retrograde flow of gastroduodenal contents into oesophagus, or adjacent organs, or both, resulting in a cariable specturm of symptoms

  • 15-20% in adults

  • reflux of contents into oesophagus noraml phsyiological event in many people after eating

  • periodic relaxation of lower oesophageal sphincter

    • exposes easily damaged squamous mucosa of oesophagus to acid, preoteolytic enzymes + bile salts

  • oesophagitis

    • 2/3 will not have visible signs of this

  • symptoms from abnormal spaces in epithelium of mucosa

  • excessive stinulation of nerve endings and peripehral sensitisation

  • Acid production = highest when empty

    • however; symptoms after eating

      • acid pocket

        • unbuffered volume acid formed in prox. region of stomach

can be exacerbated by:

  • Hiatus hernia

  • Central obesity

  • increase pressure gradient between abdomen and thorax

  • impaired oesophageal/gastric clearnace

  • stress

  • 60% of people with GORD

  • aggravated by diet and lifestyle

  • high fat foods,

  • spicy foods

  • caffeine

  • etoh

  • smoking

Risk factors

  • >7 standard drinks/week

  • first degree relative with heartburn

  • 1/2 pregnant women

  • confined to bed

  • Drugs

    • NSAIDs

    • Tetracyclines

    • K+

  • chronic respiratory disease

  • Obestiy

  • Connective tissue disaess

    • scleroderma

    • systemic sclerosis

      • atrophy of muscularis mucoa and submucosal fibrosis result in oesophageal and GI dysfunction

Diagnosis

Symptoms

Typical

clinically significant if ≥ 2d/week

  • heartburn

    • burning feeling

    • rises from stomach or lower chest towards neck

    • frequently occurs after eating

    • associated with bending, lying down or straining

    • upper abdominal pain/discomfort 2/3 of people

  • acid regurgitation

    • water brash

      • sudden and rapid production of saliva

      • associated with nausea (may)

    • 40% irriatble bowel syndorme will have regurgitation

Non-typical

  • chest pain

  • globus pharyngeus

  • Extra-oesophageal respiratory features

    • chronic cough

    • wheeze

  • Otorhinolaryngoloical

    • dysphonia

    • post. dripping

    • throat clearing

Alarm features

refer promptly for endoscopy

emperical treatment PPI started but not delay referral

  • >55yo unexplained and persisiten dyspepsia of recent onset

  • increased risk of gastric and oesophageal ca

  • dysphagia

  • if dysphagia and globus pharyngeus (lump in throat) = stritcture

  • pain on swallowing

  • severe oesophagitis

  • haematemesis/melena

  • weight loss no explaination

  • ( iron def. anaemia)

Diagnostic trial

  • tiral PPI has comparable sensitivity and specificty for diagnosisng GORD as measuring presence of oesophageal acid directly with pH monitor

  • suitable for younger patients:

    • no red flags

    • mild long term symotms

  • primary care setting: 20mg omeprazole == 40mg daily

further investigations

  • fhx cancer

  • nausea and vomiting

  • very severe symptoms

  • nocturnal symptoms

contributing medicaiotns

  • lower oesophageal sphinctre tone

    • theophyline

    • ISMN

    • nifedipine

Investigations

H.pylori

  • consider in those who present with dyspepsia

UGI endoscopy

  • role in diagnosis = limited

    • majority will not have any oesophageal abnormalities

  • has highest specificity for oesophagitis

  • differentiate:

    • infective oesophagitis

    • PUD

    • malignancy

    • other abnormal gut

  • most sensitive technique for diangosing Barrett’s

  • Peptic strictures

indications;

  • red flags

  • diagnositc uncertaintly

  • non-specific atyplical symptoms

  • doesn’t respond to PPI treatment

  • worsens

  • prior to surical intervention for GORD

  • also if mulitple risk factors for oesophagela carcinoma

  • indications

    • assesses presence and degree erosive oesophagiits

    • complications

      • Barrett’s

      • stenosis

      • oesophageal ulcerations

    • associated disorders

    • biopsy

  • Limitations

    • doens’t exclude/confirm GORD

    • expensive

Prolonged ambulatory 24hr oesophageal pHmetry

Complications:

