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Gastro Oesophageo Reflux Disease (GORD)

Contents

• Pathophysiology• Oesophageo mucosal defense mechanisms• Clinical features• Diagnosis and investigations• Treatment • Complications

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Pathophysiology

• Between swallows,• Muscles of oesophagus are relaxed,• Except for those of sphincters.

• LOS remains closed usually • Muscles of LOS get relaxed when swallowing is initiated

• Transient lower oesophageal sphincter relaxations (TLESRs)• Part of normal physiology• But occurs more frequently in GORD patients

• Little amount of reflux is normal

• Sphincter pressure also increases in response to• Rises in intra abdominal and intragastric pressures.

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The main anti reflux mechanisms

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Other anti reflux mechanisms

• Intra abdominal segment of oesophagus• Acts as a flap valve

• Mucosal rosette formed by folds of gastric mucosa & • the contraction of the crural diaphragm at the LOS

• Acting like a pinchcock,• Prevents acid reflux• Large hiatus hernia can impair this mechanism

• Oesophagus is rapidly cleared normally or refluxate• By secondary peristalsis • By gravity• By salivary bicarbonate

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Factors associated with gastro oesophageal reflux

• Pregnancy and obesity• Fat, chocolate, coffee or alcohol ingestion• Large meals• Cigarette smoking• Drugs

• Antimuscuranics• Calcium- channel blokers• Nitrates

• Systemic sclerosis• After treatment of achalasia• Hiatus hernia

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Factors associated with gastro oesophageal reflux

• Pregnancy and obesity• Fat, chocolate, coffee or alcohol ingestion• Large meals• Cigarette smoking• Drugs

• Antimuscuranics• Calcium- channel blokers• Nitrates

• Systemic sclerosis• After treatment of achalasia• Hiatus hernia

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Osophageal mucosal defense mechanisms

• Surface• Mucus and the unstirred water layer trap bicarbonate• This is a weak buffering mechanism, compared to that in the

stomach and duodenum

• Epithelium• Apical cell membrane and junctional complexes between cells

act to limit diffusion of H+ into the cells.• In oesophagitis – junctional complexes are damaged.

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Osophageal mucosal defense mechanisms

• Postepithelium• Bicarbonate normally buffers acid, in the cells and

intracellular spaces• Hydrogen ions impair the growth and replication of damaged

cells

• Sensory Mechanisms• Acid stimulates primary sensory neurons in the oesophagus

by activating the VANILOID RECEPTOR 1 (VR1)• This can initiate inflammation and release pro-inflammatory

substances from the tissue to produce pain• Pain can also be due to - contraction of longitudinal

oesophageal muscle

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Clinical fetures

Clinical Features

Heartburn Regurgitation

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Heartburn

• Is the major feature

• Aggravated by • Bending• Stooping• Lying down

• Relieved by• Oral antacids

• Patient complains pain on drinking• Hot liquids• Alcohol

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Which promotes acid exposure

Heartburn

• Correlation between heartburn and esophagitis is poor

• Differentiation of cardiac and oesophageal pain can be difficult

• In addition to the clinical features, • a trial of PPI is always worthwhile and • if symptoms persist, • ambulatory pH and impedance monitoring should be

performed

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Regurgitation of food and acid

• Particularly on bending or lying flat

• Aspiration pneumonia is unusual without an accompanying stricture• But cough and asthma can occur & respond slowly (1-4

months to a PPI

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Hiatus Hernia

Hiatus Hernia

Sliding Hiatus HerniaRolling or para-

oesophageal hernia

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Sliding hiatus hernia

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• Oesophageal-gastro junction and part of stomach• ‘slides’ through the hiatus• That it lies above the diaphragm

• Present in 30% of people over 50 years• Produces no symptoms

• Any symptoms are due to reflux

Rolling or para-oesophageal hernia

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• Part of the fundus of the stomach,• Prolapses through the hiatus,• Alongside the oesophagus

• LOS remains below the diaphragm & remains competent• Occasionally severe pain occurs due to volvulus or

strangulation

Rolling or para-oesophageal hernia

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Features of pain in GORD and Cardiac ischemia

