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Flashcards in FN: GORD Deck (17)
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1
Q

Pathophysiology

A

􏰀 LOS dysfunction → reflux of gastric contents → oesophagitis.

2
Q

RF

A
􏰀 Hiatus hernia
􏰀 Smoking
􏰀 EtOH
􏰀 Obesity
􏰀 Pregnancy
􏰀 Drugs: anti-AChM, nitrates, CCB, TCAs
􏰀 Iatrogenic: Heller’s myotomy
3
Q

symptoms Oesophageal

A
􏰀 Heartburn
􏰁 Related to meals
􏰁 Worse lying down / stooping
􏰁 Relieved by antacids
􏰀 Belching
􏰀 Acid brash, water brash
􏰀 Odonophagia
4
Q

Extra-oesophageal symptoms

A

􏰀 Nocturnal asthma
􏰀 Chronic cough
􏰀 Laryngitis, sinusitis

5
Q

Complications

A

􏰀 Oesophagitis: heartburn
􏰀 Ulceration: rarely → haematemesis, melaena, ↓Fe
􏰀 Benign stricture: dysphagia
􏰀 Barrett’s oesophagus
􏰁 Intestinal metaplasia of squamous epithelium
􏰁 Metaplasia → dysplasia → adenocarcinoma
􏰀 Oesophageal adenocarcinoma

6
Q

Differential Dx

A
Oesophagitis
􏰁 Infection: 
- CMV, candida
- 􏰁 IBD
- 􏰁 Caustic substances / burns
PUD Oesophageal Ca
7
Q

Ix

A
  1. Isolated symptoms don’t need Ix
  2. Bloods: FBC
  3. CXR: hiatus hernia may be seen
  4. OGD if:
    􏰁 - >55yrs
    􏰁 - Symptoms >4wks
    􏰁- Dysphagia
    -􏰁 Persistent symptoms despite Rx
    􏰁 - Wt. loss
    􏰁- OGD allows grading by Los Angeles
    Classification
  5. Ba swallow: hiatus hernia, dysmotility
  6. 24h pH testing ± manometry
    􏰁 pH <4 for >4hrs
8
Q

Conservative Rx

A
􏰀 Lose wt.
􏰀 Raise head of bed
􏰀 Small regular meals ≥ 3h before bed
􏰀 Stop smoking and ↓ EtOH
􏰀 Avoid hot drinks and spicy food
􏰀 Stop drugs: NSAIDs, steroids, CCBs, nitrates
9
Q

Medical Rx

A
􏰀 OTC antacids: Gaviscon, Mg trisilicate
􏰀 1: Full-dose PPI for 1-2mo
􏰁 Lansoprazole 30mg OD
􏰀 2: No response → double dose PPI BD
􏰀 3: No response: add an H2RA
􏰁 Ranitidine 300mg nocte
􏰀 Control: low-dose acid suppression PRN
10
Q

Surgical Mx

A
Nissen Fundoplication
􏰀 Indications: all 3 of:
􏰁 Severe symptoms
􏰁 Refractory to medical therapy
􏰁 Confirmed reflux (pH monitoring)
11
Q

Nissen Fundoplication

A

􏰀 Aim: prevent reflux, repair diaphragm
􏰀 Usually laparoscopic approach
􏰀 Mobilise gastric fundus and wrap around lower
oesophagus
􏰀 Close any diaphragmatic hiatus
􏰀 Complications:
􏰁 Gas-bloat syn.: inability to belch / vomit 􏰁 Dysphagia if wrap too tight

12
Q

Hiatus Hernia classification

A

sliding
Rolling
Mixed

13
Q

Hiatus Hernia Sliding

A

80%
Gastro-oesophageal junction slides up into chest
􏰀 Often assoc. ̄c GORD

14
Q

Hiatus Hernia Rolling

A

􏰀 15%
Gastro-oesophageal junction remains in abdomen but a bulge of stomach rolls into chest alongside the oesophagus
􏰀 LOS remains intact so GORD uncommon 􏰀 Can → strangulation

15
Q

Hiatus Hernia Mixed

A

5%

16
Q

Hiatus Hernia Ix

A

􏰀 CXR: gas bubble and fluid level in chest
􏰀 Ba swallow: diagnostic
􏰀 OGD: visualises the mucosa but can’t exclude hernia
􏰀 24h pH + manometry: exclude dysmotility or achalsia

17
Q

Hiatus Hernia Rx

A

􏰀 Lose wt.
􏰀 Rx reflux
􏰀 Surgery if intractable symptoms despite medical Rx.
􏰁 Should repair rolling hernia (even if asympto) as it may strangulate.

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