Erosive oesophagitis

  • when excessive gastric reflux

  • necrosis of oesophagela mucosa

  • erosions and ulcers

  • endoscopy

    • graded A-D

    • > 5 fold risk to progress to Barrett’s oesophagus

Barrett’s oesophagus

  • substitution of stratified squamous epitherlium by columnar epitherlium

  • risk :

    • increases with age

    • M>F

    • obesse

    • smoke

    • poor diet

  • 1.6% of population

  • increased risk of oesophageal cancer

    • lifetime risk = \<2%

    • adenocarcinoma

    • very few with BO die from oesophageal carcinoma

Peptic stricture

  • results from healing and fibrosis of inflammatory lesions

    • following long term exposure to GI reflux

  • substantial decline in prevalence of peptic stricutrues

    • use of PPI

  • likelihood

    • higher in older peoples

    • dysphagia

  • simple/complex

  • generally treated using invasive techniques

    • phsyically dilate the oesophagus

Adenocarcinoma

  • correlated with frequency, severity and duration of symptoms

  • >3 times/week

    • 17x more likely to develop oesophagela adenocarcinoma compared to with out GORD

  • severe symptmos >20yr

    • 40x

GORD in pregnancy

  • 30-50% women experience GORD

  • consdiered normal part of pregnancy

  • late in 1/3 or 2/3

  • hearturn becoming more severe and frequent

  • more likely who have had previous episodes, multiple pregnancies

  • incersely correlated with maternal age

  • clinical features same

  • complications rare

  • treatment conservative

    • antacids or ranitidine

  • PPI not witheld if symptoms afeting quality of life

    • overall risk to foetus is minimal

  • Omperaozle and pantoprazole ok with BF but not lansoprazole

  • levels excreted in milk low

    • large proportion of any PPI ingestted by infant destroyed by acid

Treatment

Lifestyle

  • avoiding foods that cause symptoms

    • eoth

    • coffee

    • spicy/fatty/acidic foods

    • eating 3-4 hours prior to sleeping

    • weight loss

    • smoking cess

    • riasing head of bed

      • extra pillows increase abdominal pressure so should not be used

  • review stress/anxiety

PPI

  • most potent class of acid-suppressive medicine

  • PPI offer reflux symptom relief and heal oesophagitis more rapidly than H2 receptor antagonists

    • severe oesophagitis

    • different PPI have similar defficacy

  • Begin 20mg omeprazle od for 4-6 weeks

    • pantoprazole 20mg od or lansoprazole 30mg od alternatives

    • take 30-60min prior to food

      • ideally prior to first meal of the day

      • check compliacne if PPI ineffective

  • majority of responders can be switched from daily to PRN

    • without affeting sympotm control or QoL

    • stop

    • wait for sympotms

    • 20mg od until symptoms resolve

    • symptoms likely to recur in 70% of people

  • step down to lowest dose = alternative

Incomplete response

  • consider increase dose

  • 40mg od

  • check adherence

    • 30-60min prior to meal

  • revisit lifestyle issues

  • when increase lansporazole or pantop - divide dose

  • dividied omepraolze if worsen later in day

  • consider H.Pylori

  • H.pylori

    • higher norath compared to south

    • maori, pacific, asian, indian morelikely to have H.pylori

Antacid

  • resuce for rebound acid secretion

  • abntacid + anti-foaming

    • most effective

  • liquid preparations more effective

  • ones with sodium

  • avoid using wihtin 2 hrs of taking any regular medications

  • paritally subsidised

    • Mylanta P or acidex

      • prescribe with caution for those with heart failure

    • Gaviscon

      • watch double strenght in heart failure

    • Aluinum hydroxide

      • doesn’t contain anti0foaming

H2 receptor antagoins

  • second line

  • mild symptoms who haven’t responded to 4-6wk trial PPI

    • ranitidine 500mg

    • 2-4 divided doses

    • up to 12 wks

  • prokinetic

    • domperidone 10-20mg tds/qds to max 80mg/day

    • alteranative to h2 angatonist