GORD

• Burning, worse on bending, stooping or lying down

• Seldom radiates to the arms• Worse with hot drinks or

alcohol• Relieved by antacids

Cardiac ischemia

• Gripping or crushing

• Radiates to neck or left arm

• Worse with exercise

• Accompanied by dyspnea

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Diagnosis and Investigations

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• Clinical diagnosis can be made

• Unless there are alarm signs, (esp.dysphagia),• Patients under 45 years, • Can safely be treated initially without investigations

Investigations

Assess oesophagitis & hiatus hernia by endoscopy

Document reflux by intraluminal monitoring

Intraluminal Monitoring

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• 24 hour luminal Ph monitoring or,• Impedance combined with manometry is helpful • if there is no response to PPI & • should always be performed to confirm reflux before

surgery

• Excessive reflux• pH <4 for >4% of the time

Treatment

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• Loss of weight• Raising head end of the bed at night

• Precipitating factors should be avoided,• With dietary measures• Reduction in alcohol and caffeine consumption &• Cessation of smoking

Treatment

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Treatment

Life style modifications Drugs

Endolunimal gastroplicatio

nSurgery

Treatment

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Drugs

Alginate-containing antacids

Dopamine antagonist prokinetic

agents

H2-receptor

antagonists

Proton pump

inhibitors

Alginate-containing antacids

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• 10 ml tds• ‘over the counter’ agents for GORD

• They form a gel or ‘foam raft’ with gastric contents to reduce reflux

• Magnesium containing antacids• Tends to cause diarrhea

• Aluminum containing compounds• Cause constipation

Dopamine antagonist prokinetic agents

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• Metoclopramide and domepridone

• Enhances peristalsis &• Speed gastric emptying

H2- receptor antagonists

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• Cimetidine• Ranitidine• Famotidine • Nizatidine

• Acid suppressors

• If antacids fail• They can be often obtained over the counter

Proton Pump Inhibitors

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• Omeprazole• Rabeprazole• Lansoprazole• Pantoprazole • Esomeprazole

• Inhibit gastric hydrogen/potassium- APTase• Reduce gastric acid secretion by 90%• DOC for all mild cases

• Most respond well• 20-30% will persist with heartburns

• Severe symptoms – bd dosing & prolonged Tx

Endo luminal gastroplication

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• In this endoscopic procedure, • multiple plications or pleates are • made below the gastro-oesophageal junction.

Surgery

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• Never be performed to hiatus hernia alone

• Best predictor• Typical reflux symptoms with documented acid reflux

• Current surgical techniques –• Return the oesophageal junction to the abdominal cavity• Mobilize the gastric fundus• Close the diaphragmatic crura snugly• Involve a short tension-free fundoplication

Surgery

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• Indications for operation• Not clear• Intolerance to medication• Desire for freedom from medications• Expense of therapy• Concern of long-term side effects

• Patients with oesophageal dysmotility unrelated to acid reflux, • patients with no response to PPIs and • those with undelying functional bowel disease • should NOT have surgery

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Complications

• Peptic stricture• Barrett’s oesophagus

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Peptic Stricture

• Due to usage of PPI – strictures are uncommon in this era

• Usually occurs in – patients over the age of 60

• Present with intermittent dysphagia for solids • which worsens gradually over a long period

• Mild cases• May respond to PPI alone

• Severe cases• Need endoscopic dilatation • Long term PPI therapy

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Barrett’s Oesophagus

• Part of normal oesophageal squamous epithelium is • replaced by metaplastic coloumnar mucosa • to form a segment of ‘columnar-lined oesophagus’ (CLO)

• There is almost always a hiatus hernia

• Diagnosis is made by• Endocopy showing proximal displacement of squamo

coloumnar mucosal junction • Biopsies demonstrating coloumnar lining above the proximal

gastric folds• Interstinal metaplasia is no longer a requirement – (British

Society of Gastroenterology guidelines)

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Barrett’s Oesophagus

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Barrett’s Oesophagus

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Barrett’s Oesophagus

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Barrett’s Oesophagus

• Barret’s oesophagus may be seen as• Continual circumferential sheet• Finger like projections extending upwards from the squamo-

coloumnar junction• Islands of coloumnar mucosa interspersed in areas of residual

squamous mucosa

• Central obesity increases risk of Barrett’s by 4.3 times

• Commonest in middle aged obese men• 0.12-0.5% - develop oesophageal adenocarcinoma

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