GASTRO-OESOPHAGEAL REFLUX DISEASE (GORD)

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GASTRO-OESOPHAGEAL REFLUX DISEASE (GORD)
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• Gastroesophageal reflux disease (GERD),
  gastro-oesophageal reflux disease (GORD), gastric
  reflux disease, or acid reflux disease is defined
  as chronic symptoms or mucosal damage produced by
  the abnormal reflux in the esophagus.
• This is commonly due to transient or permanent
  changes in the barrier between the esophagus and
  the stomach.
• This can be due to incompetence of the lower
  esophageal sphincter, transient lower esophageal
  sphincter relaxation, or a hiatal hernia.
• Respiratory and laryngeal manifestations of GERD
  are commonly referred to as extraesophageal
  reflux

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• Definitions in oesophageal disease
• Hiatus hernia - anatomical abnormality with part
  of the stomach in the chest, usually
  asymptomatic.
• Gastro-oesophageal reflux - reflux of gastric
  contents which can occur normally with no
  symptoms.
• Gastro-oesophageal reflux disease (GORD) -
  patient with reflux who has persistent symptoms.
• Reflux oesophagitis - inflammation of the lower
  oesophagus produced by persistent episodes of
  reflux. Patients may be asymptomatic.
• Barrett's oesophagus - presence of intestinal
  metaplastic columnar epithelium which has
  replaced squamous epithelium as a consequence of
  acid reflux.

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• Antireflux mechanisms
• The lower oesophageal sphincter (LOS) is formed
  by the distal 4 cm of oesophageal smooth muscle.
  It rapidly regains its normal tone (following
  relaxation to allow a bolus to enter the stomach)
  and thereby prevents reflux.
• It is capable of increasing tone in response to
  rises in intra-abdominal and intragastric
  pressures.
• In addition, contraction of the crural diaphragm
  exerts a 'pinchcock-like' action at the LOS.
• The oesophagus is normally rapidly cleared of any
  reflux contents by secondary peristalsis.

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• Acid reflux

• Lower oesphageal ulcerations

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• Factors associated with gastro-oesophageal
  reflux
• Pregnancy or obesity
• Fat, chocolate, coffee or alcohol ingestion
• Large meals
• Cigarette smoking
• Drugs -calcium-channel blockers, nitrates
• Systemic sclerosis
• After treatment for achalasia
• Hiatus hernia

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• The following mechanisms have been implicated
• Transient LOS relaxations.
• Low resting LOS tone which fails to increase when
  the patient is lying flat, as occurs normally.
• The LOS tone fails to increase when
  intra-abdominal pressure is increased by tight
  clothing or pregnancy.
• There is increased oesophageal mucosal
  sensitivity to acid.
• There is reduced oesophageal clearance of acid
  because of poor oesophageal peristalsis. The
  reduced acid clearance is exacerbated with a
  hiatus hernia, owing to trapping of acid within
  the hernial sac.
• Delayed gastric emptying occurs, which may
  increase the chance of reflux.
• Prolonged episodes of gastro-oesophageal reflux
  occurring at night and postprandially.

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• Clinical features
• Heartburn is the major feature of GORD.
• Pain is mainly due to direct stimulation of the
  hypersensitive oesophageal mucosa, but is also
  partly due to spasm of the distal oesophageal
  muscle. The burning is aggravated by bending, or
  lying down and may be relieved by antacids. The
  patient may complain of pain on drinking hot
  liquids or alcohol.
• The correlation between heartburn and
  oesophagitis is poor. Some patients have mild
  oesophagitis, but severe heartburn others have
  severe oesophagitis without symptoms, and present
  with a haematemesis or an iron deficiency anaemia
  from chronic blood loss.
• Regurgitation of food and 'acid' into the mouth
  occurs, particularly when the patient is bending
  or lying flat.
• Sinusitis ,hoarsness of voice, chronic cough
  and nocturnal asthma from regurgitation and
  aspiration can occasionally occur.

