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Flashcards in Oesophageal disorders Deck (53)
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1

Define dyspepsia

Upper GI symptoms typically present for 4+ weeks, including: upper abdominal pain/discomfort, heartburn, acid reflux, NaV

2

Define GORD

Gastro-oesophageal reflux disease is a chronic condition of abnormal reflux of gastric contents into the oesophagus, which causes predominant symptoms of heartburn and acid regurgitation.

3

What is 'proven GORD'?

Endoscopically-determined reflux disease

4

How does GORD typically present?

Oesophageal symptoms:
Heartburn (25%) - burning retrosternal discomfort
Acid brash - acid or bile regurgitation
Water brash - excessive salivation
Odynophagia - pain on swallowing

5

Name 3 atypical clinical features of GORD

Extra-oesophageal symptoms (atypical):
Chest pain, epigastric pain, bloating
Nocturnal asthma
Chronic cough
Laryngitis (Cherry-Donner syndrome)
Sinusitis

6

Name 5 risk factors for GORD

Lifestyle: obesity, trigger foods, smoking, alcohol, coffee, stress
Drugs: CCBs, anticholinergics, theophylline, BDZs, nitrates
Pregnancy

7

What complications can occur due to GORD?

Oesophagitis
Ulcers
Benign strictures
Iron-deficiency anaemia
Barrett's oesophagus ➔ Oesophageal adenocarcinoma

8

What is Barrett's oesophagus?

A precancerous stage seen in 10-15% GORD, associated with the development of oesophageal adenocarcinoma (1-10% in next 20yr).

Metaplasia of oesophageal stratified squamous epithelium ➔ simple columnar epithelium

9

Name 3 causes of GORD

Lower oesophageal sphincter problems
Delayed gastric emptying e.g. gastric outlet obstruction
Hiatus hernia
Obesity/pregnancy

10

What may be seen on histology of GORD?

Gastric metaplasia ➔ low risk of malignancy
Intestinal metaplasia ➔ 2 yearly surveillance
Low-grade dysplasia ➔ 90% develop cancer within 6yr
High-grade dysplasia ➔ 50% have adenocarcinoma

11

What is used to grade Barrett's oesophagus?

Prague C and M endoscopic grading system

12

How is Barrett's oesophagus treated?

High-grade dysplasia: Surgical resection, endoscopic mucosal resection, or ablation

13

Name 3 differential diagnoses for GORD

Oesophagitis from:
Corrosives
NSAIDs
Herpes
Candida

Peptic ulcer disease
Cancer
Cardiac cause e.g. MI

14

Describe the pathology of strictures in GORD

Chronic fibrosis and epithelial destruction
Eventual shortening and narrowing of the lower oesophagus ➔ potential fixation and susceptibility to further reflux

15

What are the annual and lifetime recurrence risks of GORD? Which patient group is more likely to relapse?

Annual recurrence risk of untreated GORD: 50%
Lifetime risk of recurrence: 80%

More likely to relapse in people with severe oesophagitis

16

Name 4 indications for investigations for GORD

Age >45
Symptoms last >4wks
Persistent vomiting
GI bleeding or iron deficiency
Palpable mass
Dysphagia
Weight loss
Failed medical treatment

17

Why could OGD be preformed for any presentation of GORD in over 45s?

Exclude oesophageal malignancy

18

How is GORD investigated?

Endoscopy
24h continuous pH monitoring +- manometry
Barium swallow - may show hiatus hernia

19

Describe a positive pH investigation result for GORD

GORD symptoms correspond with pH peaks

20

What physiological features protect against GORD?

Lower oesophageal sphincter
Fundus located posteriorly and superiorly
Crus of diaphragm
Expansion of stomach

21

Outline the lifestyle management of GORD

Smoking cessation
Weight loss
Decrease alcohol consumption
Small regular meals
Avoid trigger foods
Sleep with head of bed raised

22

Outline the initial medical management of GORD

Review and stop any drugs that exacerbate symptoms
-Relax LOS: nitrates, anticholinergics, CCBs
-Damage mucosa: NSAIDs, K+ salts, bisphosphonates

Full-dose Omeprazole or Lansoprazole for 4 weeks
If severe oesophagitis ➔ 8 weeks

23

How should refractory or recurrent GORD be medically managed?

Consider alternative diagnosis
Check patient adherence to initial management
Reinforce lifestyle advice
Further 4wks of PPI at full-dose or double-dose, or
Add H2R antagonist at bedtime
If severe ➔ 8wk PPI

Offer full-dose PPI long-term as maintenance treatment
Switch to H2RA if endoscopy-negative reflux

24

What are the surgical indications for GORD?

Refractory to treatment, persistent, or unexplained
Controlled on PPI/H2RA, but does not want long-term or cannot tolerate treatment
Associated with risk factors for Barrett's oesophagus

Large volume reflux with risk of aspiration pneumonia
Complications: stricture and severe ulceration

25

Outline the surgical management of GORD

Laparoscopic 'Nissen' fundoplication: wrapping the fundus around the lower oesophagus

26

Name and differentiate between the types of hiatus hernias

Sliding hiatus hernia (80%): Gastro-oesophageal junction slides up into the chest. Gross acid reflux is commoner.

Rolling hiatus hernia (20%): Gastro-oesophageal junction remains in chest, but a bulge of the stomach herniates into the chest, alongside the oesophagus. Symptoms include hiccough, 'pressure' in chest, odynophagia.

27

Outline the medical management of hiatus hernias

Weight loss
Symptomatic relief with H2RAs
PPIs
Metoclopramide - promote oesophageal and gastric emptying

28

What investigations are used for suspected hiatus hernia?

Barium swallow*
Upper GI endoscopy - exclude oesophageal mucosal pathology
CT thorax - acute presentation

29

Define hiatus hernia

Presence of part or all of the stomach within the thoracic cavity. Usually by protrusion through the oesophageal hiatus in the diaphragm.

30

Outline the surgical management of hiatus hernias

Prophylactic surgical hernia repair - avoid strangulation
Gastropexy: reduction and fixation of stomach to oesophagus
Nissen fundoplication: if GORD symptoms predominate