Gastro-oesophageal reflux (GORD)

Question 1

Describe the metaplasia seen in Barrett’s oesophagus

Answer 1

Squamous epithelium lower down oesophagus becomes a specialised columnar cell layer

Question 2

What cancer is someone with Barrett’s oesophagus predisposed to?

Answer 2

Adenocarcinoma

Question 3

What is the oesophagus?

Answer 3

A muscular tube approximately 20cm long that connects the pharynx to the stomach just below the diaphragm

Question 4

What is the function of the oesophagus

Answer 4

To transport food from the mouth to the stomach

Question 5

What epithelium is the oesophagus lined by?

Answer 5

Stratified squamous

until the squamocolumnar junction where the oesophagus joins the stomach

Question 6

Which oesophageal sphincter is responsible for the prevention of reflux?

Answer 6

Lower oesophageal sphincter

Question 7

What separates the oesophagus from the pharynx

Answer 7

Upper Oesophageal sphincter

normally closed due to tonic activity of the nerves supplying the cricopharngeus

Question 8

Describe the process of swallowing

Answer 8

The bolus of food is VOLUNTARILY moved from the mouth to the pharynx.
Before the food can enter the oesophagus, the upper oesophageal sphincter (OS) relaxes immediately and as soon as the food has passed through it immediately closes.
The reflex results in the initial relaxation of the smooth muscles of the lower OS followed by their contraction.
Pharyngeal and oesophageal peristalsis mediated by this swallowing reflex causes primary peristalsis.
Once in the oesophagus, food moves towards the stomach by a progressive wave of muscle contractions proceeding along the oesophagus. This secondary
peristalsis arises as a result of stimulation by a food bolus in the lumen,
mediated by a local intra-oesophageal reflex.

Question 9

What mediates the voluntary movement of food bolus from the mouth to the pharynx in swallowing

Answer 9

Mediated by a complex reflex involving a swelling centre in the dorsal motor nucleus of the vagus in the brainstem

Question 10

What is GORD

Answer 10

Abnormal reflux from the stomach refluxes into the oesophagus subsequently damaging the squamous oesophageal lining causing discomfort

Question 11

GORD: clinical presentation (signs and symptoms)

Answer 11

Heartburn - pain is worse in certain positions e.g. lying down/stooping and is worse after heavy meals
Acid taste in mouth - regurgitation
Water brash (excess salivation)
Dysphagia
Nocturnal asthma/chronic cough
Laryngitis
Odynophagia (pain when swallowing)

Question 12

GORD: Pathophysiology

Answer 12

Tone of the lower OS is reduced as well as frequent transient relaxations of the LOS.
Increased mucosal sensitivity to gastric acids.
Hiatus hernia (part of stomach pass through hiatus in diaphragm) can cause increased reflux, but reflex can occur without one

Question 13

GORD: Aetiology

Answer 13

Smoking, alcohol, pregnancy, obesity, big meals.
Complication of hiatus hernia
Oesophageal dismobility
Any reason for inadequate LOS function (LOS hypotension)
Gastric acid hyper secretion

Question 14

GORD: Epidemiology

Answer 14

2-3x more common in men

25% of adults experience heartburn

Question 15

*GORD: Diagnosis

Answer 15

Endoscopy

Barium swallow

Question 16

Example of a PPI

Answer 16

Omeprazole

Question 17

Example of a H2 receptor antagonist

Answer 17

Ranitidine

Question 18

GORD complications

Answer 18

Oesophageal stricture formation: worsening dysphagia. (**Peptic stricture)
**Barrett’s Oesophagus: abnormal columnar epithelium replaces the squamous epithelium of the distal oesophageus. Irreversible. Can develop into oesophageal cancer.

Question 19

*What drugs can cause GORD

Answer 19

Tricyclics
Anticholinergics
Nitrates

Question 20

What do investigations of GORD depend on?

Answer 20

Age

Question 21

Investigations of GORD for <55 year old

Answer 21

Proceed to treatment unless they have ALARM symptoms e.g. unintentional weight loss, dysphagia, haematemesis, melaena and anorexia

Question 22

Investigations of GORD for >55 year old (check correct age in mindmaps)

Answer 22

Send patient to endoscopy: diagnostic and allows for biopsy

24-h pH monitoring

Question 23

Conservative treatment of GORD

Answer 23

Education, weight loss, raising head of bed at night and avoidance of precipitating factors e.g. smoking, large meals

Question 24

**Medical treatment of GORD

Answer 24

Antacids e.g. aluminium hydroxide (or Gaviscon)
H2 receptor antagonists e.g. ranitidine
Proton pump inhibitors e.g. omeprazole

Question 25

Surgical treatment of GORD

Answer 25

Nissens fundoplication

Question 26

Causes

Answer 26

Genetic inheritance of angle of lower oesophageal sphincter
Oesophagitis
Sliding hiatus hernia
Rolling hiatus hernia

Question 27

Risk factors

Answer 27

Stress
Increased abdominal pressure e.g. obesity or pregnancy
Hiatus hernia
Smoking
Excessive alcohol
Excessive coffee
Drugs e.g. calcium channel blockers, antimuscarinics and tricyclic antidepressants

Question 28

*What is Barrett’s oesophagus

Answer 28

METAPLASIA of the normal squamous epithelium of the lower oesophagus to columnar epithelium. This occurs un patients who suffer with GORD for several years.
It is a premalignant lesion

Question 29

Investigations of Barrett’s oesophagus

Answer 29

Endoscopy with biopsy in all 4 quadrants

Question 30

Complications of Barrett’s oesophagus

Answer 30

Adenocarcinoma of oesophagus

Question 31

*Treatment of Barrett’s oesophagus

Answer 31

HALO system radio-frequency ablation

or mucosal resection for highly dysplastic lesions

Question 32

Treatment of Highly Dysplastic Barretts oesophagus lesions

Answer 32

Mucosal resection

Question 33

*Differentials

Answer 33

Pericarditis
Pulmonary embolism
Myocardial infarction

Question 34

*Red flags

Answer 34

Coughing blood
Weight loss
Dysphagia