Gastro-oesophageal reflux disease (GORD)

Anti-reflux mechanisms:

The most important mechanism is provided by the lower oesophageal sphincter (LOS):

Formed by the distal 4cm of oesophageal smooth muscle

Rapidly regains its normal tone (following relaxation to allow a bolus to enter the stomach) and thereby prevent reflux

Is capable of increasing tone in response to rises in intra-abdominal and intra-gastric pressures

The oesophagus is normally rapidly cleared of any reflux contents by secondary peristalsis

Factors associated with increased gastro-oesophageal reflux:

Pregnancy or obesity

Fat, chocolate, coffee or alcohol ingestion

Large meals

Cigarette smoking

Drugs:

Anti-cholinergics

Calcium-channel blockers

Nitrates

Systemic sclerosis

Post-rx for Achalasia

Hiatus hernia

Clinical features:

Heartburn:

The 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, stooping or lying down

Pain is often relieved by antacids

Pain seldom radiates to the arms

Nocturnal cough

Dx and investigations:

GORD is a clinical dx and many pts can be rx without investigation

Oesophagoscopy:

Is used to show and confirm the presence of Oesophagitis, with a red friable mucosa and in more severe cases, linear ulceration

The mucosa can be normal in GORD

Barium swallow:

Less sensitive than endoscopy in demonstrating Oesophagitis

May show a hiatus hernia (which, by itself, is of no diagnostic significance)

Radiolabelled Technetium:

Can be used to demonstrate reflux

Gastro-oesophageal reflux disease (GORD)

24-hour pH monitoring:

Most accurate test available

Reasonable correlation between frequency of reflux and symptoms

It is often combined with manometry

The no. of reflux episodes below pH4 occurring over 24hrs is noted

Mx:

Approx. 50% of pts can be rx successfully with:

Simple antacids

Loss of weight

Raising the head of the bed at night

Precipitating factors should be avoided, with a reduction in alcohol intake and cessation of smoking

Magnesium trisilicate:

Antacid

Causes diarrhoea

Aluminium hydroxide:

Antacid

Causes constipation

Alginate-containing antacids:

Most frequently prescribed agents for GORD

They form a gel or ‘foam-raft’ with gastric contents and thereby reduce reflux

H₂-receptor antagonists:

E.g. Ranitidine

Are widely available OTC

Proton-pump inhibitors:

E.g. Omeprazole, Lansoprazole, Pantoprazole

Inhibit gastric hydrogen-potassium ATPase

They produce almost complete reduction of gastric acid secretion and are the drugs of choice for all but the mildest of cases

Prokinetic agents:

E.g. Metoclopramide, Cisapride

These speed gastric emptying

Surgery:

Surgery should never be performed for a hiatus hernia alone.

The properly selected case with severe reflux confirmed by pH manometry and Oesophagitis responds well to surgery

Repair of the hernia and some sort of additional anti-reflux surgery is performed laparoscopically

Results show an improvement in symptoms in up to 80% of cases

Gastro-oesophageal reflux disease (GORD)

Complications:

Peptic stricture:

Usually occurs in pts > 60yrs

The symptoms are those of intermittent dysphagia over a long period

Barrett’s oesophagus:

> 3cm of specialized columnar epithelium extending upwards into the lower oesophageal mucosa

Is due to long-standing reflux

Is seen in up to 20% of pts undergoing endoscopy for GORD

Most common in middle-aged men

Is pre-malignant for adenocarcinoma