, nocturnal cough or chest pain

o   Poor correlation between symptoms and severity

·        Diagnosis:

o   Therapeutic trial

o   If going to investigate, don‟t treat in meantime: otherwise ® ¯inflammation (if any)

o   Endoscopy most sensitive and specific: use after failure of therapeutic trail or if alarm symptoms. Biopsy only to exclude malignancy or Barrett's oesophagus. 50% are normal on endoscopy

o   Gold standard: 24 hour ambulatory pH monitoring

o   Lesions graded 1 (mild) to 4 (severe), 5 (metaplasia – Barrett‟s). If Grade >= 3, then indefinite, significant acid suppression.

·        Alarm Symptoms:

o   Dysphagia

o   Early satiety

o   Night waking

o   Abrupt onset

o   Recurrent hoarseness

o   ­Severity

o   Weight loss

o   Vomiting blood

o   Symptoms for the first time > 45 years or soon after any treatment

·        Differential: Peptic ulcer, gastric or oesophageal cancer, angina/IHD, hiatus hernia

·        Macroscopic appearance: Oedema, hyperaemia (redness), ulceration, white patches with candida

·        Microscopic appearance:

o   Intraepithelial eosinophils

o   Neutrophils in the epithelium and lamina propria

o   Regenerative and degenerative features of the epithelium (® thickening)

o   Ulceration

·        Treatment hierarchy:

o  Try antacids & lifestyle changes first (e.g. tilt bed, no food before bed, avoid problem foods, weight loss)

o  Paracetamol for pain not aspirin

o  High fibre diet: reduces straining ® reduces reflux due to ¯intra-abdominal pressure (only helps if straining to start with)

o  Prokinetics: cisapride, metoclopramide or domperidone

o  H2 antagonists (OK for mild): healing after 8 – 12 weeks

o  PPI (more effective in severe): omeprazole, lansoprazole, pantoprazole

o  Nissen fundiplication (operation): also reduces hiatus hernia at same time

·        Complications:

o  Barrett's oesophagus: long-standing reflux ® Metaplasia: columnar changes above gastro-oesophageal junction. Predisposes to cancer

o  Ulceration, stricture (always biopsy strictures as some cancers present like this)

o  Adenocarcinoma