Makindo Medical Notes

Related Subjects: |Achalasia |Oesophageal Carcinoma |Diffuse Oesophageal spasm |Diffuse Oesophageal Perforation - Rupture |Gastro-Oesophageal Reflux |Barrett's oesophagus

GORD is a chronic condition in which stomach acid frequently flows back into the oesophagus, leading to symptoms like heartburn, acid regurgitation, and complications such as erosive oesophagitis and Barrett's oesophagus.

Aetiology

• Lower Oesophageal Sphincter (LOS) dysfunction: Transient or sustained reductions in LOS tone are the primary cause of GORD, allowing acid reflux into the oesophagus.
• The LOS, supplied by the vagus nerve, relies on a complex structure and function to prevent reflux. Factors include:
  • Muscle tone at the LOS
  • The acute angle of the gastroesophageal junction
  • The intra-abdominal segment of the oesophagus, providing an additional barrier
• Acid exposure from GORD can lead to conditions like erosive oesophagitis, strictures, Barrett's oesophagus, and potentially adenocarcinoma of the oesophagus.

Risk Factors

• Male gender, smoking, alcohol consumption, pregnancy, and obesity.
• Conditions like scleroderma, which affect LOS tone.
• Certain medications that reduce LOS tone, such as nitrates, tricyclic antidepressants, and calcium channel blockers.

Pathophysiology

• Relaxation of the LOS is partially mediated by nitric oxide (NO). Drugs like glyceryl trinitrate (GTN) may worsen reflux by altering NO levels and increasing LOS relaxation.
• Prolonged acid exposure damages the oesophageal mucosa, leading to inflammation, erosion, and potential changes in cellular structure, as seen in Barrett’s oesophagus.

Complications

• Chronic reflux oesophagitis: Persistent inflammation and erosion can lead to oesophageal ulceration.
• Barrett's oesophagus: Metaplasia of the oesophageal lining increases the risk of adenocarcinoma.
• Oesophageal strictures: Scarring from chronic inflammation can narrow the oesophagus, causing dysphagia and often requiring endoscopic dilatation.

Clinical Features

• Heartburn and acid regurgitation: The most common symptoms, often worse after meals, when stooping, bending, or lying flat.
• Water brash: Excessive saliva production in response to acid in the oesophagus.
• Relief with antacids; symptoms are often exacerbated by alcohol, large meals, or certain foods.
• Retrosternal discomfort can mimic cardiac pain; regurgitation may cause a nocturnal cough or bronchospasm, which can be mistaken for asthma.
• Long-term reflux can lead to complications such as oesophageal strictures and dysphagia.

Investigations

• Blood tests: FBC (anaemia may suggest oesophageal bleeding), U&E, LFTs, and CXR if indicated.
• Endoscopy (OGD): For visualising oesophagitis, erythema, erosions, and biopsy if Barrett’s or malignancy is suspected.
• 24-hour pH monitoring: Assesses acid exposure in the oesophagus. Rarely, a Bernstein test (acid infusion test) may be performed to reproduce symptoms.
• Cardiac evaluation: In cases where cardiac pain is suspected, perform ECG and Troponin testing to rule out ACS.

Differential Diagnoses

• Cardiac conditions: angina, myocardial infarction.
• Biliary conditions: cholecystitis, biliary colic.

Red Flags: Indications for Endoscopy (OGD)

• Unexplained weight loss.
• Anorexia or loss of appetite.
• Persistent vomiting.
• Dysphagia (difficulty swallowing).
• Haematemesis (vomiting blood) or melaena (black, tarry stools).

Management

• Lifestyle modifications:
  • Weight loss and avoidance of large meals and trigger foods (e.g., alcohol, fatty foods, caffeine).
  • Elevate the head of the bed to reduce nocturnal reflux.
  • Avoid tight clothing, smoking cessation, and review of medications that may worsen reflux.
• Pharmacological management:
  • Antacids and alginates (e.g., Gaviscon) provide symptomatic relief.
  • Proton Pump Inhibitors (PPIs): Lansoprazole 30 mg twice daily for 6 weeks, then stepped down to maintenance therapy as needed.
  • H2 receptor antagonists as an alternative for patients intolerant to PPIs.
  • Adjust or stop exacerbating medications like calcium channel blockers, nitrates, theophylline, bisphosphonates, corticosteroids, and NSAIDs where possible.
• Dyspepsia and H. pylori management:
  • Test for H. pylori with a carbon-13 urea breath test, stool antigen test, or validated serology.
  • If positive, initiate eradication therapy with a PPI and antibiotics (e.g., amoxicillin + clarithromycin or metronidazole) for 7 days.
  • Note: Eradication of H. pylori can sometimes worsen GORD by restoring atrophic gastritis and increasing gastric acidity.
• Endoscopic therapy: Techniques such as local injections, sutures, or radiofrequency energy to strengthen the LOS by inducing fibrosis and scarring.
• Surgical management (Nissen fundoplication): For severe, refractory cases. A laparoscopic procedure in which the gastric fundus is wrapped around the LOS to reinforce it and prevent reflux.

References

• NICE Guidance: Gastro-oesophageal reflux disease and dyspepsia in adults (CG184)