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• The differential diagnosis of the retrosternal
  pain from angina can be difficult 20 of cases
  admitted to a coronary care unit have GORD .
• Gastro-oesophageal reflux
• Burning pain produced by bending,or lying down
• Pain seldom radiates to the arms
• Pain precipitated by drinking hot liquids or
  alcohol
• Relieved by antacids
• Myocardial ischaemia
• Gripping or crushing pain
• Pain radiates into neck, shoulders and both arms
• Pain produced by exercise
• Accompanied by dyspnoea

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• Diagnosis and investigations
• GORD is a clinical diagnosis and in many
  patients the diagnosis can be made without
  investigation.
• Barium swallow is a reliable way of assessing the
  potential severity of reflux. It will also show
  the presence of a hiatus hernia.
• 24-Hour intraluminal pH monitoring combined with
  manometry , which should always be performed to
  confirm GORD before considering surgery. There
  should be a good correlation between reflux (pH lt
  4.0) and symptoms .
• It is also necessary to exclude oesophageal
  dysmotility as the cause of symptoms.

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• Assessing oesophagitis
• Fibreoptic oesophagoscopy is used to confirm the
  presence of oesophagitis,
• i.e. a red friable mucosa with ulceration in
  severe cases (erosive oesophagitis).
• The technique is also used to diagnose Barrett's
  oesophagus .

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• Treatment
• Many patients with reflux symptoms
  (approximately 50) can be treated successfully
  with simple antacids, loss of weight, and raising
  the head of the bed at night.
• Precipitating factors should be avoided, with a
  reduction in alcohol consumption and cessation of
  smoking.
• Drugs Simple antacids magnesium trisilicate and
  aluminium hydroxide are readily available and are
  often used initially by patients. The former
  tends to cause diarrhoea whilst the latter causes
  constipation.
• H2-receptor antagonists (e.g. cimetidine,
  ranitidine, and famotidine ) are used for acid
  suppression if the above measures fail.

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• Proton pump inhibitors (PPIs)
• (e.g. omeprazole, lansoprazole, pantoprazole)
  inhibit gastric hydrogen/potassium-ATPase .
• PPIs reduce gastric acid secretion by 90 and are
  the drugs of choice for all but mild cases.
  Patients with severe symptoms need prolonged
  treatment, often for years. Sometimes a lower
  dose, e.g. omeprazole 10 mg, is sufficient for
  maintenance.
• The prokinetic agents metoclopramide and
  domperidone are dopamine antagonists. They are
  occasionally helpful as they enhance peristalsis
  and speed gastric emptying. Cisapride increases
  the QT interval and has been withdrawn because of
  the risk of arrhythmias.

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• Using the above treatments, most patients can be
  kept symptom-free, but symptoms usually return
  when treatment is stopped and long-term therapy
  is then required.
• Surgery
• Surgery should never be performed for a hiatus
  hernia alone. The properly selected case with
  severe reflux symptoms confirmed by pH monitoring
  and with oesophagitis on oesophagoscopy responds
  well to surgery.
• Repair of the hernia and some sort of additional
  antireflux surgery (e.g. a modified Nissen
  fundoplication) is performed laparoscopically.

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• Management of reflux oesophagitis
• There is a poor correlation between GORD symptoms
  and the presence of endoscopic oesophagitis.
• Many gastroenterologists treat severe
  oesophagitis (even in the absence of symptoms)
  with long-term PPIs with regular surveillance
  oesophagoscopy in an attempt to reduce the risk
  of complications.
• Long-term PPI therapy appears very safe.
• Complications
• Peptic stricture usually occurs in patients over
  the age of 60. The symptoms are those of
  intermittent dysphagia over a long period.
  Treatment is by dilatation of the stricture and
  management of the reflux usually medically with a
  proton-pump inhibitor to achieve anacidity.
  Occasionally surgery is required.