Makindo Medical Notes.com

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

Aetiology

• Transient or sustained reduced tone at the Lower Oesophageal sphincter (LOS)
• Structure and function of the vagal supplied LOS is fundamental in GORD.
• Muscular tone at LOS, Acute angle of the junction, Intraabdominal part of the oesophagus.
• Results in an erosive oesophagitis, stricture or Barrett oesophagus, or adenocarcinoma

Risk factors

• Male, Smoking, Alcohol, Pregnancy, Obesity
• Scleroderma.
• Drugs e.g. Nitrates, Tricyclics, Calcium channel blockers

Physiology

• Relaxation of the LOS may be mediated in part by Nitric Oxide. GTN can theoretically alter Oesophageal symptoms

Complications

• Long term reflux oesophagitis and ulceration
• Barrett's oesophagus, Oesophageal adenocarcinoma
• Oesophageal stricture - treat with endoscopic dilatation

Clinical

• Heartburn and possibly acid reflux into the mouth and water brash, worse after stooping and bending relieved by antacids. Better when lying flat or bending, large meals, alcohol
• Retrosternal discomfort may need differentiation from cardiac pain. Night time regurgitation can produce a nocturnal cough. Aspiration may cause a degree of bronchospasm which may be confused with Asthma
• Chronic reflux can cause an oesophageal stricture and dysphagia. Nitrates and Calcium channel blockers will exacerbate the reflux

Investigations

• FBC, U&E, LFTs, CXR.
• OGD may show oesophagitis or erythema and erosions. Biopsies of suspicious lesions and Barrett's oesophagus
• 24 hr pH monitoring with a probe placed in lower oesophagus. Bernstein test of infusing diluted acid rarely used nowadays.
• Where ACS considered needs ECG and Troponin

Differential

• Cardiac Disease
• Biliary disease

Red flags: consider OGD

• Weight loss
• Anorexia
• Protracted vomiting
• Dysphagia
• Haematemesis
• Melaena

Management

• Treat cause, lose weight, avoid large meals, reduce alcohol, Stop smoking, review drugs. Not all patients need endoscopy. Consider endoscopy if red flag symptoms or older patients.
• Consider Gaviscon 10 mls PRN and Lansoprazole 30 mg BD for 6 weeks. Then step down to Lansoprazole 10 mg OD.
• Dyspepsia: Consider test for H pylori using a carbon 13 urea breath test or a stool antigen test, or laboratory-based serology where its performance has been locally validated. Eradication is a 7 day, twice-daily course of treatment with: a PPI and Amoxicillin and either clarithromycin or Metronidazole. Penicillin allergy a 7day, twice-daily course of treatment with: a PPI and clarithromycin and Metronidazole.
• Drug causes include calcium antagonists, nitrates, theophylline, bisphosphonates, corticosteroids and non-steroidal anti-inflammatory drugs [NSAIDs].
• Elevate the head of the bed. Antacids and alginates usually Gaviscon like drugs taken for symptom control
• Endoscopic therapy - various techniques now in use to improve LOS function including local injections, sutures, radiofrequency energy to cause fibrosis and scarring.
• Nissen fundoplication may be used in the few severe cases which do not respond and can now be done laparoscopically. The gastric fundus is sutured around the LOS to form a one-way valve
• HP eradication can make matters worse by restoring atrophic gastritis and increasing acidity may be used in view of the possible protection against the development of gastric cancer and peptic ulceration.

References

• Gastro- oesophageal reflux disease and dyspepsia in adults: investigation and management Clinical guideline [CG184] Published date: 03 September 2014 Last updated: 18 October 2019